Matching Unmatched OCFs
What is an Unmatched Document?
To understand how to handle an unmatched document, it’s important to understand how a document arrives in ‘Unmatched’ status in the first place.
When an OCF is received, HCAI searches existing claimants for a ‘perfect match’ based on the following five criteria:
- Claim or policy number
- Claimant date of birth
- Claim date of accident
Note that elements such as the spelling of the claimant name or address do not impact the matching process. If all of these matching elements are present in both the OCF and the claimant record, HCAI considers the OCF and the claimant to be a ‘perfect match’ and will automatically link them together and direct the OCF to the associated adjuster’s worklist.
If some of these matching elements are present, HCAI will generate a list of claimants that are possible matches and, as the matcher, you will need to manually match them together.
In this guide, we have summarized four common scenarios that would cause an OCF to be unmatched. The following sections will outline possible ways to manage the following four scenarios in the below:
- The OCF belongs to your organization, but no claim has been set up
- The OCF belongs to your organization, but it is one of many possible matches
- The OCF was sent in error
- The OCF does not belong to you, it was sent to the wrong insurer
The OCF belongs to your organization, but no claim has been set up
In this scenario, you may have some indication, either through claim/policy number, or the name that the OCF likely belongs to your organization, but you cannot locate the associated claim in HCAI.
First, you will want to search to ensure that the claimant isn’t already set up under a slightly different policy number, or with a different date of birth or loss. You can verify that no existing claimant exists by searching for other data elements such as claimant name.
Once you have confirmed that there is absolutely no matching claimant already in HCAI, you will need to investigate why the claim has not been set up and follow up internally to ensure that a claim-claimant profile is or will be set up. Some reasons may be:
- The claim has not yet been reported to your organization
- The claim was only recently been reported to your organization
- The claim was set up, but the matching elements vary widely from what was submitted on the OCF
- Your organization lacks complete information to set up the claim-claimant record in HCAI
The OCF belongs to your organization, but it is one of many possible matches
In this scenario, the document is received unmatched but several possible claimant matches are listed on the OCF. This is likely because there are several claimants with some matching elements but no single record is a complete match.
As the matcher, you need to review the possible matches to determine which claimant is correct, if any. When the correct claimant is located, press the ‘Match’ button next to the claimant name. (View screenshot)
The OCF was sent in error
If you receive a document in error and need to send it back to the facility, you’ll have to mark the document as ‘Cannot be matched’. If you have the Form Adjuster role at the insurer level of access, this will allow you to decline the form without matching it to an existing claim or claimant record.
To decline and return the form to the submitting facility:
- Open the unmatched document.
- Under the ‘Possible Match’ section, press the <Cannot Be Matched> button; the screen automatically refreshes.
- At this point, the form must be escalated to an administrator who can enter a reason code and decline the form.
The OCF was sent to the wrong insurer
Occasionally, OCFs are sent to the wrong Insurer by a Health Care Facility. When this happens, the Insurer can mark the form as ‘Sent to Wrong Insurer’ and adjudicate the OCF without viewing the Personal Health Information (PHI) of a patient on the web interface.
- Open the unmatched document.
- Click the “Sent to Wrong Insurer” button. (View screenshot)
- At this point, the Personal Health Information for the OCF will be hidden. (View screenshot)
At this point, the form must be escalated to an administrator who can enter a reason code and decline the form.