EZ-CAP Auto Adjudication. Sanjay Goel. Manager, Software Development Doug Bell Product Manager

Transcription

1 EZ-CAP Auto Adjudication Sanjay Goel Manager, Software Development Doug Bell Product Manager

2 Welcome! What is Auto Adjudication? Why Auto Adjudication? EZ-Setup of Auto Adjudication for Auth and claims. New features added in EZ-CAP v6.5.3 Questions? 2

3 Hands Free with Auto Adjudication What is Auto Adjudication? The automation of changing a record s Status, changing the data value or adding a new value to a record. Change Claim Status from 1 (Release to A/P) to 5 (A/P Hold). Change Authorization Status from 7 (Requested) to 1 (Approved). 3

4 Why Auto Adjudication? Automation Reduces human errors. Reduces manual checks and balances and lets the system do the work for you. More productivity. Bottom Line Saves time and money. 4

5 Auto Adjudication V6.5.3 Auto Adjudication Enhancements included in v6.5.3 will be reviewed at the end of this session.

6 Let s Get Started Easy to setup (3 simple steps) 1. Create a Rule Set, Description, Date 2. Set the Action to take place Change Status Add Adjustment Code Add process Status Code Change Detail Net Pay 3. Criteria What Data Element from the Auth or Claim record will trigger the rule 6

7 Authorization Auto Adjudication Setup a Mammogram Rule- 1. Create a Set and the Rule for Mammogram Enter a Set number, Description and date range Enter Rule Description and date range Unique Rule ID is assigned by the system 2. Set the Action to take place Change Auth Status to a 1 3. Criteria Age Range Diagnosis Code Gender Provider Contract Type Service Code 7

8 Authorization Auto Adjudication Step1 Creating a Rule Set by specifying a Set #, Description and Date. Define the Rule specifying a Date and Description. 8

9 Authorization Auto Adjudication Step2 Define the Action to take place Change Auth Status to 1 (Approved) 9

10 Authorization Auto Adjudication Step3 Define the Criteria What data element(s) will trigger the rule 10

11 Authorization Auto Adjudication Turn on the feature in the Company Configuration 11

12 Authorization Auto Adjudication Sets may be assigned at - 1. Company 2. Healthplan Contract 3. Option Master (HP/Option) 12

13 Authorization Auto Adjudication What if sets are assigned at all 3 levels? 1. Company 2. Healthplan Contract 3. Option Master (HP/Option) The system will always start looking at sets at the lowest level and move up - 3. Option Master (HP/Option) 2. Healthplan Contract 1. Company 13

14 Authorization Auto Adjudication Auth hits the Adjudication Rule and moves it to a Status 1. Based on the criteria defined, the Action takes place. The matching Rule ID is stored in the column Auth Rule ID at the detail line grid. 14

15 Authorization Auto Adjudication What do our clients say: Client 1 - Reduction in manual work in approving authorizations. Client 2 50% of authorizations do not require manual review. 15

16 Claim Auto Adjudication Setup PCP Encounter Rule 1. Create a Set and the Rule for PCP Encounter Enter a Set number, Description and date range Enter Rule Description and date range Unique Rule ID is assigned by the system 2. Set the Action to take place PCP Encounter = YES to move claim status to a 9 (Paid) 3. Criteria Not Required 16

17 Claim Auto Adjudication Step1 Creating a Rule Set Input Set, Description, Date Define the Rule (enter a Date and Description) 17

18 Claim Auto Adjudication Step2 Define the Action to take place PCP Encounters = YES The Claim Status will move to a 9 (Paid) 18

19 Claim Auto Adjudication Step 3 Define the Criteria PCP Encounters means the claim is from the member s PCP, adjusted for cap, and all lines are a zero pay. No Criteria definition is needed. System already knows. You do not need to use the Payment Process to release Encounters, which reduces the claims waiting to be processed. 19

20 Claim Auto Adjudication Claim hits the Adjudication Rule and moves it to a status 9. Based on the criteria defined, the Action takes place. 20

21 Claim Auto Adjudication What do our clients say: Client 1-20% of claims are Auto Adjudicated. Many of these claims are to adjust the detail line to $0.00 and insert an Adjustment Code. Client 2 100% of PCP Encounter Claims are automatically moved to a Status 9. Client 3 65% (or 3,600 claims a day) are Auto Adjudicated. 21

22 Auto Adjudication Important and easy-to-use features - Define Action and Criteria Query Builder style. Define Ranges just like Benefit Matrix. Adjudication Statistical Reports. 22

23 Authorization Auto Adjudication Adjudication Actions UDF Fields UDF #3 to UDF #20 Priority Status Payment Status Notes Memos Always Win in Scoring Skip Adjudication if pend flag hit 23

24 Authorization Auto Adjudication Most Used Adjudication Criteria Auth Status UDF #3 through UDF #20 fields Account Case Exists Healthplan Option Request Category Certification Type Auth Service Type Auth Service Package Capitated Covered Patient Status Nursing Home Code Financial Responsibility All Diagnosis Codes Auth Details Exist Facility ID Rendering Provider Service Area same as PCP Rendering Provider Specialty same as PCP Provider LOB Requested Units Authorized Units Auth Record Type C.O.B. Member Condition Codes All Master and Detail Pend Codes 24

25 Authorization Auto Adjudication All Adjudication Criteria Auth Data Elements Service Code Diagnosis Code Place of Service Age Gender Header Net Pay Detail Net Pay Priority Status Service Type Auth Status UDF #1 to UDF #20 Account Case Exists Healthplan Option Request Category Certification Type Auth Service Type Auth Service Package Capitated Covered Patient Status Auth Data Elements Nursing Home Code Financial Responsibility All Diagnosis Code Benefit Rule ID Auth Details Exists Req'd Units Auth'd Units Auth Record Type COB Member Condition Code Pend Codes Provider Requested Member's PCP Requested Provider ID Requested Provider Class Requested Provider Specialty Requested Contract Type Requested Vendor ID Authorizing Member's PCP Authorizing Provider ID Authorizing Provider Class Authorizing Provider Specialty Authorizing Contract Type Authorizing Vendor ID Facility ID Rendering Provider Service Area same as PCP Rendering Provider Specialty same as PCP Provider LOB HMO In Provider LOB HMO Out Provider LOB PPO In Provider LOB PPO Out 25

26 Claim Auto Adjudication Adjudication Actions UDF Fields UDF #1 to UDF #20 Deductible Copay Coinsurance Populate Adjustment Value with Net Pay Value Account Notes Memo Negative Net Pay Remove Existing Adjustment Code Values Always Win in Scoring 26

27 Claim Auto Adjudication Most Commonly Used Adjudication Criteria Outcome Code Benefit Rule ID Claim Details Exist Financial Responsibility Code Contract Amount Allowed Amount Detail Net Pay All Diagnosis Codes Fee Set Exists Covered UDF Fields #3 to UDF #20 Claim Record Type Case Exists Created By Provider Outside ID Account Rendering Provider Service Area same as PCP Rendering Provider Specialty same as PCP Member Condition Codes Employment Accident Other Accident Additional Insurance Code Member Service Area Healthplan Option Bill Type Admission Type Admission Source Inpatient Days Patient Status Facility ID Pend Codes (Detail) 27

28 Claim Auto Adjudication All Adjudication Criteria Claim Header Claim Status Diagnosis Code Place of Service Header Net Pay EOB Indicator # of Units Authorization Exists Pend Codes (Master) Outcome Code Claim Detail Detail Line Net Pay Capitated Service Code Modifier Code Quantity Service Type Processing Status Code Benefit Rule ID Claim Details Exists Financial Responsibility Code Allowed Amount Detail Net Pay Contract Amount All Diagnosis Code Fee Set Exists Covered Pend Codes (Detail) Provider Provider ID Specialty Vendor ID Provider Class Contract Type PCP Encounters Provider LOB HMO In Provider LOB HMO Out Provider LOB PPO In Provider LOB PPO Out Provider Outside ID Provider Qual Code Account Rendering Provider Service Area Same as PCP Rendering Provider Specialty same as PCP Claim Misc. UDF #1 to UDF #20 Claim Record Type Case Exists Created By Member Age Member's PCP Gender COB Member Condition Code Employment Accident Other Accident Additional Insurance Code Member Service Area Health plan Option Hospital Data Element Bill Type Admission Type Admission Source Inpatient Days Patient Status Facility ID 28

29 Auto Adjudication Reports Auto Adjudication Reports for both authorizations and claims to view statistical data This feature allows the user to see daily, weekly, monthly, or annual Auth/Claims volume and Adjudication Rates 29

30 Auto Adjudication or Workflow Which Comes First? Root Beer anyone? Auto Adjudication Rules are searched before Workflow Rules 30

31 Auto Adjudication Logic When a user clicks on the Save icon, the system performs Auto Adjudication. Just like Benefits and Fee Schedules, data elements on the Authorization or Claim must match all values contained in a Rule. Claim/Auth is pended when conflicting rules are hit. 31

32 Auto Adjudication Messages If a Claim is Edited that was previously Auto Adjudicated, the following message is displayed when the record is saved 32

33 V6.5.3 AA Enhancements New claim data element ACTION items Encounters Enables users to defined the criteria Final Adjustment Remove Existing Final Adjustment Code Values Financial Responsibility Replace Billed Amount with Contract Amount Adjust Contract Amount Down to Billed Amount Frequency Code Populate Adjustment Value with Contract Value Remove Capitated check mark from Claim Detail

34 V6.5.3 AA Enhancements New claim data element CRITERIA items Service Header Date From Service Detail Date From HP LOB Provider Payment Type Provider Status Adjustment Code Category Service Type Change from P to H Service Type Change from H to P Date of Service Prior to Member s From Date Date of Service After Member s To Date

35 V6.5.3 AA Enhancements New claim data element CRITERIA items Multiple Specialties Member Status Member Patient ID Provider UDFs Sub Account Carrier # Locality #

36 V6.5.3 AA Enhancements New Authorization data element ACTION items Final Adjustment Code Remove Existing Final Adjustment Code Values Financial Responsibility Replace Usual Charges with Contract Amount

37 V6.5.3 AA Enhancements New Authorization data element CRITERIA items Auth Action Header Date Auth Action Detail Date HP LOB

38 V6.5.3 AA Enhancements New Features/Functionality Overlapping Rules # #, ability to view conflicting rules Master Rules Similar to Benefit Rule Master Rules Many new operator values Modified logic when different rules are hit for different lines for changing status value New Query Builder data elements Other miscellaneous changes New Rule sequence logic

39 Auto Adjudication Worksheet Start with a simple rule by defining the rule on paper Step 1 Creating a Rule Set : Description : Date : Define the rule : Step 2 Define the Action to take place Change Status to : Apply Adjustment Code: Step 3 Criteria that will trigger the rule Service Code = All Diagnosis Code = Age > = Age <= Set up the Rules in the system. Let the rule run for a week and monitor the output before adding more Rules. 39

40 EZ-CAP Auto Adjudication Questions? 40