HEALTH INFORMATION SYSTEM (HIS)

Transcription

1 Your PHLive environment and How To document screenshots may not always match due to the dynamic nature of HIS. If any modification to the system impacts the process outlined in this document, an updated How To document will be available through the HIS Website. This guide provides support for re-billing claims denied by Medicaid in HIS. The process of re-billing in HIS is a two step process. The first step is assigning the service for re-billing. Once the service is assigned for re-billing, the next step is to include the re-billed service in your electronic 837 file. NOTE: If you have questions related to denied Medicaid services and if the service qualifies for rebilling, please address your question to the appropriate person (i.e., state billing contact). The following forms are used within this process: Electronic Re-Billing Service Assignment Use this form to assign previously claimed services for re-billing on the 837 Professional. Electronic Billing Use this form to generate an 837 Professional electronic billing file. In this guide, you will learn how to: Identify the preliminary steps that should be completed prior to starting the re-billing process. Assign a service for re-billing. Identify services currently assigned for re-billing. Include re-billed services in an 837 file. Identify re-billed services on the Client Ledger. Delete a service from re-bill assignment. Verify the re-claim has been deleted from re-bill assignment. Page 1 of 13

2 1. Preliminary steps that should be completed prior to starting the re-billing process Before starting the process of re-billing your denied Medicaid service, it is important to verify that rebilling is a viable option. Step Action Determine if your local agency has any denied services. Determine why the service was denied. NOTE: Steps 2 4 should be repeated for each denied service. Determine if the cause of your denied service can be corrected. Determine if the denied service should be assigned for re-billing. Step 1: Did my local agency have denied services? Review your local agency s paper Remittance Advice (RA) to determine if any services were denied. Step 2: Why was the service denied? Data is missing or incorrect: Contract limits: Guarantor error: Denials caused by missing or incorrect data can typically be corrected and re-billed. Missing/incorrect data can occur at these levels: o Root System Code (RSC) setup o Client setup o Service recording There are legitimate reasons for a service to be denied. Such services are typically not re-billed. Examples include: o Client not eligible o Coverage limits exceeded (e.g. for T1017HI for the month) o Prior approval not in place prior to providing specialized therapy Guarantor mistakenly denied a service that should not be denied. Page 2 of 13

3 Step 3: Can the cause of the denial be corrected? If the service was submitted with all correct information and it has been rightfully denied by the guarantor, then there is nothing to correct. Follow your standard procedure to bill the service to the next guarantor. Verify that the client s Cross Episode Financial Eligibility reflects the additional guarantors (i.e., Patient Pay, SFS Adjustment and ITP Services) and transfer the balance to the appropriate guarantor. If the service was submitted with all correct information and should not have been denied, then contact the guarantor s provider services department for assistance. If the service was denied due to missing or incorrect data, then correct the error following the identified action below. Error Action For missing or incorrect RSC setup data: Each RSC is responsible for RSC setup of insurance companies in the Guarantor/Program Billing Defaults form. Please refer to the How to Set Up Medicaid Guarantor/Program Billing Defaults for CDSA guide for the specific steps needed to set up the Medicaid guarantor. NOTE: All How To resources are located on the HIS Website (Training & System Manuals > How To Help Guides). For missing or incorrect client setup data: For service entry errors: Each RSC is responsible for Client setup. Please refer to the CDSA How To Setup Cross Episode Financial Eligibility guide for the specific steps needed for setting up and managing a client s guarantor liability distribution in HIS. Access the service through Edit Service Information form and attempt to correct the service. If the service cannot be corrected using either form, then the service must be deleted and re-entered correctly. NOTE: Never delete a service to correct it if it can be changed using one of the forms identified. Deleting a service to correct it should always be the last resort. To delete a service, follow the instructions in the How To Edit a Service guide. Once the service has been properly deleted, return to original form where the service was entered (Client Charge Input (Medical Diagnosis)) and re-enter the service with the correct values. NOTE: Before submitting the re-entered service, double-check to make sure it has been entered correctly. Page 3 of 13

4 Step 4: Should the denied service be assigned for re-billing? Due to current policies of North Carolina Medicaid, services that have been deleted and re-entered in order to be corrected should not be assigned for re-billing. The re-entered service will automatically be picked up in the next, new batch file and be billed as a new service. Therefore, once the service(s) has been correctly re-entered, no further action is required to re-bill. Contact your local HIS Billing representative or DHHS.Customer.Support@dhhs.nc.gov if assistance is needed correcting a service entry. NOTE Continue to the next section if it is determined that re-billing is the appropriate action Assign a service for re-billing. Page 4 of 13

5 2. Assign a service for re-billing If you have services that do qualify for rebilling after considering the preliminary steps, the next phase is to assign a service for re-billing. The first item that must be done in HIS is to assign a service for re-bill. In HIS, the process of selecting a denied service to be electronically re-billed occurs in the Electronic Re- Billing Service Assignment form. For each service to be re-billed, you will first need to select the client of the service being re-billed. Avatar Path to Electronic Re-Billing Service Assignment: Avatar PH > Billing > Bill Production > Electronic Re-Billing Service Assignment Figure 1: Electronic Re-Billing Service Assignment 1. Enter the client s name in the Client ID field. 2. Click the Process Search button. NOTE: If there are multiple client matches, select the appropriate client from the Client ID dropdown field. 3. Select Add Claim To Re-Bill in the Add/Delete field. Page 5 of 13

6 4. Select the correct HIS claim number of the service being re-billed in the Claim Number dropdown field. NOTE: The HIS claim number of each service can be found in the Client Ledger or the Crystal Client Ledger in the Claim Number column. Figure 2: Sample Client Ledger Claim Number column identified 5. Select Exclude All in the Service Inclusion/Exclusion Default field. 6. Select 837 Professional billing form type in the Billing Form field. 7. Select Original (Admit Through Discharge Claim) in the Claim Submission Reason Code field. 8. Verify that the Claim Original Reference Number field is blank. Page 6 of 13

7 9. Click the Select Service(s) For Re-Billing button. NOTE: The Select Service(s) For Re-Billing window displays. Figure 3: Select Service(s) For Re-Billing window 10. In the Select Service(s) For Re-Billing window, select each service within this claim that needs to be re-billed. 11. Click the OK button. NOTE: You will return to the Electronic Re-Billing Service Assignment form. 12. Click the Submit button. NOTE: The Form Return dialog box displays. Click the Yes button to return to the form to generate a report for all client services assigned for rebilling or enter a new client s denied service for re-bill. When you return to the Electronic Re-Billing Service Assignment form, the fields will reset to their default settings. If you wish to exit the form, click the No button. Page 7 of 13

8 3. Identify services currently assigned for re-billing Within the Electronic Re-Billing Service Assignment form, you can generate the Electronic Re - Billing Service Assignment Report that will display all services currently assigned for re-billing. Services listed in the Electronic Re - Billing Service Assignment Report are ready to be billed in your next electronic 837 file as long as you have selected all clients in the Electronic Billing form. Figure 4: Electronic Re-Billing Service Assignment 1. Verify that the Client ID field is blank. Page 8 of 13

9 2. Click the Display Re-Bill Information button. NOTE: The Electronic Re-Billing Service Assignment Report displays. You must submit each new re-bill assignment and return to the Electronic Re-Billing Service Assignment form before it will appear on the Electronic Re - Billing Service Assignment Report. Figure 5: Electronic Re-Billing Service Assignment Report 3. Locate the service in this report and verify the service has been correctly assigned for re-billing. Page 9 of 13

10 4. Identify re-billed services on the Client Ledger Up to this point, you have assigned denied Medicaid services for re-bill and have included the re-billed services in a new 837 file. Once you selected Create Claim = Yes within the Electronic Billing process, the re-billed client service will now display on their Client Ledger. Re-billed services will display with a lower-case r suffixed to the original HIS claim number. In Figure below, two services have been re-billed since they both have a lower-case r next to the original HIS claim number. Figure 6: Client Ledger NOTE This does not apply to services that had to be deleted and re-entered to correct them. Those services are treated as new and will be assigned a new HIS claim number when billed. Page 10 of 13

11 5. Delete A Service From Re-Bill Assignment Re-bill assignments can only be deleted by Claim Number. You cannot delete individual services within the claim. To delete a service from the re-bill assignment, you will need to access the Electronic Re- Billing Service Assignment form. NOTE: You are not deleting the claim or service; only the re-bill assignment for the service. Since individual services cannot be removed from the re-bill assignment, you have to select the claim associated with the service. Figure 7: Electronic Re-Billing Service Assignment 1. Enter the client s name in the Client ID field. 2. Click the Process Search button. NOTE: If there are multiple client matches, select the appropriate client from the Client ID dropdown field. Page 11 of 13

12 3. Click the Display Re-Bill Information button. NOTE: The Electronic Re - Billing Service Assignment Report displays. Figure 8: Electronic Re-Billing Service Assignment 4. Verify the correct client s re-bill assignments are in the report. 5. Print the report. NOTE: Having a printed report available will help to ensure you select the appropriate variables, such as the correct claim number. In the printed report, you will want to locate the service(s) that need to be removed and highlight the claim number of the service. Page 12 of 13

13 6. Close the report. The Electronic Re-Billing Service Assignment form displays. 7. Select Delete Claim From Re-Bill in the Add/Delete field. 8. Select the claim number of the service to be deleted in the Claim Number drop-down field. NOTE: A client may have many claims, but only their claims that have at least one service assigned for re-bill will appear in the dropdown list. Reference your Electronic Re-Billing Service Assignment Report printout to verify the correct claim number is selected. 9. Click the Submit button. NOTE: A Warning dialog box displays verifying that you want to delete the claim number selected from the re-bill. Figure 9: Warning dialog box 10. Click the Yes button to confirm the deletion. NOTE: The Form Return dialog box displays. Click Yes to return to the Electronic Re - Billing Service Assignment form. Figure 10: Form Return dialog box You have deleted a service from re-bill assignment. To verify the service has in fact been deleted from re-bill, replicate the steps within the Identify services currently assigned for re-billing section to verify that the service is not listed on the re-bill report. ***End of Document*** Page 13 of 13