HP Systems Unit. Clear Claim Connection User Guide

Transcription

1 HP Systems Unit I N D I A N A H E A L T H C O V E R A G E P R O G R A M S Clear Claim Connection Guide L I B R A R Y R E F E R E N C E N U M B E R : S Y A P P R O C E D U R E S A S O F F E B R U A R Y 2 1, 2012 P U B L I S H E D : F E B R U A R Y 2 8, V E R S I O N 3. 0

2

3 Clear Claim Connection Guide Library Reference Number: SYAP10014 Address any comments concerning the contents of this manual to: HP Systems Unit 950 North Meridian Street, Suite 1150 Indianapolis, IN Fax: (317) Copyright 2012 Hewlett-Packard Development Company, L.P. CPT copyright 2010 American Medical Association. All rights reserved. Library Reference Number: SYAP10014 i

4 Glossary OnDemand Guide Revision History Version CO Revision Date Reason for Revisions Completed By June 2007 New manual Project team December 2011 Update to reflect system Project team changes February 2012 Update to reflect system changes Project team ii Library Reference Number: SYAP10014

5 Clear Claim Connection Guide Table of Contents Revision History... ii Table of Contents... iii Section 1: Overview Overview Section 2: Using the Clear Claim Connection Tool Accessing the Clear Claim Connection tool Entering Claim Information Overview Entering Information Viewing Claim Audit Results Section 3: Additional Information Recommendation Values Accessing Clinical Edit Clarifications Overview Requesting a Clinical Edit Clarification Additional Clear Claim Connection Submission/Error Information Submit the Claim How to Correct Errors Menu Bar Session Timeout Index... I-8 Library Reference Number: SYAP10014 iii

6

7 Clear Claim Connection Guide Section 1: Overview Overview The Indiana Health Coverage Programs (IHCP) is applying the National Correct Coding Initiative (NCCI) code auditing methodology to CMS-1500 and outpatient UB-04 claims with dates of service on or after October 1, In April 2011, the IHCP implemented additional code auditing methodologies applicable to both medical and outpatient claims. These methodologies, along with future code auditing enhancements, are critical to the IHCP to promote and enforce correct coding and accurate program reimbursement. To offer the provider community transparency and disclosure of coding rules and editing rationales, the IHCP introduced a Web-based tool, Clear Claim Connection 1, on July 1, The benefits for this tool include the following: Provides the rationale for each edit Provides policy and editing logic to improve physician and outpatient hospital coding Reduces provider administrative costs associated with claim resubmissions Gives providers access to code auditing methodologies 24 hours a day, seven days a week Note: The edit criteria do not represent claims processed through managed care entities (MCEs). Shown in this document is an example, with illustrations, of the process for entering claims in Clear Claim Connection. Also included is how to navigate to and from the web pages used during this process. 1 Clear Claim Connection, ClaimsXten, CodeReview, and the McKesson Health Solutions logo are registered trademarks of McKesson Health Solutions, Inc. All rights reserved. Library Reference Number: SYAP

8

9 Clear Claim Connection Guide Section 2: Using the Clear Claim Connection Tool Accessing the Clear Claim Connection tool Use the following steps to access the Clear Claim Connection tool. 1. Log on to Web interchange. 2. Access the Clear Claim Connection option. There are two ways to access this option: a. From the Claim Submission window: 1) Click Claim Submission. 2) In the Code Auditing section, click Clear Claim Connection. The Clear Claim Connection Tool window appears. See Figure 2-3. Figure 2-1 Additional Link to the Clear Claim Connection Tool b. From the Claim Inquiry window: 1) Access a specific claim using the Claim Inquiry option. 2) In the Helpful Hints area, click Clear Claim Connection. The Clear Claim Connection Tool window appears. See Figure 2-2. Library Reference Number: SYAP

10 Section 2: Using the Clear Claim Connection Tool Clear Claim Connection Guide Figure 2-2 Additional Link to the Clear Claim Connection Tool 3. Type your National Provider Identifier (NPI) or, if you are an atypical provider, type your Legacy Provider Identifier (LPI). Note: The first active primary Provider Specialty will be used for editing. This may affect the outcome of some of the Code Auditing. Figure 2-3 Log on to Clear Claim Connection 4. Click Continue. A Terms and Conditions window appears. 2-2 Library Reference Number: SYAP10014

11 Clear Claim Connection Guide Section 2: Using the Clear Claim Connection Tool Figure 2-4 Clear Claim Connection Terms and Conditions window 5. Review the terms and conditions statement provided, and then click the Agree button. The Initial Claim Entry window appears. See Figure 2-5. Note: The appearance of the Claim Entry window indicates successful access to Clear Claim Connection. Entering Claim Information Overview The purpose of the Claim Entry window is to collect claim information and to submit it for claim auditing results and recommendations. Before doing these steps, log on to Web interchange and access the Clear Claim Connection tool. The Claim Entry web page consists of the following set of data elements available for claim entry by a user. Library Reference Number: SYAP

12 Section 2: Using the Clear Claim Connection Tool Clear Claim Connection Guide Gender Date of Birth Facility Flag Bill Type ICD Code Set Revenue Code Procedure Table 2-1 Clear Claim Connection Data Elements Field Name Description Default Value Mod 1, Mod 2, Mod 3, Mod 4 DX 1, DX 2, DX 3, DX 4 Units Date of Service From Date of Service To Place of Service This is the member s gender; options are Male or Female This is the member s date of birth; format is mm/dd/yyyy. This indicates whether the claim is a facility or professional claim. Options are Y to indicate the claim is a facility claim or N to indicate that the claim is a professional claim. This is the type of bill. This field is only used when Facility Flag is set to Y. If Facility Flag is set to N, the field is locked. This identifies the International Classification of Diseases (ICD) code set used for processing the diagnosis codes on the claim example. Currently only ICD-9 is available. ICD-10 will be available October 1, This is the revenue code for facility claims. This is the procedure code for the claim. These are the modifiers for the claim. These are the diagnosis codes for the claim. Enter the total number of units per line. Enter the from date of service from the claim Enter the to date of service from the claim Select the appropriate place of service from the list. There is no default. This is a required entry field. There is no default. This is a required entry field. The default value is N. The default value is 131; the value can be changed. The field is required when the Facility Flag field is set to Y. The default value ICD-9. There is no default. Currently, this field is not used. There is no default. This is a required entry field. There is no default. Entry of modifiers is optional. There is no default. Entry of diagnosis is optional. However, if a rule requires a diagnosis code and you leave the field blank, you may get incorrect results. The decimal point must be used. The default is one unit. The default is the current date. The default is the current date. The default is 11-Office. 2-4 Library Reference Number: SYAP10014

13 Clear Claim Connection Guide Section 2: Using the Clear Claim Connection Tool Entering Information Figure 2-5 Clear Claim Connection Claim Entry window 1. Type the claims information: a. Select Gender then press Tab to move to the Date of Birth field. b. For Facility Flag click Y for facility or N for professional If Facility Flag is Y, Bill Type will default to 131, but can be changed. If Facility Flag is N, Bill Type will default to blank and cannot be changed. c. For ICD Code Set, allow to default with ICD-9. ICD-10 will be available after implementation of ICD-10. d. To move to other fields, press Tab. e. Type the claims information in the fields. The window provides five lines for data entry. Click Add More Procedures to add five more lines. The maximum number of lines is 10. To clear the input fields and start over, click Clear. 2. To print this page, use the Internet Explorer print command. Note: Because different versions of Internet Explorer work differently, specific steps for printing are not listed here. For assistance with printing, see the Internet Explorer Help option. 3. Click Review Claim Audit Results. The Claim Audit Results window appears. See Figure 2-6. Library Reference Number: SYAP

14 Section 2: Using the Clear Claim Connection Tool Clear Claim Connection Guide Viewing Claim Audit Results After successfully entering valid claim information, the Claim Audit Results window appears. In Figure 2-6, the recommendation for line 1 is Allow and the recommendation for line 2 is Disallow. Figure 2-6 Claim Audit Results window 1. To view additional information, click Disallow. The Clinical Edit Clarification window appears. Figure 2-7 shows a sample of the response you might receive. 2-6 Library Reference Number: SYAP10014

15 Clear Claim Connection Guide Section 2: Using the Clear Claim Connection Tool Figure 2-7 Sample Clinical Edit Clarification Response window 2. After reviewing the information, do one of the following: a. Click New Claim to return to the Claim Entry window. All claim data entered in the window is deleted, so you can start with a new claim. b. Click Current Claim to return to the Claim Entry window. The data previously typed in the window is not deleted. c. Click Review Claim Audit Results to return to the Claim Audit Results window. This option enables you to review additional lines that were disallowed. d. Click Printable Version to print this screen. e. Click Logoff to exit the Clear Claim Connection tool. Library Reference Number: SYAP

16

17 Clear Claim Connection Guide Section 3: Additional Information Recommendation Values Each procedure in the procedure information grid is accompanied by a Recommendation value. Allow Indicates that there is no edit for the procedure code(s) submitted. Allow Add Indicates that one or more additional procedure lines were added by the system during the editing of a claim. Disallow Indicates that there is an edit for the procedure submitted. For additional information on why the procedure code received this type of recommendation, review the Clinical Edit Clarification. Review Indicates that the procedure code should be evaluated against the information on the Clinical Edit Clarification to determine if the data entered and/or procedure code can be corrected prior to submission. Review may also indicate that additional information is required to process the claim. A disclaimer appears toward the bottom of the web page stating The results displayed do not guarantee how the claim will be processed. See Figure 2-6. This message indicates that factors such as member eligibility, deductions, and coordination of benefits may impact the final payment of a claim. The following are examples of reasons claims could be denied; these reasons would not be identified by Clear Claim Connection: IndianaAIM audits and edits IndianaAIM will process audits and edits prior to the claim being sent to McKesson and upon its return, which can result in denial of a claim detail. Note: The first active primary Provider Specialty will be used for editing. This may affect the outcome of some of the Code Auditing. Claims in history Claim details that have been processed and reside in history can result in denial of a claim detail. Incorrect claim type Unit restrictions Age or gender restrictions Prior authorization required Duplicate claim Program eligibility restrictions Note: The list of examples is not an exhaustive list of reasons claims a claim might be denied. Library Reference Number: SYAP

18 Section 3: Additional Information Clear Claim Connection Guide Accessing Clinical Edit Clarifications Overview After viewing the Clear Claim Connection recommendation on the Claim Audit Results window, the next step is to determine why a procedure was assigned a recommendation value of Disallow or Review. Essentially, these results mean that the procedure generated an edit during the code auditing process. Requesting a Clinical Edit Clarification While on the Claim Audit Results web page, click the link for a Disallow or Review recommendation. The words, Disallow and Review, act as the links to the Clinical Edit Clarification. Only those procedure lines that have a Recommendation value of Disallow or Review are eligible for Clinical Edit Clarification inquiries. Note: Clear Claim Connection has been developed to disclose information regarding edits generated during claims auditing. Consequently, if an edit is not generated for a procedure, a clinical edit clarification for the procedure s Allow or Allow Add recommendations are not available in Clear Claim Connection. Additional Clear Claim Connection Submission/Error Information Submit the Claim Once all pertinent information has been entered, a user submits the claim by one of the following: Clicking the Review Audit Results button Pressing the Enter key on the keyboard When the claim is submitted, Clear Claim Connection performs checks on the claim information that has been entered. Certain fields that need data and certain data elements (which users input) also require specific formats. If not entered or entered incorrectly, errors will be reported. Below is a list of conditions that would produce an error and generate a notification via a Windows pop-up message. Figure 3-1 Sample Error Message 3-2 Library Reference Number: SYAP10014

19 Clear Claim Connection Guide Section 3: Additional Information Gender Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth Date of Birth Procedure Procedure Modifier Table 3-1 Sample Clinical Edit Clarification Response Field Condition Message or System Error Value not entered in Gender field Value not entered in Date of Birth month field Value not entered in Date of Birth day field Invalid data was entered in the Date of Birth month or day field, such as a number greater than 12 for the month or a number greater than the maximum days for the associated month. Value not entered in Date of Birth year field Date of Birth year less than four digits entered. Must be four digits. Future date was entered. Must be a value less than or equal to Date of Service. Age exceeds maximum limits Date of birth is greater than the Date of Service Value not entered in Procedure field Procedure code is not valid Invalid modifier format. Value entered is not alphanumeric. Gender is a required field. Please select Male or Female. Date of Birth: Month is a required field. Date of Birth: Day is a required field. Invalid Date of Birth. Date of Birth: Year is a required field. Invalid Date of Birth. Date of Birth cannot be a future date. Date of Birth: Age cannot be greater than 120 years. Date of Birth must be less than or equal to Date of Service Procedure Code is a required field. Invalid Procedure Code [x]. Please reenter. Invalid characters, field [x]. Modifier Modifier is not valid Invalid Procedure Modifier [x]. Please reenter. Library Reference Number: SYAP System System

20 Section 3: Additional Information Clear Claim Connection Guide Diagnosis Diagnosis Date of Service Date of Service Field Condition Message or System Error Diagnosis Code is not valid Decimal is not entered with the Diagnosis Code If user input, invalid date format was entered by user Invalid date was entered, for example, 2/30/05 Invalid Diagnosis Code. Please reenter. Invalid Diagnosis Code. Please reenter. Invalid Date of Service. Please enter Date of Service as mm/dd/yyyy. Invalid Date of Service. Please enter Date of Service as mm/dd/yyyy. Server Checks that are made on the validity of the entry (for example, Procedure Code not found in the database) will return errors as informational alerts, indicating the field that produced the error. Figure 3-2 Sample message 3-4 Library Reference Number: SYAP10014

21 Clear Claim Connection Guide Section 3: Additional Information Table 3-2 Conditions that would generate an information alert Field Condition Procedure Modifier 1, 2, 3, 4 Modifier 1, 2, 3, 4 Diagnosis 1, 2, 3, 4 Diagnosis 1, 2, 3, 4 Units Procedure code is not valid Modifier is not valid Invalid characters used for Modifier entry Diagnosis code is not valid Diagnosis code was not entered with the decimal Claim submission failed. ERROR: [XML validation: Line: 34, source:, error: pattern constraint failed. The element: ''QUANTITY'' has an invalid value according to its data type. ] Table 3-3 Step action chart for responding to errors Step # Errors What to do? Additional Entry Information 1 Dismiss the error dialog box If the error message is a Windows dialog box, click OK. 2 Click the field in error and retype a correct entry in that field 3 Repeat step 2 until all field errors are corrected 4 Click Review Claim Audit Results. Or Click Clear at any time to clear all information that has been entered on the Claim Entry web page and start over. If the error message is an information alert, click one of the following: Current Claim button to return to the Claim Entry web page and edit the claim New Claim button to return to the Claim Entry web page and start anew See Additional Entry Information in Entering Claim Information of this document for more information. The claim information has been verified when the Claim Audit Results web page appears. Library Reference Number: SYAP

22 Section 3: Additional Information Clear Claim Connection Guide Menu Bar A menu bar appears just below the Clear Claim Connection banner on the web page and contains these options: McKesson Edit Development Not used by the IHCP. Help View online help for the web page that currently appears. When finished viewing the information, click Close to return to the web page where this option was accessed. Click the link on the menu bar to view. Figure 3-3 Sample help page 3-6 Library Reference Number: SYAP10014

23 Clear Claim Connection Guide Section 3: Additional Information Logoff Exit Clear Claim Connection. Figure 3-4 Logoff page Session Timeout Your connection to Clear Claim Connection times out after 30 minutes of inactivity. For example, if you leave the Clear Claim Connection tool running and go to a different Web interchange window, your Clear Claim Connection session will time out after 30 minutes and you see the following message: Figure 3-5 Information Alert window Web interchange times out after 20 minutes of inactivity. If your Web interchange session is completely inactive, you are logged out of Web interchange after 20 minutes. Note: If your session times out, close the browser window and log on again. Library Reference Number: SYAP

24 Clear Claim Connection Guide Library Reference Number: SYAP10014 I-8

25 Clear Claim Connection Guide Section 3: Additional Information Index A accessing Clear Claim Connection allow allow add B benefits C clarifications CMS contents... iii D data elements data entry , 2-5 disallow E entering claim information error information , 3-3 error response F fields I ICD , 2-5 ICD , 2-5 information alert L Legacy Provider Identifier log on LPI M menu bar N National Provider Identifier NPI O overview R recommendation values results values viewing review revision history... ii S session timeout T table of contents... iii terms and conditions timeout U UB V viewing results Library Reference Number: SYAP10014 I-9