Troubleshooting. Presentation by: Yolanda Barrera, Eldorado Rod Wall, Teamsters

Transcription

1 Presentation by: Yolanda Barrera, Eldorado Rod Wall, Teamsters

2 Agenda Welcome everyone to our EDI Session Claims End of Day ABF Workflow System Maintenance and Red Screens HIPAA Log errors EDI: COB 5010 Formula Patient & Provider Match 834 s

3 Claims

4 Claims Claims not pricing correctly, what should I check? Benefit Plan settings Benefit code exception, DGN exception or Exclusion Contract MDR, ADP, HIA, RVRBS etc. settings CES edits (group master and/or benefit plan/network level BAD benefit code check benefit code cross reference Fee schedules (provider/network screen & benefit plan default settings) EDI Pricing Episode Record

5 Claims ICD9 and ICD10 Comparisons of the Diagnosis Code sets:

6 Claims ICD9 and ICD10 Comparisons of the Procedure Code sets:

7 How does it look currently in HEALTHpac?

8 Claims ICD9 and ICD10 So how much work is needed for HEALTHpac to process claims with the ICD10 codes? The following programs will need to be updated to have the ICD10 codes: Benefit Code Categories Diagnosis Code cross reference table Adjudication Logic Category definitions Pre-existing (benefit plan and/or member level) Contract Maintenance Fee schedules Episode Records

9 Exception codes How do I know what a certain exception code means? Online Customer Support has a full table of exception types and codes used within HP4

10 Claim exceptions 770 Table The 770 Table within HP4 also has a list of exceptions

11 Workflow

12 Workflow Orphaned claim exists in your workflow queues, you will need to run the m9qorphn program.

13 Workflow Workflow recovery (black hole) utility: M9QRCVR Program reads through claims file looking for claims without a workflow record attached. If it finds any claims without a record, it will create it. Also, generates a report of these claims.

14 Workflow O9EXCWK2.dbc: same functionality as the m9qrcvr program. This program is ran from the command line instead of HP4 Menu. This means no user interface and there isn t a report. There is however a file left behind with information: o9excwk2.txt

15 Workflow Is there a way to delete claims in a workflow queue?

16 Workflow Claims are showing up in multiple queues but I can t view them in workflow.

17 Check Run Process

18 End of Day check run process Incorrect benefit plan errors during check run process? X9fixpln will correct these claims.

19 End of Day check run process Avoid problems by always reviewing the current batch audit report and daily check register reports before posting.

20 End of Day - ABF What is the calculation for the ABF patient responsibility fields? If it doesn't find any denied reason codes to apply patient responsibility then the system will follow the below formula: CLM-CHARGE - LINE_PAID Otherwise it will do the following for any of the values that have a valid denied reason code: (CLM-CHARGE - LINE_PAID) - CLM_OUCR - CLM_PENALTY - CLM_INELIG - CLM_COPAY - CLM_DISCNT - CLM_NCOTHER LINE_PAID = CLM_PAID - (CLM_COBP + CLM_COBE)

21 System Maintenance

22 System Maintenance HEALTHpac reindex maintenance program: Licensed clients recommended to have a regular set schedule for system reindex. ASP clients automatically are reindexed once per month.

23 Red Screens Purpose of Lesson To learn how to read Red Screen error messages and how to avoid some common causes What is the error trying to tell us? What can be fixed by a re-index? How to resolve a network-related errors Understanding index files & breakage demonstration

24 Red screens, cont. Cheat sheet for common red screens:

25 Red screens, cont. Cheat sheet for red screens Return code: DB/c error code and description single most important element Release: Version of HEALTHpac Program name: Program that triggered error File name: File or program in question File key: Key to record in question Label: Internal program label being called Error: Key to type of problem Program info: Program compile information

26 When to re-index system files Attempt to read past file end Write or insert of duplicate key Invalid index file Attempt to read a record that does not exist or is deleted

27 Corrupted data errors requiring ECI assistance Invalid file type Record too long Record too short Wrong record length

28 Network-Related Errors Open mode conflict Unable to open Unable to close Unable to read Unable to lock file Error during write Device or print file name is null or invalid Program or file not found

29 Program errors (most of the time) Array pointer reference out of bounds Return stack overflow External label not found Read with null key and invalid position Update with invalid position

30 Transient errors Invalid data used with SCRNRST, STATEREST,WINREST or TRAPREST Return or trap on an unloaded module

31 HIPAA Log errors

32 HIPAA Log Messages The HIPAA log file tracks all claims (by number) including those that incorporate syntax errors (i.e., errors that reflect missing data or misplaced data according to HIPAA requirements), and those that couldn't be built at all. Data begins accumulating in log files as soon an X12 Manager initiates a read or write process. Remember you must exit the X12 Manager program for the HIPAA log to complete recording all/any errors.

33 HIPAA Log Messages General file info Time stamp I info TS start of file read TE end of file read E error ** send to vendors ** ***** - Claim(s) not created in HEALTHpac U Up; the X12 Manager has come up (will also display the ecix12.jar version you are running) D Down; the X12 Manager has terminated

34 How can I identify where a claim is in a file? (t-#) segment number in that transaction set (s-#) segment number in the file Will identify the segment in question If a segment is missing, there is no way to identify it, because it is missing

35 HIPAA Log Error AK5 - Transaction set response to acknowledge acceptance or rejection and report errors in a transaction set This just tells you that somewhere in the txn set there was an error There will be a AK4 or AK3 error to define the error further

36 HIPAA Log Error AK4 - Data Element note» To report errors in a data element and identify location of that element» This is when a data element is missing (like the state in a city, state, zip segment)» This is when a data element does not meet HIPAA requirements (like when a state is 4 characters instead of the HIPAA required 2) AK3 - Data Segment note» To report errors in a data segment and identify the location of the data segment

37 HIPAA Log Error If you have a data element error, you will see an AK3, AK4 & AK5 error. The AK3 tells you what segment has a problem The AK4 tells you what element has a problem The AK5 tells you what transaction set has a problem These are HIPAA errors. If there is all 3, focus in on AK4 error this will be the most defined.

38 HIPAA Log: claims in their own transaction set 08:11:55 U ecix12 version :11:56 TS /501/prod/x12/ftp/yoly/put/837/Inbound TEST file.txt :11:56 08:11:56 I Claims sent to HP: 1 08:11:56 I Total CLM segments in Transaction set ST(0001): 1 08:11:58 I yoly: file Inbound TEST file.txt Batch claim 402ABF208B ADJ 08:11:58 08:11:58 I Claims sent to HP: 1 08:11:58 I Total CLM segments in Transaction set ST(0002): 1 08:11:58 I yoly: file Inbound TEST file.txt Batch claim 402ABF208B ADJ 08:11:58 08:11:58 I Claims sent to HP: 1 08:11:58 I Total CLM segments in Transaction set ST(0003): 1 08:11:58 I yoly: file Inbound TEST file.txt Batch claim 402ABF208B ADJ 08:11:58 08:11:58 I Claims sent to HP: 1 08:11:58 I Total CLM segments in Transaction set ST(0004): 1 08:11:59 I yoly: file Inbound TEST file.txt Batch claim 402ABF208B ADJ

39 HIPAA Log: example of syntax errors Procedure code is missing in the SV1-02 segment: 14:21:20 U ecix12 version :21:22 TS /901/prod/x12/ftp/yoly5010/put/837/missingprocedure.txt :21:22 14:21:22 I Claims sent to HP: 1 14:21:22 I Total CLM segments in Transaction set ST(0001): 1 14:21:22 E Parsing errors: IK4 error (1 - mandatory data element missing) with 1 subelement 2 in GS 1 (HC)/Txn set 0001 (837)/SV1 (T-26) (S-29) IK3 error (8 - segment has data element errors) in GS 1 (HC)/Txn set 0001 (837)/SV1 (T-26) (S-29) Segment in error: SV1*HC*150*UN*1***1~ IK5 error 5 - segment errors in GS 1 (HC)/Txn set 0001 (837) TA1 error 024 with message 14:21:22 I Entity: yoly5010 Inbound File: missingprocedure.txt Status: Batch claim 055DIS EXC BD CPT 14:21:22 I Connection to X12 Manager closed 14:21:22 D

40 HIPAA Log: example of a critical error Subscriber Loop missing: 14:34:23 U ecix12 version :34:25 TS /901/prod/x12/ftp/yoly5010/put/837/missingpatientloop.txt :34:25 E Transaction set ST(0001) skipped 14:34:25 E Parsing errors: IK5 error 4 - number of included segments doesn't match count in GS 1 (HC)/Txn set 0001 (837) TA1 error 024 with message Missing SubscriberLvl(2000B) IK3 error (2 - unexpected segment) in GS 1 (HC)/Txn set 0001 (837)/CLM (T-10) (S-13) Segment in error: CLM* *150***11:B:1*N*A*Y*I~ 10 additional segments ignored 14:34:25 TE /901/prod/x12/ftp/yoly5010/put/837/missingpatientloop.txt TxnSet: 837 To HP: 0 14:34:26 X com.eldocomp.hipaa.dbcutils.dbchipaaexception at com.eldocomp.hipaa.dbcutils.dbcxchangedispatcher.makesimpleerrorrsp(dbcxchangedispatcher.java:1649) at com.eldocomp.hipaa.dbcutils.dbcxchangedispatcher.makesimpleerrorrsp(dbcxchangedispatcher.java:1664) at com.eldocomp.hipaa.dbcutils.dbcxchangedispatcher.gettxnsetid(dbcxchangedispatcher.java:1493) at com.eldocomp.hipaa.dbcutils.dbcxchangedispatcher.verifytxnsetid(dbcxchangedispatcher.java:2442) at com.eldocomp.hipaa.dbcutils.dbcxchangedispatcher.formathipaaack(dbcxchangedispatcher.java:877) at com.eldocomp.hipaa.dbcutils.dbcxchangedispatcher.processtxn(dbcxchangedispatcher.java:227) at com.eldocomp.hipaa.dbcutils.xchangerunner.run(dbchipaaslave.java:308) at java.lang.thread.run(thread.java:662) 14:34:26 I Connection to X12 Manager closed 14:34:26 D

41 HIPAA Log: example of a non-critical error Segment count doesn't match, but the claim was built: 08:49:40 U ecix12 version :49:41 TS /501/prod/x12/ftp/yoly/put/837/incorrect segment count.txt :49:41 08:49:41 I Claims sent to HP: 1 08:49:41 I Total CLM segments in Transaction set ST(0001): 1 08:49:41 E Parsing errors: AK5 error 4 - number of included segments doesn't match count in GS 1 (HC)/Txn set 0001 (837) TA1 error 024 with message 08:49:41 I yoly: file incorrect segment count.txt Re-priced claim 055DIS EXC PE ZRO Service line(s) repriced as zero dollars 08:49:41 08:49:41 TE /501/prod/x12/ftp/yoly/put/837/incorrect segment count.txt Txn set: 837 To HP: 1 Txn sets skipped: 0 Tot CLM segments in processed txn sets: 1 08:49:43 I Connection to X12 Manager closed 08:49:43 D

42 5010 and COB

43 EDI 5010 COB Formula Formula for Medicare INPATIENT Professional and Institutional claims: Claim Level: Assigned claims (CLM07 = A) Medicare Paid amount AMT*D plus any of the following CAS segments from loop: 2320, if present on the 837 inbound claim. AMT*D segment (Loop: 2320) plus + CAS*PR*1 1 indicates deductible amount + CAS*PR*2 2 indicates co-insurance amount + CAS*PR*66 66 indicates blood deductible + CAS*PR* indicates psychiatric reduction + CAS*PR* indicates + CAS*CO*B4 B4 indicates late filing penalty + CAS*CO*45 45 indicates charge exceeds fee schedule + CAS*CO*94 94 indicates processed in excess of charges + CAS*OA*A7 A7 indicates presumptive payment adjustment Will equal the Medicare Approved Amount

44 EDI 5010 COB Formula Formula for Medicare INPATIENT Professional and Institutional claims: Claim Level: Non-assigned claims (CLM07 = C) The sum of 2320 AMT*D (AMT02) plus any one of the following CAS*PR segments from Loop: 2430, if present on the 837 inbound claim. AMT*D (Loop: 2430) + CAS*PR*1 (Loop: 2430) 1 indicates deductible amount + CAS*PR*2 (Loop: 2430) 2 indicates co-insurance amount + CAS*PR*3 (Loop: 2430) 3 indicates co-payment amount + CAS*PR*122 (Loop: 2430) 122 indicates psychiatric reduction Will equal the Medicare Approved Amount

45 EDI 5010 COB Formula Formula for Medicare OUTPATIENT Professional and Institutional claims: Claim Level: Assigned claims (CLM07 = A) Medicare Paid amount (SVD02) plus any of the following CAS*PR and/or CAS*CO segments loop: 2320, if present on the 837 inbound claim. SVD02 segment (Loop: 2430) + CAS*PR*1 (Loop: 2430) 1 indicates deductible amount + CAS*PR*2 (Loop: 2430) 2 indicates co-insurance amount + CAS*PR*45 (Loop: 2430) 45 indicates charge exceeds fee schedule + CAS*PR*66 (Loop: 2430) 66 indicates blood deductible + CAS*PR*122 (Loop: 2430) 122 indicates psychiatric reduction + CAS*CO*B4 (Loop: 2430) B4 indicates late filing penalty Will equal the Medicare Approved Amount

46 EDI 5010 COB Formula Formula for Medicare OUTPATIENT Professional and Institutional claims: Claim Level: Assigned claims (CLM07 = C) Medicare Paid amount AMT*D (AMT02) plus any of the following CAS*PR segments from loop: 2430, if present on the 837 inbound claim. AMT*D segment (Loop: 2430) + CAS*PR*1 (Loop: 2430) 1 indicates deductible amount + CAS*PR*2 (Loop: 2430) 2 indicates co-insurance amount + CAS*PR*122 (Loop: 2430) 122 indicates psychiatric reduction Will equal the Medicare Approved Amount

47 Regular COB claims (non-medicare claims) This applies when Loop 2000B SBR09 does NOT=MA or MB but COB data is present on the claim COB will only be read at the Claim Level for Non-Medicare claims We do not apply the CAS claims adjustment cross references (m9adjcas) for Non-Medicare claims The Allowed amount as determined by the payer is calculated using the prior payer's payment information coupled with adjustment information in the CAS segments. The prior payer payment + the sum total of all patient responsible adjustment amounts = the Allowed amount. The Patient Responsible adjustments are identified by use of the Category Code PR in CAS01. Other Insurance Allowed will come from the Claim level and be divided to the service lines using a weighted distribution. Other Insurance Allowed: If CAS segment is sent at loop 2320, follow the formula above If CAS segment is not sent at loop look at the 2430 CAS segments If no CAS segments are present at Claim/2320 or Service Line/2430, create an exception of BD COB

48 Claim Adjustment Reason codes list Where can I obtain the current list of claim adjustment reason codes?

49 5010 Professional claim example

50 5010 & COB View/Original screen results

51 5010 COB Professional claim example Charge: $ CAS formula: $ OI paid: $48.33 $35.80 Net Payment

52 General EDI Information

53 Provider & Patient Match rules Questions: 1. Why did my claim attach to the incorrect provider? 2. Why did my claim stop with the patient not found exc? 3. Can you provide me a specific set of EDI controls? Answers: 1. We can run the m9prvlk.dbc program 2. We can run the m9patlk.dbc program 3. Unfortunately, the answer to this question is no, because everyone s provider and patient database is different. Files may not always have accurate information.

54 New data elements for header DTP segment: 090 and 091

55 New Data Element: RX Replace Currently this new data element exists for outbound files. Anyone expect to use this new option for inbound files?

56 New data element for INS08 segment: AC

57 EDI - Claims Need to delete a batch of claims? M9DELBCH.dbc As long as the claims are not in a PAID status, you may run the m9delbch program to delete the claims that have been attached to a particular batch.

58 EDI Report And last but not least! The EDI report we can extract from HEALTHpac: M9X12LOG.dbc

59 Resources CMS See HIPAA section CMS ICD10 and 5010 updates HIPAA Implementation Guides Eldorado Support Team (602) ext: 709 EDI ext: 710 Admin ext: 711 Claims After hours support: (480)

60 Questions and Answers