Quick Reference Guide for Part B Providers

Transcription

1 Quick Reference Guide for Part B Providers 621_0813_Professional

2 Table of Contents 621_0110 Minimum System Requirements...3 Online Help Feature...3 Getting Started Using PC-ACE PRO Submitter Setup...4 Referring Physician Setup...6 Facility Setup...7 Charges Master Setup (Optional)...8 Medicare Solo Provider Setup...10 Group Record Setup for Medicare...12 Individual Group Member Record Setup for Medicare...14 Claims Entry...16 Prepare Claims Function...21 List Claim Features...23 Reactivating Previously Transmitted Claims and Reactivation of Individual Claims...24 How to Backup PC-ACE Pro32 Claims Processing System...26 Additional Features...28 Tips and Hints...30 Coordination of Benefits...30 Medicare Secondary Payer...32 Claim-Level Entry...36 Line-Level Entry

3 Minimum System Requirements Super video graphics array (SVGA) monitor resolution (800 x 600) Windows Vista, XP, or NT 4.0 operating system Adobe Acrobat Reader Version 4.0 or later (for overlaid claim printing) Note: When the Windows large fonts display setting is enabled, the screen resolution must be 1024 x 768 or higher. The CMS-1500 claim form will not display properly at lower screen resolutions. Online Help Feature The PC-ACE Pro32 program has an online help feature that can be accessed from the PC-ACE Pro32 Claims Processing System main menu. 1. Select Help, then select Help Topics (Figure 1). Figure 1 2. Select the Index tab (Figure 2) a. To search for a particular word, type a few letters of the word. b. Select the index entry and select Display. That portion of the topic will appear. The information can be printed or read. Figure 2 3

4 Getting Started Using PC-ACE PRO From the main menu of PC-ACE Pro32 Claims Processing System, select the PC-ACE Pro32 icon (Figure 3). Figure 3 2. Select the Reference File Maintenance folder (yellow folder) (Figure 4). Figure 4 3. Enter SYSADMIN in the User ID and Password fields in the Sign On box and select OK (Figure 5). Submitter Setup Figure 5 1. Select the tab marked Codes/Misc (Figure 6). 2. Select SUBMITTER. Figure 6 3. Select the Professional button (Figure 7). 4. Select View/Update with the submitter record highlighted (Figure 7). 4

5 Figure 7 General Tab 5. Enter submitter number (e.g., NYBXXXX) in the ID field (Figure 8). 6. Enter name and address of submitter. 7. Enter phone number and contact. 8. Select Save. Figure 8 5

6 Referring Physician Setup Referring physician National Provider Identifier (NPI) record should be created for all doctors ordering diagnostic tests and consultations. 1. Select SUBMITTER on the Provider (Prof) tab (Figure 9). 2. Select New (found on bottom left of screen) (Figure 10). Figure 9 Figure Enter physician s last name, first name, and middle initial (Figure 11). 4. Enter physician s NPI number. 5. Select Save. Figure Select Close to exit Physician Information box (Figure 12). Figure 12 6

7 Facility Setup A facility record must be created for all places of service other than home and office. If a modifier QU is utilized for a health professional shortage area (HPSA) location or if there is a second provider location within the same pricing jurisdiction, a facility record will need to be created. 1. Select FACILITY (Figure 13). Select New (Figure 14). Figure 13 Figure Enter in the following fields: (Figure 15) Facility Name Address City/St/Zip NPI number for facility (only needed for purchased services and laboratory) 3. Select Save. Figure Select Close to exit the Facility Information box (Figure 16). Figure 16 7

8 Charges Master Setup (Optional) To have charges automatically populate in charge field the charges master must be set up. 1. Select CHARGES MASTER (Figure 17). 2. Select New (Figure 18). Figure 17 Figure 18 Charges Master Information 3. Fill in the following: (Figure 19) Enter procedure code in Code field. Description will automatically populate after entering procedure code. Enter money amount in Charges field. 4. Select OK. Figure 19 Repeat the above steps for each code to be entered. 5. Select Close to close the Charges Master Information box (Figure 20). Figure 20 8

9 6. Select Close to exit from the Reference File Maintenance box (Figure 21). To activate the Charges Master list do the following: Figure From the PC-ACE Pro32 Claims Processing System main menu, select File (Figure 22). 2. Select Preferences (Figure 23). Figure 22 Figure Under the General tab, select Use Charge Master Reference files for Professional procedure code lookups (Figure 24). 4. Select OK. Figure 24 9

10 Medicare Solo Provider Setup To set up an individual provider number electronically, set up must be in a ten-digit format for the NPI. Note: Instructions for group provider and individual group members set up are on pages From the PC-ACE Pro32 Claims Processing System main menu select Reference File Maintenance (yellow folder) (Figure 25). 2. Select Provider (Prof) tab (Figure 26). Figure Select New. 4. Enter the following information: (Figure 27) Figure 26 Figure 27 10

11 Field Name Information Provider Type Select Solo Practice button. Last/First/MI Enter practitioner s name. Address Enter practitioner s address. City/St/Zip Enter practitioner s city, state, and ZIP Code. Phone Enter office phone number. Contact Enter contact name for office. Provider ID/No. Use the ten-digit NPI number. LOB (line of business) Press <F2> key to show list, then select MCB. Payer ID Press <F2> key to show list, then select the appropriate payer ID. NPI Enter ten-digit NPI number. Tax ID Enter Social Security Number (SSN) or Employer Identification Number (EIN) as appropriate. Type Enter S for SSN or E for EIN. Specialty Press <F2> key to show list, then select the appropriate specialty. Type Org Press <F2> key to show list, then select the appropriate Org. Accept Assign? Press <F2> key to show list, then select the appropriate assign code. Participating? Press <F2> key to show list, then select Y or N. Signature Ind Press <F2> key to show list, then select Y or N. Signature Date Enter date electronic data interchange (EDI) agreement was signed for electronic billing. 5. Select the Extended Info tab (Figure 28). 6. Enter Clinical Laboratory Improvement Act (CLIA) number, if appropriate. 7. Enter XX in the Group ID/No. field. 8. Select Save. Figure Select Close to exit the Reference File Maintenance box (Figure 29). Figure 29 11

12 Group Record Setup for Medicare 1. Select Reference File Maintenance (yellow folder) from the PC-ACE Pro32 Claims Processing System main menu (Figure 30). 2. Select the Provider (Prof) tab (Figure 31). 3. Select New. Figure 30 Figure New Provider Options box appears with Create a completely new provider (all fields blank) button selected (Figure 32). 5. Select OK. Figure 32 12

13 6. Enter the following information: (Figure 33) Figure 33 Field Name Provider Type Group Name Address City/St/Zip Phone Fax Contact Group ID/No. LOB Payer ID Group Label NPI Tax ID/Type Specialty Type Org Accept Assign? Participating? Signature Ind Signature Date Action Select Group Practice button. Enter group name. Enter group service location. Enter group city, state, and ZIP Code. Enter office phone number. Optional field Enter office contact name. Enter ten-digit group NPI number. Press <F2> key to show list, then and select MCB. Press <F2> key to show list, then select the appropriate payer ID. Enter abbreviation to link group to individual records. Note: The group label is very important. A user-assigned identifier that is used to link the group and individuals within the group (e.g., AMD for American Medical Doctors) group label is assigned by the provider. Enter the group NPI number. Enter tax identification number and E for tax ID. Press <F2> key to show list, then select appropriate specialty. Press <F2> key to show list, then select appropriate Org Press <F2> key to show list, then select appropriate assign code. Press <F2> key to show list, then select Y or N Press <F2> key to show list, then select Y or N Enter date EDI agreement was signed for electronic billing. 7. Select the Extended Info tab (Figure 34). 8. Enter CLIA No./Mammography No. if appropriate. 9. Enter XX for the NPI in the Group ID/No Type field. 10. Select Save. 13

14 Figure 34 Individual Group Member Record Setup for Medicare 1. Highlight group record and select New (Figure 35). 2. Select the Inherit name/address information from the selected provider button. 3. Select OK. Figure Change Group Practice to Individual in Group (Figure 36) Figure 36 14

15 Field Name Provider Type Last/First/MI Provider ID/No. LOB Payer ID Group Label NPI Specialty Action Select Individual in Group button. Enter name of provider. Remove provider number, and enter ten-digit NPI number of individual. Press <F2> key to show list, then select MCB. Press <F2> key to show list, then select appropriate payer ID. Enter label used for group setup. Remove the group NPI, and enter the individual NPI number. Press <F2> key to show list, then select the appropriate specialty ID. Select the Extended Info tab (Figure 37). 5. Enter CLIA No./Mammography No. if appropriate. 6. Enter XX for the NPI in the Group ID/No Type field. 7. Select Save. 8. Select Close to exit the Reference File Maintenance. Figure 37 15

16 Claims Entry 1. Select the PROF icon from the PC-ACE Pro32 Claims Processing System main menu (Figure 38). Figure Enter SYSADMIN in Sign On box, if it appears (Figure 39). 3. Select OK. Figure Select Enter Claims (Figure 40). Figure Enter in required fields: (Figure 41) Figure 41 16

17 Field Name LOB Billing Provider Patient Control No. Information Press <F2> key to show list, then select MCB. Press <F2> key to show list, then select the appropriate provider. Press <F2> key to show list, if patient has been added previously in the Patient Selection select the patient. If the patient is not in the Patient Selection select New (Figure 42). 6. Enter in the following fields: (Figure 43) Figure 42 Figure 43 Field Name Action Last Name/First Name/MI Enter patient s name. Patient Control No (PCN) Enter patient s last name, space, first name. Or if preferred use a numbering system. Address Enter patient s address. City/State/Zip Enter city, state, and ZIP Code. Phone Optional Sex Enter M for male or F for female. DOB (date of birth) Enter the date in the MM/DD/CCYY format. SOF (signature on file) Press <F2> key to show list, then select the appropriate code. Release of Info (ROI) Press <F2> key to show list, then select the appropriate code. ROI Date Enter date released signed or earliest date billing was made on this claim. 17

18 7. Note: Do not select Save. 8. Select the Primary Insured (Prof) tab (Figure 44). Figure Enter the following information: (Figure 44) Field Name Action Payer ID Press <F2> key to show list, then select the appropriate payer. Rel (relationship to insured) Enter 18 for self. Enter 01 for spouse. Enter 19 for child. Insured ID Enter Medicare Health Insurance Number or subscriber number. Assignment of Benefits Enter Y for yes or N for no. 10. Select Save. 11. The Professional Claim Form box will appear (Figure 45). 12. In box 10 enter N for condition related to employment and N for condition related to an accident. 13. In box 20 enter N for outside lab charges not included in claim or Y for outside lab charges included in claim. 14. If billing for a place of service other than home, office, or using a modifier QU, enter a Y in Facility? field. 18

19 Figure When the Facility Setup box appears press the <F2> key for the facility information (Figure 46). 16. Select the facility. Note: Additional facilities may be added by selecting New, then adding the facility data, and then selecting Save. Figure 46 19

20 17. Select Billing Line Items tab (Figure 47). Figure Enter the following information: (Figure 47) Field Name Action Claim Diagnosis Codes Enter up to four diagnosis codes. Service Dates Enter dates of service. PS (place of service) Press the <F2> key to show list, then select the appropriate value. TS (type of service) Leave field blank. Proc (procedure code) Enter procedure code. Modifiers If necessary, press the <F2> key to show list for appropriate values, then select modifier. Diagnosis Enter values 1 4. Charges Enter charge. Note: When entering a charge that includes cents, a decimal point is required (e.g., $12.01, $25.24). Units Only enter field if more than one unit. Rendering Phys. If billing in a group, press the <F2> key to show list of rendering providers of service. 19. Select Recalculate (Figure 47). 20. Select Save. 21. Resolve any edits if prompted. 20

21 Prepare Claims Function Medicare claims must be prepared and transmitted using communication software before another batch can be prepared. Failure to follow these instructions will overwrite the previous claim file. When ready to prepare claims for transmission, do the following: 1. Select PROF from PC-ACE Pro32 Claims Processing System main menu (Figure 48). 2. Select Prepare Claims (Figure 49). Figure 48 Figure The Professional Claims Prepare For Transmission box appears (Figure 50). 4. Select Prepare Claims. Figure The Confirm box appears and says, Ready to prepare selected Professional claims for transmission? (Figure 51). 6. Select OK. Figure 51 21

22 7. The Information box appears and says, The claim operation has completed successfully. (Figure 52). 8. Select OK. Figure The Claim Prepare For Transmission box appears (Figure 53). 10. Select View Results. Figure PC-ACE Pro32 Transmission Detail Report will appear. To print this report select the print icon (top of tool bar, to the left of Close). This report does not confirm the transmission of claims. The claim file must then be transmitted via the network service vendor (NSV) (Figure 54). Figure The preparation of claims has now been completed. Prepared claims must be transmitted. Continue to the transmission process. Using the NSV s software 22

23 List Claim Features 1. Select the PROF Processing icon from the PC-ACE Pro32 Claims Processing System main menu (Figure 65). 2. Select List Claims (Figure 66). Figure 65 Figure Enter the following information in the Claim List Filter Options box: (Figure 67) Figure 67 Location field Select down arrow on right and select option to narrow search (Figure 68). Figure 68 Status field Select down arrow on right, and select desired status (Figure 69). Figure 69 23

24 Reactivating Previously Transmitted Claims and Reactivation of Individual Claims To resubmit a transmitted claim, these claims must first be reactivated. Only claims in the transmitted (TR) location may be reactivated. 1. Select the PROF icon from the PC-ACE Pro32 Claims Processing System main menu (Figure 70). Figure Select List Claims (Figure 71). Figure Select Location (Figure 72). 4. Select CL (to be transmitted). 5. Select TR (transmitted only). Figure Check one claim or several claims to be reactivated. 7. Select Actions (Figure 73). 8. Select either Reactivated Claim (if only one claim) or Reactivate All Checked Claims (for more then one claim). 24

25 Figure The Confirm box appears (Figure 74). 10. Select OK to reactivate claim/claims. Figure Change Location field to CL to be transmitted (Figure 75). Figure 75 25

26 12. Reactivated claims will be listed with a status of UNP. These must be corrected before sending. 13. Double click the claim to open and make the necessary corrections (Figure 76). 14. Select Save. Figure The claim status will change to CLN. These claims are now ready to be prepared and transmitted. How to Backup PC-ACE Pro32 Claims Processing System Each time the program is exited the following message will appear: Perform System Backup? An external backup file of the program must be maintained in the event a fatal system crash occurs. 1. To do this, the backup may be placed on the desktop by selecting the Browse button and choosing the hard drive (system C) and desktop (Figure 77 and 78). Figure 77 Figure 78 26

27 2. This will put the backup file named PCACEPBK.ZIP on to the desktop (Figure 79). Figure From the desktop, save to a CD-ROM or flash drive. This external device must be maintained to assure the restore capabilities in the event of a fatal system crash. 4. Select My Computer on the desktop and drag the PCACEPK.ZIP file from the desktop to the CD-ROM and then burn it, or drag to the flash drive (Figure 80). Figure 80 27

28 Additional Features Copying Claims To bill claims that are identical (e.g., same patient, same procedures, etc) except for the dates of service, instead of creating a new claim each time, simply copy the previous claim, enter the correct dates of service, and save it. 1. In the Professional Claims Menu window, select List Claims. 2. In the Professional Claim List window, in the bottom left section of the screen, choose the Location of TR transmitted only. 3. Put a check mark in the box in front of the claim(s) to be copied. 4. On the Actions Menu, select Copy All Checked Claims. 5. Select OK in the confirmation window. Note: If only one claim is chosen to copy, the Professional Claim Form will be displayed instead of the Professional Claim List window. Change the dates of service and save the claim. 6. In the bottom section of the window, select the Location of CL to be transmitted. The claims will be listed and have a status of UNP. 7. Double-click each claim in turn, enter new dates of service 8. Select Save. Reactivating an Entire Batch of Claims Changes cannot be made to a batch of claims that has been reactivated. This operation will restore the batch of claims so that it can be retransmitted. To make changes to already-transmitted claims, see the section titled Reactivating Claims. 1. In the Professional Claims Menu window, select the Maintain Menu 2. Select Transmission Log. The Professional Claims Transmission Log window will be displayed. 3. Select the batch of claims to reactivate. To see a summary of what is in the batch, highlight the line, then select View Details. 4. Once the batch of claims is determined to reactivate, highlight the line and select the Reactivate button. 5. Read each window that pops up, then select OK in each. 6. Transmit this batch before selecting the Prepare Claims button. Archiving Claims Archiving claims in PC-ACE Pro32 improves performance and helps prevent database corruption. 1. Select the Prof button on the main toolbar. 2. Select the List Claims button. 3. Select the File Menu 4. Select Maintain Claim Archives 5. Select the New button and enter a name for the archive 6. Select OK. 7. Select the Close button. 8. The Professional Claim List window will appear. 9. In the Claims List Filter Options section at the bottom of the Professional Claim List window, select the drop down arrow and select TR-transmitted only. 28

29 10. Select the Advanced Filter Options button near the bottom of the Professional Claim List window, and enter the filter criteria. Example: If today s date is March 13, 2009, to archive everything except the past three months, do the following: Check the box in front of Invert filter logic at the bottom of the Advanced Claim List Filter Criteria window. Enter 01/01/2009 in the first box in the Transmit Date: field, then enter 3/13/2009 in the second box. Select OK. The Professional Claim List window appears and the only claims displayed are those that were transmitted more than three months ago. These are the claims to be archived. 11. Select the Filter Menu and select check all claims. Each claim now has a checkmark in the box at the left of the line it is on. 12. Select the File Menu and select Open Claim Archive 13. Double-click the archive that was created in the steps above. An information window will pop up. Read the contents, then select OK. 14. Select the Actions Menu and select Archive All Checked Claims (near the bottom of the Actions menu.) Do not select Archive Selected Claim, as that will only archive the claim that is highlighted. 15. An information window will appear. Read the contents, then select OK. 16. The claims are no longer shown in the list. They are not gone, they have been stored in the archive. To see these claims, select the File menu, then select View Archived Claims. Note: Do the following to view these claims again once PC-ACE Pro32 has been exited: Open the claims list Select the File Menu and select Open Claim Archive. Double-click the archive to view, read the information in the pop-up information window, select OK. Select the File Menu and select View Archived Claims. To see current claims, select the File Menu and select View Current Claims. Transferring PC-ACE Pro32 to Another Computer 1. On the old computer, upgrade PC-ACE Pro32 to the current version. 2. On the new computer, install the full installation of the current version from our Web site. 3. On the old computer, open PC-ACE Pro On the main toolbar, select the last button, which has a gear and a wrench on a French flag. 5. Sign in. The System Utilities window is displayed, the Backup/Restore tab should be selected and the Backup sub-tab displays the text This utility performs a backup 6. Select the small button with three dots on it at the right end of the Destination Drive or Folder field. 7. In the Select Backup Destination Directory window, select the drop down arrow at the right end of the Look in field, select Desktop at the very top of the list, then select the Open button. The System Utilities window will appear. 8. Select the Start Backup button and select OK in the Confirm window. 9. After the backup operation completes, the Information window will appear. If the text says The backup operation has completed successfully, select OK. Note: If the text indicates that the backup failed, please contact the National Government Services EDI Help Desk at (888)

30 10. In the System Utilities window, select the Validate sub tab, browse to the computer s desktop as in the earlier steps, then select the Start Validate button 11. Select OK in the Confirm window. 12. When the validation is complete, the Information window will appear with the text The validation operation has completed successfully: Note: If the text indicates that the validation failed, please contact the National Government Services EDI Help Desk. 13. Select OK in the Information window 14. Select the Close button in the System Utilities window. 15. The back up file on the computer s desktop is named PCACEPBK.ZIP. Copy this file to the desktop of the new computer. 16. On the new computer, open PC-ACE Pro On the main toolbar, select the last button, which has a gear and a wrench on a French flag (as directed above). 18. Sign in. The System Utilities window will appear and the Backup/Restore tab should be selected and the Backup sub tab displays the text This utility performs a backup 19. Select the Restore sub tab, browse the computer s desktop, and select the Open button. Do not select the file, because the program knows the file name already. 20. Continue with the restore, following the prompts. Once it is complete, PC-ACE Pro32 on the new computer is identical with what was on the old computer. Tips and Hints Pressing the <F1> key while a PC-ACE window is open will display the online help for the active window. A right-click in many fields will display a list of valid values for that field; select the value to insert. Pointing at a field with the mouse cursor will briefly display a description of what goes in that field. When entering certain procedure codes in the Billing Line Items window causes a new sub tab to appear at the right end of the billing line items sub tabs (e.g., podiatry or chiropractic procedure codes that require more information.) The tab is line-item-specific, so if there are two lines, each with a code requiring more information, the tab will appear for each line, and must be filled out with each line. To make the tab visible for a line, select in any field on that line. When entering billing line items, to copy information from the field or line directly above a field or line, select on the field or line to copy to, then press the <F4> key to copy the value directly above the field, or press the <F5> key to copy everything from the line above except the dates of service. Coordination of Benefits The Professional Claim Form includes fields to allow entry of coordination of benefits (COB) information at the claim or line adjustment level. Claims submitted to secondary payers may be required to report the payment remittance data returned by prior payers. Medicare Secondary Payer (MSP) claims must include specific COB information obtained from the primary payer in order to ensure prompt processing by Medicare. This information can be reported either in the claim-level adjustment or line-level adjustment. Do not use claim-level adjustments and line-level adjustments on the same claim. 30

31 Examples Claim level: When there is only one line of service or on rare occasions when all the lines of service are the same except the date. Line level: When there are multiple lines of service to be billed. Both instructions are enclosed. The COB screens are hidden to minimize confusion. 1. To show the COB screens on the claims, enter a Y in the COB? field located at the bottom right of the Patient Info & General tab (Figure 81). Figure This will trigger the display of primary and secondary claim level COB Info sub tabs from the Extended Payer/Insured tab and line-level MSP/COB tabs on the Billing Line Items tab (Figure 82). Figure 82 All COB-related data is entered on these tabs. The explanation of benefits (EOB) summary or remittance notification from the primary carrier are needed in order to fill in the information in the required fields. 3. Select <F2> key or right click the mouse to access help to find out what information is to be entered in the associated field (Figure 83). 31

32 Figure 83 Medicare Secondary Payer Claim-Level Adjustment Entry When entering a claim for MSP the EOB or remittance from the primary insurance carrier is needed in order to enter the information that is necessary on the screens. This information is necessary for Medicare to process the secondary claim. To start the secondary claim, enter the primary payer and patient data (Figure 84). Fiqure 84 Adding a Primary Payer 1. Open the PC-Ace Pro 32 program and click on the Reference File Maintenance Icon (Figure 85). Figure Select the Payer tab (Figure 86). 3. Select the New button. 32

33 Figure Filled in the following fields: (Figure 87) Figure 87 Field Name Payer ID LOB Full Description Source Media Usage Action Type the insurance ID (99999 can be used if the ID is not known). Press the <F2> key and pick appropriate code. Type the name of the primary insurance company. Click in the field, press the <F2> key and pick appropriate code. Click in the field, press the <F2> key and pick appropriate code. Click in the field, press the <F2> key and pick appropriate code. 5. Click on the Patient tab in Reference File Maintenance window (Figure 88). 6. Select the New button. 33

34 Figure Fill in the following required information for the patient: (Figure 89) Figure 89 Field Name Last Name First Name Patient Control No (PCN) Active Patient Sex DOB Signature On File Release of Info ROI Date Action Enter the patient s last name. Enter the patient s first name. Enter the Patient account number assigned by the office. Press <F2> key and select appropriate code. Press <F2> key and select appropriate code. Enter patient s date of birth. Press <F2> key and select appropriate code. Press <F2> key and select appropriate code. Enter date patient signed release of information. 34

35 8. Select Primary Insured (Prof) tab, right click in the Payer ID and pick the primary insurance for this patient. Note: If the primary insurance does not appear on the list, follow the instructions above for entering it. 9. Fill in the following fields: (Figure 90) Figure 90 Field Name Rel Insured ID Assign of Benefits Action Press <F2> key and select appropriate code Enter the ID from the insurance card Press <F2> key and select appropriate code Note: Many of the fields will auto fill from data entered on the General Information tab. 10. Click on the Secondary Insured tab and choose Separate Inst & Prof (Figure 91). Figure The tab name will change to Secondary Insured (Prof). 12. Right click in the Payer ID field and select the secondary insurance for this patient (it will be Medicare.) 13. Fill in the following fields: (Figure 92) 35

36 Field Name Action Figure 92 Rel Press <F2> key and select 18 Insured ID Enter the HICN from the Medicare card Assign of Benefits Press <F2> key and select appropriate code Note: Many of the fields will auto fill from data entered on the General Information tab. Claim-Level Entry 1. When creating a claim level MSP claim, enter the appropriate information in the Patient Info & General tab and type Y in the COB? Field (Figure 93). Figure Select the Billing Line Items tab and enter the appropriate information. 3. Select Ext. Patient/Insured tab. 4. Select the COB Info-Primary sub tab and enter the information into the appropriate fields from the EOB of the primary insurance carrier (Figure 94). 36

37 Figure Fill in the following fields: (Figure 95) Figure 95 Field Name Allowed Paid Insurance Type Zero Payment Ind Claim Level Adjustments (CAS) COB/MOA Amounts Claim Adjudication Date Action Fill in the total allowed amount which should be the same as the balance due on the Billing Line Items tab. Fill in the total amount paid. Press <F2> key for appropriate values. Press <F2> key for appropriate values. Take values from EOB or press <F2> key to select appropriate value. Take values from EOB or press <F2> key to select appropriate value. Enter date of remittance from the primary payer. Note: The paid amount and the claim-level adjustments amount (CAS) must equal the total billed charges. 6. Select Save and resolve any edits that appear. 37

38 Example In this example, the information from the EOB is entered into the Common Payer MSP Information (the balance due in the billing line items must equal the claim amount from the EOB), then details are entered in the Claim Level Adjustments (CAS) section and COB/MOA Amounts section (Figure 96). NOTE: Note: If If more lines are required, click the down arrow. Figure 96 Claim Level Adjustments Num 1 Code CO = Contractual Obligations. Num 1 Reason 45 = Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement (use group codes or CO depending on liability.) Num 1 Amount = Disallowed other from common payer MSP information Num 2 Code PR = Patient responsibility Num 2 Reason 2 = Coinsurance amount Num 2 Amount = Coinsurance from common payer MSP information COB/MOA Amounts Num 1 Code D = Payer paid amount Num 1 Amount = Paid from common payer MSP information Num 2 Code F2 = Patient responsibility amount Num 2 Amount = Coinsurance from common payer MSP information 38

39 Edits Associated with MSP Claims M384 INVALID VALUE 2300/CLM02 If there is a primary paid amount on the claim, the paid amount plus all line level and claim level adjustment amounts must equal the total claim charge. M304 REQUIRED INFO MISSING 2320/AMT If a claim level allowed amount and primary payer paid amount submitted on a claim, either the line level allowed amount or line level adjudication information is missing. M312 INVALID MSP AMOUNTS 2320/AMT If the payer being billed is the primary or secondary payer, the secondary or tertiary payer paid information cannot be submitted on the claim as the secondary or tertiary would not have paid on the claim yet. M301 REQUIRED INFO MISSING 2400/SVD The MSP claim approved amount has been submitted but the line level primary paid is missing. Line-Level Entry When entering a claim for MSP, enter the claim as a line-level adjustment entry. The EOB or remittance from the primary insurance carrier is needed in order to enter the information that is necessary on the screens. This information is necessary for Medicare to process the secondary claim. 1. Enter Y in the COB? field at the bottom of the Patient Info & General window (Figure 97). Figure Enter the billing information on each line of service 3. Select a billing line for which MSP information needs to be entered. The name of the MSP/COB Line sub tab will change depending on which billing line item has been selected (Figure 98). 39

40 Figure Select the MSP/COB (Line 1) sub tab. 5. Fill in the following fields: (Figure 99) Figure 99 Service Line Adjudication SVD Information Field Name Action P/S Press F2 for appropriate values PROC Press F2 for appropriate values Qual/Code Procedure Code Modifier Enter any modifiers (if necessary) Paid Amount Enter amount paid Paid Units Enter units paid 40

41 Line Level Adjustment (CAS) Field Name Group Reason Amount Units Adj/Payment Date Action Press F2 for appropriate values Press F2 for appropriate values Amount of adjustment Units Date of Remittance from the primary payer Note: This information must be entered for each line of service. The SVD paid amount and the line-level adjustment amount (CAS) must equal the submitted amount. 6. After entering the information for each line of service, the Ext Payer/Insured screen can be accessed. 7. Select the Info (Primary) tab. 8. Information has to be entered in the following fields: Field Name Allowed Paid Insurance Type Zero Payment Ind Action Fill in the combined total allowed amount for all services. Fill in the combined total paid amount for all services. Select <F2> key for appropriate values Select <F2> key for appropriate values 9. After the appropriate fields are filled in, select Save and resolve any edits that appear. 41