E-Z Frame-E-Claims (EDI) Integration Users Guide

Transcription

1 E-Z Frame-E-Claims (EDI) Integration Users Guide For Versions and Higher This guide will explain how you can setup and use the E-Claims Integration module (commonly referred to as EDI or Electronic Data Interchange) within E-Z Frame Platinum software. Once setup is complete, you can submit e-claims directly from E-Z Frame to the TriZetto Provider Solutions clearinghouse. TriZetto Provider Solutions (formerly Gateway EDI) Enrollment: Before you can submit claims to TriZetto Provider Solutions, you must first enroll with TriZetto Provider Solutions to select and signup for an e-claims package that best fits the needs of your office. The cost for submitting e-claims (per provider/per month) with TriZetto will be billed separately from any add-on module or annual support charges with First Insight. In addition, you must also purchase and install the E-Z Frame-E-Claims (EDI) Integration from First Insight which requires a one-time setup/license fee and an annual subscription and maintenance fee (USD/per location).

2 Information in this document is subject to change without notice. Companies, names, and data used in examples herein are fictitious, unless otherwise noted. No part of the document may be reproduced or transmitted in any form without the express written consent of First Insight Corporation. The software programs described in this document are confidential and proprietary products of First Insight Corporation or its licensors. Other product and company names listed may be the trademarks of their respective owners. First Insight and E-Z Frame are registered trademarks of First Insight Corporation First Insight Corporation. All rights reserved. First Insight Corporation NW Bennett Street, Suite 200 Hillsboro, OR Customer Support: Fax: E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 2 of 26 Rev 6/24/15

3 Table of Contents Overview of E-Z Frame-E-Claims (EDI) Integration... 4 Enroll with TriZetto Provider Solutions... 4 E-Z Frame-E-Claims (EDI) Integration Setup... 4 E-Z Frame Required E-Claims Data... 5 Practice Details for E-Claims... 5 Provider Details for E-Claims... 6 Adding Ordering Provider for E-Claims... 7 Selecting an Ordering Provider for HCFA/Claim... 8 Ordering Provider on Sale Window... 8 Ordering Provider on HCFA/Claim Window... 8 Entering Facility Information... 9 Selecting Facility for HCFA/Claim Adding HCFA Type of Service Adding Insurance Plan Information Workflow: From Insurance Details to Claim Submission Steps to Create and Submit an E-Claim Insurance and Policy Holder Details Patient Insurance Policies Adding a Referring Physician (optional) E-Claims: Creating, Batching, and Transmitting to the Clearinghouse Creating an E-Claim Batching: Single and Multiple Claims Single Batch Claims Multiple Batch Claims Transmitting Claim Files to TriZetto Provider Solutions Start E-Claims Process Transmitting (Uploading) Claims TriZetto Provider Solutions Claim Reports Troubleshooting Your E-Claims Tips and Best Practices E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 3 of 26 Rev 6/24/15

4 Overview of E-Z Frame-E-Claims (EDI) Integration The E-Z Frame-E-Claims (EDI) Integration will allow you submit claims directly from E-Z Frame Platinum Software to TriZetto Provider Solutions (formerly Gateway EDI). This integration will save your staff time by eliminating redundant data entry and streamlining the claims submission process. Before you can begin using the E-Z Frame-E-Claims (EDI) Integration, you must: Enroll with TriZetto Provider Solutions. Contract First Insight to setup the E-Z Frame-E-Claims (EDI) Integration, which requires a one-time setup/ license fee and an annual subscription and maintenance fee (USD/per location). Complete additional setup within the E-Z Frame application prior to submitting e-claims. Enroll with TriZetto Provider Solutions First Insight has partnered with TriZetto Provider Solutions as our preferred clearinghouse vendor. TriZetto Provider Solutions handles all enrollment processes and will discuss pricing information with your office. This allows for a seamless enrollment process, as TriZetto Provider Solutions coordinates your enrollment with your Go Live date to ensure all necessary payers are enrolled by the time you begin using the E-Z Frame-E-Claims (EDI) integration. Contact the First Insight EDI Enrollment department via at EDIEnrollment@first-insight.com with any questions. E-Z Frame-E-Claims (EDI) Integration Setup An E-Z Frame customer support technician will need to connect to your system to complete the initial backend setup to allow you to submit e-claims. The technician will setup your system with your specific TriZetto Provider Solutions account information that is required to electronically submit claims. How to Contact an E-Z Frame Customer Support Technician Telephone: , Option 4 Live Online Support: Support: E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 4 of 26 Rev 6/24/15

5 E-Z Frame Required E-Claims Data Please take the time to review the instructions listed below. It's important to update each section in E-Z Frame that is outlined below to properly setup your system with the data that is required for you to submit E-Claims. Practice Details for E-Claims 1. Select Configure > Practice Info > Edit to add/update the Practice information. 2. Enter the Submitter Info, which is typically the same as your practice details. If the data for Submitter is the same as Practice data, click on Copy Practice Details to fill in the data for the Submitter automatically. 3. Click Save. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 5 of 26 Rev 6/24/15

6 Provider Details for E-Claims 1. Select Configure > Providers > Edit to add/update the Provider information. 2. Enter all the provider details. Enrollment Type and Provider Specialty are required for E-Claims. 3. Once all the details are entered, click Save. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 6 of 26 Rev 6/24/15

7 Adding Ordering Provider for E-Claims The Ordering Provider may be required for some E-Claims, such as those going to DME/Medicaid. Follow the steps listed below to enter any provider(s) as an Ordering Provider. NOTE: A second entry will be needed for each provider in order to identify them as an "optometrist/ophthalmologist" and separately as an Ordering Provider. E-Z Frame will only display provider(s) with the Provider Type ordering provider in the applicable areas where an ordering provider can be selected. 1. Select Configure > Providers to add the Ordering Provider information. 2. Click Add a New Provider. Or edit an Existing Provider by clicking the Edit button. 3. Enter all the details then from Provider Type drop-down, choose Ordering provider as highlighted in the image below. 4. Click the Save option to Save the Ordering Provider. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 7 of 26 Rev 6/24/15

8 Selecting an Ordering Provider for HCFA/Claim There are two places where the Ordering Provider can be selected: Sales and HCFA. Refer to the screenshots below for examples. Selecting the Ordering Provider on the Sale window will automatically carry forward to the HCFA/Claim. NOTE: Billing scenarios can be where the Provider and Ordering Provider are the same. Ordering Provider on Sale Window Ordering Provider on HCFA/Claim Window E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 8 of 26 Rev 6/24/15

9 Entering Facility Information Enter any facilities where services are provided outside of the main office. 1. Click Overview Menu > Configure > Application > Edit. 2. Click the Facilities button. 3. The following screen will open. Click the Add option to add a new facility. 4. Click the Add option. The following screen will open and you can enter all details related to the Facility in this section. 5. Click the Save option. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 9 of 26 Rev 6/24/15

10 Selecting Facility for HCFA/Claim 1. From the HCFA/Claim window, click the E-Claims tab. 2. Select Facility from the drop-down menu. Adding HCFA Type of Service 1. Click Overview Menu > Application > CPT. 2. Each CPT will need a HCFA Type Of Service entered. The service type of 1 will most likely be used, unless your office provides services other than medical (e.g., surgery, anesthesiology, etc.). Note: The HCFA Type of Service that is populated will automatically populate on the E- Claims. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 10 of 26 Rev 6/24/15

11 Adding Insurance Plan Information 1. Click Overview and Insurance to add the insurance information. 2. Click Add a New Insurance Plan or double-click an existing plan to edit. 3. Add the required insurance plan details. Policy Contact Information and E-Claim Information section are required for E-Claims. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 11 of 26 Rev 6/24/15

12 4. Click the Save option to save the insurance plan. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 12 of 26 Rev 6/24/15

13 Workflow: From Insurance Details to Claim Submission The following section will outline the steps you need to setup, create, and submit a successful E-Claim. Listed below is a quick outline of the processes, followed by step-by-step instructions, from Insurance and Policy Holder details, to submitting a claim or a batch of claims to TriZetto Provider Solutions. Steps to Create and Submit an E-Claim 1. Select the Patient s Insurance and enter the Policy Holder details. 2. Enter Referring Provider (only if needed). 3. Create the Sale with Procedures and Diagnosis Codes. 4. Create Claim/HCFA. 5. Batch Claim/HCFA. 6. Start E-Claims. Insurance and Policy Holder Details Patient Insurance Policies 1. Select Overview and Patient to add the insurance policy for the patient. 2. Select a patient. In the Insurance Policies section, click the Add option if no Insurance is present. 3. Click View or Edit to update any Insurance Policy information already entered for the patient. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 13 of 26 Rev 6/24/15

14 4. The fields highlighted in green are required for E-Claims. 5. Click Save and close the window. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 14 of 26 Rev 6/24/15

15 Adding a Referring Physician (optional) Follow the steps below to add a Referring Physician for any patient office visit which will require the Referring Physician on the E-Claim. 1. Select Overview and Patient Records. 2. Edit a patient. 3. Click the Referral tab then select Referral Type as Physician and click the Find Referring Physician button. 4. Other than the regular referral physician information, the following fields are required for E-Claims: SSN, Federal TaxID, ID to use on HCFA and Specialty. NOTE: If the user selects Federal Tax ID in field ID to use on HCFA, then the Federal Tax ID must have data in it. Similarly, if the user selects SSN in the field ID to use on HCFA, then SSN must have data in it. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 15 of 26 Rev 6/24/15

16 5. Click the Save button to save this Referral Physician Information and click the Select option to select it for the specific patient. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 16 of 26 Rev 6/24/15

17 E-Claims: Creating, Batching, and Transmitting to the Clearinghouse Creating an E-Claim To create an E-Claim, you must create a Sale with an amount toward the Insurance Owes. 1. Click Overview Menu > Insurance, then select Claims from the main menu. 2. Click Add a New Insurance Claim to create an E-Claim. 3. From the list of Sales/Invoices, choose the invoice to create a claim for by either double clicking on an Invoice or left clicking on the invoice then clicking Continue from the menu. NOTE: By default the Filter will be for Invoices pending claims with Insurance Balances. 4. Choose the Type of HCFA you want to create from the list as shown in the image below and click Select. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 17 of 26 Rev 6/24/15

18 5. You can change or edit data directly on the claim form that is shown below. Review each tab, HCFA-1 and HCFA-2 pages, E-Claims button, and E-Claims to review and edit any claim data as needed. a. Click the ECLAIMS button on the HCFA 2 page (located on the right side as shown below) to enter additional HCFA information, if required. b. Click on Edit button shown below. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 18 of 26 Rev 6/24/15

19 c. Enter the required data and click on save button. NOTE: For most claims the information in the E-CLAIMS section will not be needed. d. Close this window. 6. The E-Claims related data will be shown and the data will automatically populate if data is entered on the respective forms. Any incorrect or missing data can be edited or added on this screen. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 19 of 26 Rev 6/24/15

20 7. Once the data has been entered, click the Save button. 8. The claim status will automatically be set as Not Submitted/New. You will be able to search for and submit claims based upon this status as outlined in the following section. NOTE: Data entered on this screen will not update to the other areas of the patient record or sale. It is best to enter the data in the patient record, insurance details, etc. prior to creating the claim. In the scenario that a claim has to be resubmitted, all the data will pull forward without having to be re-entered. Batching: Single and Multiple Claims Batching is the process of formatting all the data from patient records, insurance details, Insurance Policy Holder, and Sale into the proper ANSI 5010 format that accepted by the clearinghouse and insurance payers. Claims can be batched as individual or in groups. A search must be completed to create the group of HCFAs to batch. First Insight recommends batching your claims in groups as it is more efficient. Single Batch Claims Once the claim is saved, the Batch HCFA option will be enabled to create the claim file for you to upload to the clearinghouse. 1. Click Batch HCFA. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 20 of 26 Rev 6/24/15

21 Multiple Batch Claims To Batch a group of claims, you must complete a Search to create the group. 1. From the Overview Menu, click Insurance then click the Claims option. 2. Click on Advance Search. 3. Enter the following to find a list of all claims that need to be batched for submission. a. First Row: Choose the Column Name as HCFA Type and Criteria as EClaim-- Clearinghouse or EClaim--Clearinghouse--Secondary' and click the Execute button. b. Second Row: Choose the Column Name as Claim Status and Criteria as Not Submitted/New and click the Execute button. 4. All claims with the selected HCFA Type and Claim Status will be listed. 5. Select the HCFAs to be batched and click the Batch HCFAs button. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 21 of 26 Rev 6/24/15

22 6. A successful batch of either a single batch or multiple claim batch will display the following screen as the batch process completes. 7. Once the claim(s) is successfully batched, the following message will appear indicating the number of claims successfully batched as well as the number of claims rejected. The claim status of the successful claims will be changed to Submitted. Claims that are rejected will retain the default status of Not Submitted/New. NOTE: Once a batch file has been created with at least one successful claim it must be submitted before any other claims can be batched. Each time the Batch HCFA process is executed, the previously created batch file is overwritten. 8. Click the OK button to display the Electronic Claims Submit Reports. The Electronic Claims Submit Report will provide a list of all the claims successfully batched, as well as a list of all the claims that failed to batch. The report will also specify why each claim failed with the batch. First Insight recommends that you save or print this report for your records. Any claims that were successful should immediately be submitted to the clearing house. After submitting all the successful claims to the clearing house you will return to this report and correct each of the failed claims. Once they are corrected the claims can be batched and submitted. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 22 of 26 Rev 6/24/15

23 Transmitting Claim Files to TriZetto Provider Solutions Start E-Claims Process Start E-Claims is the name of the process to initiate the upload of the batched E-Claim file to TriZetto Provider Solutions. After you click the Start E-Claims button the E-Z Frame Electronic Claim window will be displayed with options for you to select the transmission file and initiate the transfer. 1. Click on Start E-Claims option from the menu. 2. If multiple HCFAs were batched, then Start E-Claims can be found from the list view as well. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 23 of 26 Rev 6/24/15

24 Transmitting (Uploading) Claims Once the batch file has been created the final setup will be to transmit (upload) the claim to TriZetto Provider Solutions. 1. Select the transmission file option from the drop-down menu. Click the Transmit Claim button. For example: Select CLEARING-HOUSE1: Gateway from the drop-down menu and click the Transmit Claim button as shown below. 2. Click the Connect button to initiate the SFTP connection. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 24 of 26 Rev 6/24/15

25 3. As the connection is established you will begin to see activity in the main directory text box in the middle of the window. Once the connection is established, the Refresh, SendFile and Cancel buttons will be enabled. NOTE: Once you click the Refresh button, the directory list will be refreshed and displayed as shown in the screenshot above. Once you click the Cancel button, the connection to FTP will be disconnected. Also, any operation being performed will be cancelled. 4. Click the SendFile button to upload the claim file. 5. After the claim file is uploaded successfully the following message will be displayed. Click the OK button. 6. Click the Close button to disconnect the session. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 25 of 26 Rev 6/24/15

26 TriZetto Provider Solutions Claim Reports TriZetto Provider Solutions offers many tools to help your office manage your submitted claims from confirming the claims were received to being paid. These reports and tools are available to you 24/7 on the TriZetto Provider Solutions website. Troubleshooting Your E-Claims Please contact an E-Z Frame technical support agent for assistance if you are not able to create, batch, or transmit your claims. E-Z Frames support technicians will be able to assist with any technical issues related to setup and submission of E-Claims. How to Contact an E-Z Frame Customer Support Technician Telephone: , Option 4 Live Online Support: Support: Tips and Best Practices 1. Aging Report: Check your Accounts Receivable Aging Repots on a regular basis to make sure you are filing all claims in a timely manner. Claims falling into the Over 60 column should be followed up on to ensure they do not become write-offs. 2. TriZetto Provider Solutions Reports: Check your TriZetto Provider Solutions reports on a daily basis to catch any rejected claims that need to be fixed and re-submitted before the timely filing period expires. E-Z Frame-E-Claims (EDI) Integration Guide 2015 First Insight Corporation Page 26 of 26 Rev 6/24/15