Health Care Facility | Insurers | Related Initiatives
Health Care Facility | Insurers | Related Initiatives  

Matching Unmatched OCFs

About OCF Matching in HCAI

In an ideal world, all OCFs would arrive to an insurer, automatically link up with an existing clamant in HCAI and then be automatically directed to the assigned file owner’s worklist. However, as we know, things are not always ideal.

Inevitably, you will encounter documents in ‘Unmatched’ status. This status indicates that the OCF couldn’t link up with an existing claimant. When this happens, the insurer needs to go into the OCF and investigate whether it was sent to the correct insurer and, if it was, link it to the correct claimant.

Anyone who has been involved with matching documents in HCAI can tell you this is a skill all on its own—the matcher needs to assess whether the OCF was correctly submitted to their organization and, if it is, how to search for the correct claimant. Unmatched documents should be dealt with as soon as possible because a file owner cannot review or mark an adjudication decision on the form unless it is matched to a claimant.

In this section, we’ll break down the matching process and outline the steps needed to make the match happen.

Continue reading from the left-hand menu to learn more.

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
  • Gender
  • 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 file owner’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.

Matching Unmatched OCFs

Tips for Reducing the Number of Documents Received in 'Unmatched' Status

Investigating unmatched documents can impact the number of days an adjuster has to evaluate a document. Below are some tips on how your organization can cut back on the number of documents your organization receives in ‘Unmatched’ status:

  • Ensure the claim and policy number given to claimants matches the claim and policy number inputted into HCAI
    For example, if you input claim numbers into HCAI with a 0000 at the beginning but then give claimants a policy number without the zeros, you reduce the likelihood of a form being matched perfectly without intervention from a matcher
  • Ensure your telephone adjusters collect the five matching data elements at the first point of contact with the claimant
    The first point of contact with a claimant—when they report the accident—is important because it might be the only opportunity to confirm the five matching elements before a form is submitted. It is important that your organization communicate the importance of accurately capturing those five matching elements so that the claimant information can be properly matched to the information on the OCF without intervention by a matcher.

Matching Unmatched OCFs

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About OCF Matching in HCAI

In an ideal world, all OCFs would arrive to an insurer, automatically link up with an existing clamant in HCAI and then be automatically directed to the assigned file owner’s worklist. However, as we know, things are not always ideal.

Inevitably, you will encounter documents in ‘Unmatched’ status. This status indicates that the OCF couldn’t link up with an existing claimant. When this happens, the insurer needs to go into the OCF and investigate whether it was sent to the correct insurer and, if it was, link it to the correct claimant.

Anyone who has been involved with matching documents in HCAI can tell you this is a skill all on its own—the matcher needs to assess whether the OCF was correctly submitted to their organization and, if it is, how to search for the correct claimant. Unmatched documents should be dealt with as soon as possible because a file owner cannot review or mark an adjudication decision on the form unless it is matched to a claimant.

In this section, we’ll break down the matching process and outline the steps needed to make the match happen.

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
  • Gender
  • 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 file owner’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.

Tips for Reducing the Number of Documents Received in 'Unmatched' Status

Investigating unmatched documents can impact the number of days an adjuster has to evaluate a document. Below are some tips on how your organization can cut back on the number of documents your organization receives in ‘Unmatched’ status:

  • Ensure the claim and policy number given to claimants matches the claim and policy number inputted into HCAI
    For example, if you input claim numbers into HCAI with a 0000 at the beginning but then give claimants a policy number without the zeros, you reduce the likelihood of a form being matched perfectly without intervention from a matcher
  • Ensure your telephone adjusters collect the five matching data elements at the first point of contact with the claimant
    The first point of contact with a claimant—when they report the accident—is important because it might be the only opportunity to confirm the five matching elements before a form is submitted. It is important that your organization communicate the importance of accurately capturing those five matching elements so that the claimant information can be properly matched to the information on the OCF without intervention by a matcher.
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