HCFA 1500 Billing Export

Transcription

1 Procura Health Management Systems Contact Procura Corporate Office: 1112 Fort St, Suite 600 Victoria, BC Canada V8V3K8 Phone: FAX: Software version Procura 7 Documentation version Last Update Date Maintenance Guides Maintenance of Assessments, Maintenance of Reference Numbers, FARLs and ERLs, Maintenance of Billing, Maintenance of Funders,

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4 Table Of Contents HCFA 1500 Billing Export... 5 Billing Rate Records... 5 Diagnosis... 6 Funder Agency Reference Labels... 7 Funder Client Reference Labels... 7 Funder Departments... 8 Rebilling for Services... 9 Reference Numbers Retroactive Billing Claims The HCFA 1500 Billing Export Form To Run the HCFA Billing Export Appendices Valid Billing Rate Values for the HCFA 1500 Billing Export Billing Information To Create and Configure your Profile To Transmit your Billing Files to DSHS MACNET Using HyperTerminal To Perform Billing Adjustments for Retroactive Billing Records To Perform Billing Adjustments for Rebilling of Services iv

5 HCFA 1500 Billing Export Billing Rate Records In order to store the required reporting information in the billing codes fields, your System Administrator must define Billing Rate Records in the Billing Rates table for your HCFA funder. The Statutory Holiday Billing Codes are the same as the Regular Billing Codes. The Regular Rate Billing Code is used to store values for multiple HCFA fields based on the position of the value in the field. The first character in the Billing Code refers to the type of services; the second characters refers to the place of service; characters 3-7 refer to the procedure code. 5 of 26

6 Diagnosis The HCFA 1500 Billing export requires the ICD-9-CM diagnosis codes to be imported into Procura, and then attached to the client records. The Diagnosis tab in the Client Information form does not have a dedicated Priority field to indicate a primary/secondary diagnosis. Therefore the Intervention box has been adapted to suit this purpose. You must report all Primary (P) diagnosis by typing a P in the Intervention box. For Secondary (S) diagnosis, you can type an S in the box. 6 of 26

7 Funder Agency Reference Labels Prior to running the HCFA 1500 Billing export utility, your System Administrator must create two Funder Agency Reference Labels (FARLs). One Customer Type FARL must be defined for all HCFA funders and another for all insurance company funders. Keep in mind that insurance companies will not be the recipient of the billing export file. However, they may be defined as source or target orders for billings for which the recipient of the billing export file is involved. In other words, a funding agreement might have been arranged between the state and the insurance companies. Alternatively, the state might require billing to be directed to the insurance company first, and then uninsured services, (i.e., overages), would be directed to the state using the export. Funder Client Reference Labels Prior to running the HCFA 1500 Billing export utility, your System Administrator must create the required Funder Client Reference Labels (ERLs). A PAR ERL must be defined for the funder who is the recipient of the billing export. The value will be defined in the client order. A Total Billed ERL can be defined for retroactive billing from an insurance company. This amount will only be entered in cases where an insurance company has denied all, or a portion, of a claim and the service provider has obtained approval for payment from the HCFA funder. The amount is entered as it is represented on the invoice. Keep in mind that retroactive billing will always be drawn from a separate order. 7 of 26

8 Funder Departments Your System Administrator must ensure that, for all Funder Departments that will receive the HCFA 1500 Invoice, the HCFA 1500 Paper Invoice is defined as the preferred invoice type. 8 of 26

9 Rebilling for Services Sometimes, services that were directed to the HCFA funder are rejected when the original electronic invoice file is submitted. In order to support the Rebilling for Services, Procura supports the entry of billing adjustment records. Keep in mind that, if you export Procura billing data to an accounts receivable, the original insurance company order will have an outstanding accounts receivable balance for the claim. Therefore, we recommend that you reverse the balance for the insurance company and ensure that an accounts receivable account exists for the DSHS (HCFA) claim. The next accounts receivable export will transmit the claim amount to accounts receivable for the appropriate accounts receivable account number. When you receive approval to rebill for the claim, you must enter it into the Billing module for the client. Keep in mind that you should complete all other billing activities for the client for your current billing period prior to entering the billing adjustment for the rebilled claim into Procura. This will ensure that it is retained when you run your HCFA billing export. You must have an open billing batch and billing period for the HCFA funder prior to entering your billing adjustment for the rebilled claim. DSHS can reject a billing record for a number of reasons. You can obtain clarification of the reasons for a rejection by reviewing your remittance advice or by contacting your DSHS claims contact. When you determine the reason for the rejection, correct the source data in Procura. This might require you to review and verify the required fields that are passed to DSHS, including Gender, Client ID (PIC), Birth Date, Client Indicator, Referral Source, Primary Diagnosis Code (ICD-9) and Secondary Diagnosis Code. Then, edit the order for those records that were rejected. Ensure that the Start Date is equal to the Prior Authorization Date and the Stop Date is equal to the date the insurance company stopped paying for service. The order references should include Total Billed, (i.e., the total amount that was billed to the insurance company), and PAR, (i.e., the Prior Authorization number). 9 of 26

10 Reference Numbers Two Reference Numbers are required to support the HCFA 1500 billing export: The Patient Identification Code, which could appear on a client s Medical Assistance Identification (MAID), as well as the Client Indicator. Your System Administrator must define these reference numbers in the master table. The Unique Value box should be checked for the Patient Identification Code but not checked for the Client Indicator. The No Free Form (Lookup only) should be checked for the Client Indicator but not for the Patient Identification Code. Keep in mind that they must also define a lookup table to support this Client Indicator reference number for which the following values are valid: Value B G I Q Description Baby using the Parent s PIC TPR Bypass for MNCP Involuntary Treatment Act Claim Take Home / School / Camp / Wk-end / Meds 10 of 26

11 Retroactive Billing Claims In order to support the rebilling of services that were originally directed to an insurance company, Procura supports the entry of retroactive billing records. The intent is to support the denial of payment by an insurance company from the health services provider after the services have been performed. The provider must then arrange for a state Medicaid claim to be made. Keep in mind that, if you export billing data to an accounts receivable and the rebilled claim is for an amount that is different from the original claim, the original billing amount will have an outstanding accounts receivable balance for the claim. We recommend that you reverse the balance for the insurance company and ensure that an accounts receivable account exists for the DSHS (HCFA) claim. The next accounts receivable export will transmit the claim amount to accounts receivable for the appropriate account number. In order to support a Retroactive Billing Claim, you must create a separate order in your client record for your DSHS funder. This is required because the claim must be submitted as an independent item in the billing record, in addition to billing for the current period. This procedure also allows you to organize the retroactive billing claim from any current period claims in your Accounts Receivable application. You can enter the order for the retroactive claim at the time you initiate contact with DSHS. It will then be retained in the client record when you receive approval to submit the claim. Set up the client profile to support billing to DSHS. Include Gender, Client ID (PIC), Birth Date, Client Indicator, Referral Source, Primary Diagnosis Code (ICD-9) and Secondary Diagnosis Code. Create an order for the client whereby the Start Date is equal to the Prior Authorization Date and the Stop Date is equal to the date the insurance company stopped paying for service. The order references should include Total Billed, (i.e., the total amount that was billed to the insurance company), and PAR, (i.e., the Prior Authorization number). When you receive approval to bill for a retroactive claim, you must enter the claim into the Billing module for the client. You must have an open billing batch and billing period for the HCFA funder prior to entering your retroactive billing adjustment. Keep in mind that you should complete all other billing activities for your current billing period, prior to entering retroactive billing into Procura. This will ensure that the retroactive claim is retained when you run the HCFA billing export. 11 of 26

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13 The HCFA 1500 Billing Export Form The HCFA 1500 Billing Export form enables you to use the HCFA 1500 Billing export utility to transfer billing information into the HCFA 1500 file format so you can submit it to the Washington State Department of Social & Health Services (DSHS). This utility was designed to support the specifications that have been defined by their Health and Recovery Services Administration. When you are ready to invoice, you can create an invoice run and attach to it your insurance company funders and the billing periods for DSHS. Then, you can run paper invoices for the applicable funders, (e.g., insurance companies), and create your electronic billing submission using the export utility. The utility provides for a trial mode, which verifies that all client and billing setup has been completed correctly, prior to running the final export. The claim batches are color-coded in a table to differentiate between those that are Open, Calculated, Invoiced and Closed. Once you have exported your billing information to a HCFA 1500 file, you can connect to DSHS MACNET using BBS connection software, such as Windows HyperTerminal, and then submit it to DSHS. Keep in mind that, prior to running the export utility, you must complete all Timekeeping activities and close those Timekeeping periods that have the same timeframe as your new billing periods. You can then create the billing batch for your billing month and calculate it. It is also recommended that you read the Electronic Billing Guide that is downloadable from Washington State Department of Social & Health Services. Batch (activates a drop-down box that enables you to specify the billing batch you want to work with) (this box is only available if Medicaid is selected from the Claim Type box) Show All (displays in a table all records that pertain to the specified billing batch) (this box is only available if Medicaid is selected from the Claim Type box) Specific HCFA Funder (activates a drop-down box that enables you to specify the geographical location you want to work with) (this box is only available if New Claim Batch is selected from the Claim Batch box) 13 of 26

14 Client ID (PIC) (the code by which you refer to your client, i.e., Patient Identification Code) Generate Client ID (specifies that you want the Patient Identification Code to be generated during the export) Client Indicator (the code by which you refer to your client, i.e., HCFA Client Indicator) Submitter ID (the identification number by which you refer to your organization) Provider No. (the number by which the funder refers to your organization) Claim Type (the code by which you refer to the type of claim you are submitting) Generate Order Acct# (specifies that you want the Order Account number to be generated during the export) Validate Authorization No. (PAR) (specifies that you want the export to ensure that the Prior Authorization Reference number is valid prior to running) Tax 1 (the billing code for Tax 1) Tax 2 (the billing code for Tax 2) Grouping/Rounding Options (specifies that records will be grouped during the export, based on 15 minute units, rather than on 1 hour units, which is the default) Validate DM Quantity - Reject Fractions (specifies that only hour-based units will be accepted during the export) File Name (the name of the text file in which you want your information to be stored) Path (the location in which you want your reports and results to be stored) Flag Records as Exported (identifies those billing records for which HCFA is the target funder as having been exported) Ignore Previously Exported Records (excludes from the export those records that have already been exported) Generate New Invoice # (specifies that new invoice numbers will be generated during the export) Trial (enables you to run a trial version of the export, prior to running the actual export) Final (enables you to run the export) (if the Generate New Invoice # box is unchecked, the invoice numbers that are generated during the trial export run are retained and used for the final export run) 14 of 26

15 Execute Batch File (activates a button that enables you to browse for the location of a batch file that will be executed when the export is run) Keep DOS Window Open (specifies that the DOS window will remain open when the export is run so you can execute DOS commands to transfer other files) Display Export Results (specifies that, when the export is complete, the results will be displayed) Display Billing Support Form Print Details (specifies that the details of the export will be printed after it is run) 15 of 26

16 To Run the HCFA Billing Export 1. Go to Imports/Exports Billing HCFA 1500 Billing Export. The HCFA 1500 Billing Export form displays. 2. From the Batch drop-down box, select the billing batch you want to work with. 3. If you want to work with all billing batches, click the Show All checkbox. Otherwise, if you want to work with a specific batch, click the Specific Billing Batch checkbox, and then select from the drop-down box the type of batch you want to work with. 4. Click the checkboxes in the table that correspond to the batches you want to work with. 5. If you have used Order Rules to support insurance company billing, select the billing periods for those insurance companies. 16 of 26

17 6. If you want to work with a specific funder, click the Specific HCFA Funder checkbox, and then select the funder from the drop-down box. 7. From the Client ID (PIC) drop-down box, select the client reference number that corresponds to the client identification number. 8. If you want to generate PICs for clients who do not have them, click the Generate Client ID checkbox. 9. If you use a client indicator, click the Client Indicator checkbox, and then select the client reference number that corresponds to the indicator value. 10. In the Submitter ID textbox, type the submitter identification number. 11. In the Provider No textbox, type the provider number. 12. From the Claim Type drop-down box, select P, (i.e., for Home Care). 13. If your state requires you to bill taxes to DSHS, specify the applicable information in the Tax s Bill Codes section. 14. In the File Name text box, type a name for your file. 15. Click the button in the Export Options section, and then browse for the location in which you want your reports and results stored. 16. Click the Flag Records as Exported checkbox. 17. Click the Generate New Invoice # checkbox. 18. In the Invoicing section, select the Trial option. 19. If you want to continue to transfer files using DOS commands after the export is run, click the Keep DOS Window Open checkbox. 20. Click the button in the Transmission Batch File section, and then browse for the location in which the transmission batch file exists. 21. Click the applicable checkboxes in the Print Reports section. 22. Click Validate to check for errors in the assessment. 23. When you have corrected your validation errors, select the Final option in the Invoicing section. 24. Click Export. 17 of 26

18 Appendices Valid Billing Rate Values for the HCFA 1500 Billing Export Position Description Position 1 Position 2 Position 3-7 Type of Services Valid Values: 3 Practitioner HCFA Dental/ (1-88) 9. Medical vendor/supply HCFA-1500 Z Practitioner Ambulatory Surgery R Medical Vendor HCFA-1500 Place of Service Valid Values: 1. Inpatient Hospital 2. Outpatient Short Stay Hospital 3. Office or Ambulatory Surgical Center 4. Client s Residence 5. Emergency Room 6. Congregate Care 7. Nursing Facility (formerly ICF) 8. Nursing Facility (formerly SNF) 9. Other Procedure Code The Procedure Code is a five-character description of the services performed. 18 of 26

19 Billing Information Cell 24 of the invoice contains the billing information and provides up to six lines for reporting billing information. Therefore, if more than six lines are required, a second page will be required. The invoice will group each line by the billing code. Column A Start and Stop Dates Column B Place of Service Column C Type of Service Column D Procedure Code Represents the start and stop dates according to the first and last billing record created in range. The Place of Service will be identified in the Billing Code of the Billing Rate Record for all rates attached to Funders receiving the HCFA invoice format. The Place of Service is represented by one character and it will take Position 2 of the billing code. The Type of Service will be identified in the Billing Code of the Billing Rate Record for all rates attached to Funders receiving the HCFA invoice format. The Type of Service is represented by one character and it will take Position 1 of the billing code. The Procedure Code will be identified in the Billing Code of the Billing Rate Record for all rates attached to Funders receiving the HCFA invoice format. The 3-7 position of the billing code will represent the Procedure Code. 19 of 26

20 To Create and Configure your Profile In order to connect to DSHS MACNET, you must create a connection profile. The profile can be saved and will then be available for use with subsequent connections. Create your connection profile on the PC that has HyperTerminal and your MODEM installed. You will need to have the following information available at the time that you create your profile: The DSHS MACNET MODEM phone number, the MODEM speed (baud rate) for the MACNET MODEM (e.g. 9600) and the DSHS MACNET password. 1. Load HyperTerminal (click the Windows Start Button Programs Accessories Communications, select HyperTerminal and run the HYPERTRM.EXE program). 2. Name your connection and select an icon. 3. Click OK. 4. Enter the Country Code, Area Code, and Phone Number for the DSHS MACNET MODEM line. 5. Select the MODEM that is attached to your PC (it should default to the correct setting). 6. Click OK. The Connect is displayed. 7. Click Modify. This will display the properties of your connection profile. 20 of 26

21 8. Check the Redial on busy option. 9. Click Configure. This will display the MODEM properties that will be used for this connection profile. 10. Select the correct MODEM speed (Maximum speed) based upon the maximum speed that the DSHS MACNET system will support. 21 of 26

22 11. Click OK to return to the connection profile properties. 12. Click OK to save the settings of your connection profile. You will be returned to the Connect form. 13. Click Dial. Your MODEM should dial out and connect to MACNET. 14. Enter the MACNET Password. 15. Press the Enter key. You will be logged onto MACNET. 16. From the File menu, select Save As. Make note of the drive, folder (path), and file name where the connection profile is stored. 22 of 26

23 To Transmit your Billing Files to DSHS MACNET Using HyperTerminal 1. Load your HyperTerminal connection profile. By default it is stored in a location that is accessible by clicking Start Programs Accessories Communications HyperTerminal. The Connect form will be loaded. 2. Click Dial. Your MODEM should dial out and connect to MACNET. 3. Enter the MACNET password. 4. Press the Enter key. If your login is successful, the MACNET menu system will be displayed. 5. Type 4 to select XMODEM as your transmission protocol. Note: MACNET and HyperTerminal both accept several connection protocols. 6. Type the file name that you will be transmitting and press the Enter key. The Send File window displays.. 23 of 26

24 7. Click Send. 8. Browse for the billing file that you created when you used the HCFA 1500 billing export program. 9. Select a transmission protocol (e.g. XMODEM). 10. Click Send. MACNET will confirm the transmission and ask if you wish to send another file. 11. If you want to send another file, type 1 and press Enter. You will then be prompted to type the file name, after which you can click the Send button again and proceed with your selection of the new file. 12. When you have finished sending files, type 2 and press Enter. 13. When you have finished transmitting type 9 and press Enter to disconnect. 24 of 26

25 To Perform Billing Adjustments for Retroactive Billing Records 1. From the Billing menu, select Details. The Billing Details form displays. 2. From the Batch drop-down box, select the current billing batch. 3. From the Client drop-down box, select the client for whom you want to enter the claim. 4. From the Period drop-down box, select the current billing period for your HCFA funder. 5. Click Add Adjustment. The Billing Adjustment window is displayed. 6. From the Target Order drop-down box, select the order you created for submitting the retroactive billing claim. 7. From the Service Type drop-down box, select the service type that corresponds to the billing code for your claim. 8. In the Duration and Units textboxes, enter the duration and units for the record. 9. If you want to establish a cross reference between the original claim order and the HCFA claim order, and you want to define the original insurance company as the source order, click the Source Order checkbox, and then select the order from the corresponding drop-down box. 10. Click OK to return to the Billing Details form. The record is displayed in green. 25 of 26

26 To Perform Billing Adjustments for Rebilling of Services 1. From the Billing menu, select Details. The Billing Details form displays. 2. From the Batch drop-down box, select the current billing batch. 3. From the Client drop-down box, select the client for whom you want to enter the claim. 4. From the Period drop-down box, select the current billing period for your HCFA funder. 5. Click Add Adjustment. The Billing Adjustment window is displayed. 6. From the Target Order drop-down box, select the order you created for submitting the retroactive billing claim. 7. From the Date drop-down box, select the billing date. 8. From the Service Type drop-down box, select the service type that corresponds to the billing code for your claim. 9. In the Duration and Units textboxes, enter the duration and units for the record. 10. Click the Source Order checkbox, and then select from the corresponding drop-down box the order that is specified in the Target Order box. 11. Click OK to return to the Billing Details form. The record is displayed in green. 26 of 26