The Dispute Resolution screen is a combination dashboard and reporting tool used to show dispute resolution status.

Dispute Resolution Home: provides an overall view into the dispute resolution status of any claims marked for dispute. Savings potential relating to disputes in progress is communicated in lower left portion of screen, while savings obtained from state agreement to credit units is displayed in lower right portion of the screen.

Medicaid Reports:
Summary:
displays information needed to communicate overall disputed units by product, period, and program, why the units were disputed by CMS dispute reason code, and dispute resolution outcome to-date. Report is generally used when processing invoices in order to identify the total number of units to leave in dispute vs. the number of units to release from dispute as a result of dispute resolution efforts
**If NDC has more than one issue, there will be two different lines (example: one for duplicate claim “M” and another for PHS “X”)
**Client Plan IDs: sourced from client provided cumulative invoice data

  • Active Open Dispute - Pre-Dispute: state has either not been sent a dispute report, or has been sent a dispute report and not responded
  • Active Open Dispute - Formal Dispute: state has reviewed dispute report and responded 'R' (reject), meaning they do not agree to credit the transaction(s) and therefore an impasse has been reached
  • Dismissed Dispute (Kalderos) - Client's Favor: state has reviewed dispute report sent by Kalderos and responded 'A' (accept), meaning they agree to credit the transaction(s) during Anticipated Credit Qtr
  • Dismissed Dispute (Client) - Client's Favor: state has reviewed dispute report sent by client and responded 'A' (accept), meaning they agree to credit the transaction(s) during Anticipated Credit Qtr. In order for Kalderos to display this information in the reporting tool, it will require the completed dispute report to be sent to Kalderos
  • Resolved Dispute - State's Favor: state has reviewed dispute report sent by Kalderos and responded with evidence that the transaction(s) is no longer in question, so Kalderos 'C' (closed) the transaction(s)

Detail: displays transactions flagged for dispute that have yet to be resolved with the state

  • Within tool: highlighted means the transaction was flagged for that reason
  • Exported: "1" means the transaction was flagged for that reason, "0" means not flagged

Final: provides claim-level information regarding any claim marked for dispute and the dispute resolution outcome to date

  • Dispute in     Process  Predispute: state has     either not been sent a dispute report, or has been sent a dispute report     and not responded
  • Dispute in     Process - Formal Dispute: state has reviewed dispute report and     responded 'R' (reject), meaning they do not agree to credit the     transaction(s) and therefore an impasse has been reached
  • Dispute     Resolved in Client's Favor: state has reviewed dispute report and     responded 'A' (accept), meaning they agree to credit the transaction(s)     during Anticipated Credit Qtr

To align Final Report values with Summary Report values:

  • Dispute in Process: Predispute (Column P) filtered to show '1', then add Kalderos Contacted CE: Rebate Dollars (Column T) + Kalderos Did Not Contact CE: Dollars (Column V) = sum of "Active Open Dispute: Pre-Dispute - Dollars" in Summary Report
  • Dispute in Process: Formal Dispute (Column Q) filtered to show '1', then add Kalderos Contacted CE: Rebate Dollars (Column T) + Kalderos Did Not Contact CE: Dollars (Column V) = sum of "Active Open Dispute: Formal Dispute - Dollars " in Summary Report 
  • Dispute Resolved in Client's Favor (Column R) filtered to show '1', then add Kalderos Contacted CE: Rebate Dollars (Column T) + Kalderos Did Not Contact CE: Dollars (Column V) = sum of "Dismissed Dispute (Kalderos): Client's Favor - Dollars" in Summary Report


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