EZ-CAP Claimshop Interface. Sanjay Goel. Manager, Software Development Daren DeBow Account / Sales Support Manager
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1 EZ-CAP Claimshop Interface Sanjay Goel Manager, Software Development Daren DeBow Account / Sales Support Manager
2 Welcome! What is Claimshop? Why use Claimshop? EZ-Steps on pricing and getting Edits via Claimshop. EZ-CAP Claimshop Configurations. Processing information and results. Claimshop changes in Auto Adjudication and Workflow. Q&A 2
3 What is Claimshop? Pricing Hospital and Professional Claims using MedAssets managed care insurance pricing. Get Contract and Copay values for the successfully priced claims. Show DRG grouper details for Hospital Inpatient Claims. Show APC details for each detail line for Hospital Outpatient Claims. Send various processing information. CCI Edits Hospital (Outpatient) and Professional Claims using MedAssets CCI Edits. NCD, LCD, Policy, Age Gender, Modifier and many more. Show Trigger Code, Excluded Code and Description for each detail line for Hospital Outpatient and Professional Claims. DRG Claims (Hospital Inpatient Claims) not applicable for CCI Edits as they are included as part of pricing. 3
4 Why Claimshop? More accurate Pricing/Edits based on Medicare. Beats manual pricing and Edits. Seamless integration from EZ-CAP saves time. Interface already included with EZ-CAP 651 onwards. Only activation is needed. No server installation and updates. Web service is hosted by MedAssets on their server with the latest changes always included. 99.9% up time. 4
5 Pricing Supported by Claimshop 1. IPPS (MS-DRG) all aspects and variations including CAH, SCH, EACH, MDH, RRP, VBP, low volume, and the rest 2. OPPS including APC, all four fee schedules, and reasonable cost (SI = F or L) 3. Physician RBRVS includes all localities 4. LTCH including SSO and VSSO 5. SNF 6. ASC 7. Ambulance 8. Inpatient psych 9. Inpatient rehab 10. ESRD 11. Hospice both inpatient and outpatient 12. RHC 13. DME everything except portable oxygen, which requires a series of if-then decisions 14. POS Prosthetics, Orthotics and Surgical Supplies 15. PEN Parenteral and Enteral Nutrition 16. ORF Outpatient Rehabilitation Facility 17. CORF Comprehensive Outpatient Rehabilitation Facility 18. CMHC Community Mental Health Center 19. HH- Home Health 5
6 Claims Pricing/Edits Processing Two ways to price/edit claims - 1. Batch claims based on filter criteria for multiple claims processing and scheduling. 2. On-Demand for individual claims. 6
7 EZ Steps for Processing Claims 1. Assign an NPI or Medicare 1C to provider identification. 2. Create a claim with all mandatory fields. 3. Configuration (Global/Company/Reimbursement) if required. (For CCI Edits these are not required). Global level. Company level at Health Plan, Option. Copay/Coinsurance, Allowed Amounts calculations. Reimbursement Value calculations. 4. Process the claim. Batch. On Demand. 7
8 Step 1 for Processing Claims Add Provider NPI 8
9 Step 1 for Processing Claims Or Medicare ID as 1C Identification Type 9
10 Step 1 for Processing Claims Zip Code for Professional Claims 10
11 Step 2 for Processing Claims Create a claim with all mandatory fields entered 11
12 Step 3 for Processing Claims Create Configuration (Global/Company/Reimbursement) if required 12
13 Processing Claims - Batch Company ID, Batch Description and Batch Information. Add a criteria to the Filter. Pick Price, CCI Edit or both. Preview the claim result with the criteria. Create the Batch. Process Batch with Claimshop or schedule the Batch to run later. 13
14 Processing Claims - Batch 14
15 Processing Claims On Demand Right-click Menu > Utilities > Price Via Claim Shop or CCI Edits or Price and CCE Edits 15
16 Processing Claims Results 16
17 Processing Claims Results 17
18 Processing Claims Results 18
19 Processing Claims Reports 19
20 Processing Claims Reports 20
21 Claimshop Configuration Claim Adjustment handling Copay/Coinsurance Calculation (Inpatient/Outpatient) Allowed Amount determination (Hospital/Professional) Global Applies to all Claimshop processed claims 21
22 Claimshop Configuration Company Healthplan Healthplan Option 22
23 Claimshop Configuration Reimbursement Apply Percent to Priced Amount coming from Claim Shop. Default is 100%. Setup just like Fee Set Assignments. 23
24 Edits Supported by Claimshop Included Edits in DRG and APC Groupers (UB) IOCE (Outpatient Facility) Includes, but not limited to the following: Inpatient procedure conflict with TOB Age/Gender Invalid Procedure Inpatient Procedure Procedure and Gender Conflict MCE Medicare Code Edits (Inpatient Facility) Includes, but not limited to the following: Inpatient specific validation Invalid diagnosis or procedure code Age/Gender Non-covered procedures NCCI National Correct Code Initiatives Other Edits (UB and 1500) NCD National Coverage Determination LCD Local Coverage Determination NCCI National Correct Code Initiatives Diagnosis code Validation Age Edits Gender Edits Modifier Edits Advance Beneficiary Notice of Non-coverage (ABN) edits History Edits/Global Pricing ICD9 Manifestation Edits ICD9 Unacceptable Principal Diagnosis ICD9 Validation Edits (for DOS) MUE Medically Unlikely Edits CPT Validation Edits (for DOS) CPT Place of Service Edits CPT EM Surgical Edits with proper Modifiers RVU functionality/edits Diagnosis Validation History Edits/Global Billing 24
25 Claim Shop Bill Types 25
26 Auto Adjudication & Workflow Elements added for Claim Shop with new pend codes for Auto Adjudication 26
27 Auto Adjudication & Workflow And Workflow 27
28 Auto Adjudication & Workflow AUTO ADJUDICATION CRITERIA Value Description CLAIM SHOP PRICE STATUS 0 TO 6 Various status returned by Claim Shop IS CLAIM PRICED BY CLAIM SHOP? YES/ NO IS CLAIM EDITED BY CLAIM SHOP? YES/ NO PEND CODE MASTERS P25 PSU PRICE SUSPENDED P25 PNR PRICE NEEDS REVIEW P26 EDF EDIT FAILED PEND CODE DETAIL DP23 CEF CLAIMSHOP EDIT FAIL WORK FLOW RULES CLAIM SHOP PRICE STATUS 0 TO 6 Various status returned by Claim Shop IS CLAIM PRICED BY CLAIM SHOP? YES/ NO IS CLAIM EDITED BY CLAIM SHOP? YES/ NO PEND CODE MASTERS P25 PSU PRICE SUSPENDED P25 PNR PRICE NEEDS REVIEW P26 EDF EDIT FAILED PEND CODE DETAIL DP23 CEF CLAIMSHOP EDIT FAIL 28
29 Pricing, Edits and Benefits After the claim is priced via Claim Shop, the claim will still hit the EZ-CAP Benefits, Auto Adjudication and Workflow. Copay and Coinsurance can be calculated based on benefit setup. Non-covered services will not be paid and an Adjustment Code will be applied. 29
30 Summary Claims can be Priced, sent for Edits or Priced and Edited together. Batched or per claim. No installation is required. NPI is required for Hospital Claims and Zip Code is required for Professional Claims. Both Auto Adjudication and Workflow include Claimshop elements. All required information for pricing and edits are stored in the claim. Activation key is required to process claims which can be received from MedAssets and OrangeMZI. 30
31 EZ-CAP Claimshop Interface Questions? 31
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