EDI, ANSI 837 Files, & Clearinghouse 101
|
|
- Moses Jackson
- 8 years ago
- Views:
Transcription
1 EDI, ANSI 837 Files, & Clearinghouse 101 National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210 Bethesda, MD FAX
2 Agenda Introduction What is EDI Origins Paper vs. Direct Submission vs. Clearinghouse Pro & Con Analysis Clearinghouses A History What Is It Nuts & Bolts Transition to v5010 & ANSI 837 Files A Step by Step Process Example Best Practices & Tools for EDI Optimization Summary
3 Disclaimer: 1. The guidelines, interpretations, and recommendations set forth as part of this training session are presented as a guide only. Attendees understand and recognize that actual coding/billing decisions are the sole liability and responsibility of the provider(s) and respective billing staff. Neither NACHC nor Priority Management Group, Inc. accepts any liability or responsibility in this regard. 2. The presentation today includes discussion about a particular commercial product/service and the presenter may have a significant financial interest/relationship with the organization that provides this product/service.
4 Speakers: Ray Jorgensen, MS, CPC, CHBME Raymond T. Jorgensen is President and CEO of Priority Management Group, Inc. (PMG). Ray is responsible for oversight of consulting operations as well as coding, reimbursement, and payer related issues for the out-sourced billing component of PMG s services (more than one million annual encounters). He has personally trained thousands of providers from over 35 states on coding, billing, and reimbursement in addition to authoring two books and dozens of articles. Ray s health care experience and education is unique in that he was schooled by the payers. Having worked for Blue Cross and Blue Shield as well as United HealthCare Corporation, primarily in professional relations and contracting, Ray has an understanding and perspective on the payer s objectives and process unlike other medical business consultants groomed from the provider side. BA from The College of the Holy Cross (Worcester, MA) MS from Northeastern University (Boston, MA) CPC from the American Academy of Professional Coders (Salt Lake City, UT) CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)
5 Speakers: Caroline Peucker, CPC, CPC-H, CPC-I PMG s Vice President, Consulting and Compliance, Caroline has more than 25 years experience in the physician billing and coding industry. Her extensive experience includes serving as the Vice President, Coding and Compliance, Manager of coding and Billing Operations Manager for physician billing companies that serviced a wide range of specialties and practice types. She has broad experience with hospitalbased physician and private practice where she was integral to coding and compliance education and training for clinical providers, practice and billing office staff members. She has performed and managed chart audits with objective of both compliance and optimizing reimbursement through correct coding and thorough documentation. Caroline holds a Bachelor of Science degree in Health Service Administration from Providence College. She is an AAPC certified coder and PMCC instructor.
6 Speakers: Robert Skeffington, CHBME Robert Skeffington, a founding partner and Executive VP of Sales and Marketing for Priority Management Group, Inc. (PMG). Responsible for PMG s overall business development strategy, Robert also works with staff to assess the impact of Health Care Reform on PMG and its hundreds of clients. Robert works diligently to enhance relationships with the National Association of Community Health Centers, state and regional CHC organizations, and individual community health sites. In addition to his role in PMG Billing, Robert also leads marketing and sales efforts for PMG Consulting which provides CHC centric education, operational assistance, and training services around revenue cycle management, coding, and other health care finance related matters. During his more than 17 years in health care Robert has worked with CHCs in the 48 contiguous states with an exclusive focus on revenue cycle management for the past 12 years with PMG. He is a speaker for NACHC and other regional CHC associations on a variety of health care revenue cycle related topics. BS from Salve Regina University (Newport, RI) CHBME from the Healthcare Billing & Management Association (Laguna Cliffs, CA)
7
8 Clean Claims Objective: Paid all the money anticipated on first claim submitted CMS Billing Formats: 1500 (ANSI 837p; Part B/Professional) UB-04 (ANSI 837i; Part A/Facility and NGS) Top Reasons for Non-Payment Demographic Issues Eligibility Prior-Authorization Medical Necessity (ICD) First Pass Rate: Clearinghouse (EDI) Level Report Clean Claim Rate: Post Pay Adjudication
9 Converting Clinic Data to EDI ICD Codes In Order of Provider s Perceived Acuity: 1. Abscess: Acne: Warts: Psoriasis: Rendered Services: Linked ICD to CPT A (Level 3, established patient) 1, 2, 3, & 4 B (Any benign lesion destruction) 3 C (I&D, Simple) 1
10 Electronic Data Interchange (EDI): A History Paper Claims USPS Delivery Millions of providers sending claims to thousands of payers Billions of Claims Trillions of line items Proof of Receipt? Error Rate? Sustainability? Logistical madness The Birth of EDI Why? Computers & Practice Management Software Savings Money & Time Claim Complexity Payer Edits (e.g., CCI) Improved Accountability Local & Payer Centric Clearinghouses National clearinghouse roll up of local & regional entities
11 Note: Some content adopted from article by Michael J. Sculley A Clearinghouse What is it? Rectifying a problem; i.e., moving past a paper process Millions of licensed providers (billable NPI numbers) Thousands of third party payers Billions of claims resulting in trillions of line items USPS Managed for Years No edits, payers take all claims without exception Payers created clearinghouses Centralized aggregators as they just send & receive data Paid by providers AND by payers literally coming & going Claims bounce back BEFORE payers even see them Payer imposed edits (controls) to prevent faulty data receipt
12 A Clearinghouse Nuts & Bolts 1. Encounter form or EMR capture of patient visit is charge entered into practice management software 2. Claim is formatted into electronic file format 3. PM claim file is pushed or uploaded one of two ways: A. Direct to Payers B. To Clearinghouse 4. Clearinghouse scrubs claim based on payer guidelines 5. Claim either forwarded to payer or returned to provider for corrective action 6. Claim adjudicated by payer(s) 7. EOB/RA back to provider with payment status and (hopefully) actual payment Note: Some content adopted from article by Michael J. Sculley
13 A Clearinghouse Pro & Con Advantages of Going Direct FREE No Middleman Challenges of going direct Thousands of payers Complexity (Redundancy?) Help Desk Access PM Software Interface Updates Inability to aggregate claim data Conversion from v4010 to v5010 Advantage of Clearinghouse 24/7 Knowledge-Base Access Claim Advocate Pre-Submission Edits TAT Commitments Automated Forms Aggregated Claim Status Challenges of Clearinghouse Large Corporate Entities Unique CHC Claim Files Expensive (But Cost Effective) Note: Some content adopted from article by Michael J. Sculley
14 Transition to v5010 (1 of 3) ANSI Transaction Version 5010 (v5010) replaces v4010 ANSI: American National Standards Institute Electronic Data Interchange (EDI) transactions Impacted transaction types: Health Care Claims (format 837) Eligibility Inquiry and Response (format 270/271) Claim Status Request and Response (format 276/277) Enrollment format (format 834) Remittance Advance (format 835) Authorizations (format 278) Attachments (format 275) Version 5010: > 850 structural, technical, & content changes Renovation (v5010) versus mapping/adaptation (v4010)
15 Transition to v5010 (2 of 3) Payer Leadership Essential they run the show Only they can eliminate proprietary adaption and comply with single, standardized format Compliance Timeline (as of 1/16/09 final rule publication): Jan 2010: Level 1 testing (internal payer & provider (e.g., CHC)) Jan 2011: Begin Level 2 testing (external payer trading partners (e.g., clearinghouses, provider networks, etc.)) Jan 2012: Mandatory implementation Benefits: Increase transaction uniformity & efficiency (single standardized method versus v4010 which allowed customized mapping) Support pay-for-performance (ICD-10 specificity) Lead to fewer denials (Cleaner submission = cleaner payments)
16 Transition to v5010 (3 of 3) Center for Information Technology Leadership (CITL) 2001 study Aggregate of payer, hospital & practices on administrative overhead: $898 per capita or $253 billion (18% of national health care expenditures) Overhead defined as checking eligibility, processing claims and conducting referral and authorization requests Gartner (think tank) research estimated implementation costs against potential financial benefits of full v5010 (system wide compliance Industry wide (payer & provider) net savings: $11.6 billion to $33.8 billion HIPAA v5010: A second chance for the industry to implement transaction standards to reduce costs and increase efficiency. Healthcare Information and Management Systems Society (HIMSS), February 2009
17 Timelines for Change Initial schedule: 5010: Apr 2010 ICD-10: Oct 2011 Jan 2009 Revised Federal Register Update: 5010: Jan 2012 ICD-10: Oct : To Do list for providers Transition team development & needs assessment Individual plan creation & Launch Jan 2011 Testing of 5010 by CMS
18 ANSI 837 Claim Files ANSI 837-I I = Institutional Paper Version: UB-04 Qualifiers (Examples) HC: CPT; XX: NPI Encounter Rate (Part A) Revenue Codes CR 7038, HCPCS also Attending Provider Billable is FQHC group, not actual (rendering) provider ANSI 837-P P = Professional Paper Version: CMS 1500 Qualifiers (Examples) HC: CPT; XX: NPI Medicaid, Part B, & Commercial HCPCS Codes For Example, CPT Rendering Provider Billable is actual provider, not FQHC group
19 ANSI 837 Loops, Segments, & Elements Loops: First Identifier in 837 File Format Segments: Secondary identifier modifying or delineating the Loops Elements: Tertiary identifier modifying or delineating the Segments Analogy: Paragraph (Loops) Sentence (Segments) Word (Elements) File Viewer necessary to delineate raw 837 data Beginning of new line in raw data indicated by ~ Each Payer may have unique Companion Guide assigning unique definitions to these loops CHECK WITH COMMERCIAL & MEDICARE PAYERS
20 ANSI 837 Qualifiers BK = ICD Code (a.k.a., diagnosis or reason for visit code) EI = Employer Identification Number (e.g., EIN, Tax ID) HC = HCPCS (e.g., CPT) Code MI = Patient (Payer s Member) ID Number SY = Social Security Number XX = National Provider Identifier (NPI) ZZ = Taxonomy Code 82 = Rendering Provider 85 = Billing Provider
21 ANSI 837- Professional ISA*00* *00* *ZZ*RI105 *ZZ*MCC *110208*0143*U*00401* *1*P*:~GS*HC*SUBID*RECEIVER NAME* *0143* *X*004010X098A1~ST*837*0033~BHT*0019*00*0033* *0143*CH~ REF*87*004010X098A1~NM1*41*2*SENDER NAME*****46*SUBID~PER*IC*JANE NAME*****46*XYZ~HL*1**20*1~NM1*85*2*COMMUNITY HEALTH CENTER*****XX* ~N3*DBA COMMUNITY HEALTH CENTER*PO BOX 99999~N4*ANYWHERE*RI* ~REF*EI* ~HL*2*1*22*0~SBR*P*18*******MB~NM1*IL*1 *MOUSE*MICKEY****MI* A~N3*101 ANY DRIVE~N4*ANYWHERE*RI*12345~DMG*D8* *F~NM1*PR*2*MEDICARE*****PI*MCARE~N3*P O BOX 999~N4*WHOVILLE*GA*98765~CLM*447540*13***11::1*Y*A*Y*Y*B~REF*X4*99D ~HI*BK:2859* BF:71590*BF:4019~NM1*DN*1*SANBERG*JONAS*G**MD*XX* ~REF*EI* ~NM1*82*1 *SANBERG*JONAS*G**MD*XX* ~PRV*PE*ZZ*261QF0400X~REF*EI* ~NM1*77*2*CO MMUNITY HEALTH CENTER*****XX* ~N3*123 MAIN ST~N4*ANYTOWN*RI*12345~LX*1~SV1*HC:85018:QW*13*UN*1***1:2:3~DTP*472*D8* ~REF*6R *75572~HL*3*1*22*0~SBR*P*18*******MB~NM1*IL*1*DUCK*DONALD***JR*MI* A~N3*130 MAINST~N4*ANYTOWN*RI*12345~DMG*D8* *M~NM1*PR*2*MEDICARE*****PI*MCARE~N3*P O BOX 999~N4*WHOVILLE*GA*98765~CLM*447870*13***11::1*Y*A*Y*Y*B~REF*X4*99D ~HI*BK:V700~ NM1*DN*1*SANBERG*JONAS*G**MD*XX* ~REF*EI* ~NM1*82*1*SANBERG*JONA S*G**MD*XX* ~PRV*PE*ZZ*261QF0400X~REF*EI* ~NM1*77*2*COMMUNITY HEALTH CENTER*****XX* ~N3*12S MAIN ST~N4*ANYTOWN*RI*12345~LX*1~SV1*HC:81002*13*UN*1***1~DTP*472*D8* ~REF*6R*75616~ SE*60*0033~GE*1* ~IEA*1* ~
22 ANSI 837- Institutional ISA*00* *00* *ZZ*HM57570 *28*00450 *110211*0526*U*00401* *1*P*:~GS*HC*HM57570*00450* *0526* *X*004010X096A1~ST*837*0789~BHT*0019*00*0789* *0526*CH ~REF*87*004010X096A1~NM1*41*2*SENDOR NAME*****46*HM57570~PER*IC*JANE *2*MEDICARE*****46*00450~HL*1**20*1~NM1*85*2*HEALTH CENTER*****XX* ~N3*123 UNKNOWN ST~N4*ANYTOWN*RI*01234~REF*EI* ~HL*2*1*22*0~SBR*P*18******* MA~NM1*IL*1*MOUSE*MICKEY****MI* A~N3*P.O BOX 123~N4*ANYTOWN*RI*01234~DMG*D8* *M~NM1*PR*2*MEDICARE UGS*****PI*00450~N3*6775 WEST WASHINGTON STREET~N4*MILWAUKEE*WI* ~CLM*993170*136***77:A:1*Y*A*Y*Y *********Y~DTP*434*RD8* ~REF*EA*52427~HI*BK:25000~HI*BF:4011*BF:2722~NM1*71*1*SMITH*J OSEPH*M**MD*XX* ~PRV*AT*ZZ*207Q00000X~REF*EI* ~N M1*FA*2*HEALTH CENTER*****XX* ~N3*123 UNKNOWN ST~N4*ANYTOWN*RI* ~REF*EI* ~LX*1~SV2*0521*HC:99214* 136*UN*1~DTP*472*D8*
23 Step by Step: Ntierprise Example (1 of 10) VALIDATING CLAIMS Validating Electronic Claims 1. In Ntierprise go to Billing 2. Go to Insurance Billing 3. On the Validate Claims tab choose Electronic Format 4. Sort Claims By: Provider 5. Select Print Claims Validation List so you may correct any errors 6. Choose Run, then Preview
24 Step by Step: Ntierprise Example (2 of 10)
25 Step by Step: Ntierprise Example (3 of 10) The Claim The Claim Validation Validation List List will will populate. populate. This This may contain may errors contain that will errors need that to will need to be corrected be corrected in Ntierprise in Ntierprise in order for the in order claim(s) for to be the billed. claim(s) to be billed.
26 Step by Step: Ntierprise Example (4 of 10) When/if all corrections have been made, follow the above steps to create another validation with preferably no errors. If you do not validate after making corrections those claims will not be included in the next billing.
27 Step by Step: Ntierprise Example (5 of 10) VALIDATING PAPER CLAIMS 1. In Ntierprise, go to Billing 2. Go to Insurance Billing 3. On the Validate Claims tab choose Paper Format 4. Sort Claims By: Provider 5. Select Print Claims Validation List 6. Choose Run, then Print
28 Step by Step: Ntierprise Example (6 of 10)
29 Step be listed by in the Step: Failed Validation column. Ntierprise Example (7 of 10) Totals of the claims ready to be printed will be in the Passed column. If there are any errors they will be before the Total Summary and will also be listed in the Failed Validation column.
30 Step by Step: Ntierprise Example (8 of 10) COMPLETING A PREPARE To be completed after validating claims. 1. In Ntierprise go to Billing 2. Go to Insurance Billing 3. Prepare Electronic Claims tab 4. Highlight the format you are going to bill 5. Choose Run 6. Press Print
31 Step by Step: Ntierprise Example (9 of 10)
32 Now the prepare can be submitted to the clearinghouse so the claims can be sent to the payers. Step by Step: Ntierprise Example (10 of 10) The Prepared Claims List will populate. number On the of last claims page billed you will along find with the the total total number dollar amount of claims of the billed prepare. along with the total dollar amount of the prepare. The Prepared Claims List will populate. On the last page you will find the total
33 A Sample of Rejected EDI Analysis **EDI: Electronic Data Interchange 55% Denial due to Eligibility Issues
34 Better Sample of Rejected EDI Analysis
35 Front Desk Feedback: Sample CBO Communication
36 Best Practices & EDI Optimization Tools Consistent transmission timeline (frequency) Redundant systems Who has skills & access to written process Back-up players must get in the game CMS1500 conversion to 837P (Boxes to Loops) S1500.html# Rapid Response to EDI failures How do you catch it, fix it, & prevent repeat?
37 Summary EDI (e.g., ANSI 837 file) Format is consistent nationally EDI Process varies dramatically Use First Pass (Validation Failures) to educate staff and improve process/rules Work with Clearinhouse for v5010 transition Performance benchmarks are critical Automation is not always automatic Stay educated and informed
38 Contact Information Priority Management Group, Inc. (PMG) 700 School Street Pawtucket, RI P: F: Raymond Jorgensen, President & CEO Robert Skeffington, CHBME, Partner and Co-founder Caroline Peucker, Vice President, Consulting and Compliance
Unpaid Claims Management
Unpaid Claims Management National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210 Bethesda, MD 20814 301-347-0400 301-347-0459 FAX www.nachc.com AGENDA Introduction Clean
More informationCharge Capture via EMR vs. Manual Charge Entry
Charge Capture via EMR vs. Manual Charge Entry National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210 Bethesda, MD 20814 301-347-0400 301-347-0459 FAX www.nachc.com Agenda
More informationMedical Billing - Top 5 Most Commonly Asked Questions
Agenda Charge Capture via EMR vs. Manual Charge Entry National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210 Bethesda, MD 20814 301-347-0400 301-347-0459 FAX www.nachc.com
More informationPriority Management Group, Inc.
Priority Management Group, Inc. Presents Priority Management Group, Inc. 700 School Street Pawtucket, RI 02860 P: 401-616-2000 F: 401-616-2001 www.chcbilling.com Agenda Introduction Clean Claim Components
More informationMedicare FQHC Changes 2011 Change Request 7038
Medicare FQHC Changes 2011 Change Request 7038 National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210 Bethesda, MD 20814 301-347-0400 301-347-0459 FAX www.nachc.com Agenda
More informationPriority Management Group, Inc.
Priority Management Group, Inc. Presents Priority Management Group, Inc. 700 School Street Pawtucket, RI 02860 P: 401-616-2000 F: 401-616-2001 www.chcbilling.com Agenda Introduction Clean Claim Components
More informationICD-10 What To Expect
ICD-10 What To Expect National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210 Bethesda, MD 20814 301-347-0400 301-347-0459 FAX www.nachc.com Agenda Introduction Common
More informationCredentialing, 855 Forms and NPI for Community Health Centers
Credentialing, 855 Forms and NPI for Community Health Centers National Association of Community Health Centers (NACHC) 7200 Wisconsin Avenue, Suite 210 Bethesda, MD 20814 301-347-0400 301-347-0459 FAX
More information837I Health Care Claims Institutional
837 I Health Care Claim Institutional For Independence Administrators - 1 Disclaimer This Independence Administrators (hereinafter referred to as IA ) Companion Guide to EDI Transactions (the Companion
More information837P Health Care Claim Professional
837P Health Care Claim Professional Revision summary Revision Number Date Summary of Changes 6.0 5/27/04 Verbiage changes throughout the companion guide 7.0 06/29/04 Updated to include the appropriate
More informationSection 9. Claims Claim Submission Molina Healthcare PO Box 22815 Long Beach, CA 90801
Section 9. Claims As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your
More informationCLAIMS Section 5. Overview. Clean Claim. Prompt Payment. Timely Claims Submission. Claim Submission Format
Overview The Claims department partners with the Provider Relations, Health Services and Customer Service departments to assist providers with any claims-related questions. The focus of the Claims department
More information837 I Health Care Claim Institutional
837 I Health Care Claim Institutional Revision Number Date Summary of Changes 6.0 5/27/04 Verbiage changes throughout the companion guide 7.0 06/29/04 Updated to include the appropriate AmeriHealth qualifier
More informationCompensation and Claims Processing
Compensation and Claims Processing Compensation The network rate for eligible outpatient visits is reimbursed to you at the lesser of (1) your customary charge, less any applicable co-payments, coinsurance
More informationGlossary of Terms. Account Number/Client Code. Adjudication ANSI. Assignment of Benefits
Account Number/Client Code Adjudication ANSI Assignment of Benefits Billing Provider/Pay-to-Provider Billing Service Business Associate Agreement Clean Claim Clearinghouse CLIA Number (Clinical Laboratory
More informationMEDICAL CLAIMS AND ENCOUNTER PROCESSING
MEDICAL CLAIMS AND ENCOUNTER PROCESSING February, 2014 John Williford Senior Director Health Plan Operations 2 Medical Claims and Encounter Processing Medical claims and encounter processing is part of
More informationUnderstanding the HIPAA standard transactions: The HIPAA Transactions and Code Set rule
Understanding the HIPAA standard transactions: The HIPAA Transactions and Code Set rule Many physician practices recognize the Health Information Portability and Accountability Act (HIPAA) as both a patient
More informationICD-10 Overview. The U.S. Department of Health and Human Services implementation deadline for compliance with ICD-10, Mandate is October 1, 2014.
ICD-10 Overview ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD), a medical classification list by the World Health Organization
More information837 I Health Care Claim HIPAA 5010A2 Institutional
837 I Health Care Claim HIPAA 5010A2 Institutional Revision Number Date Summary of Changes 1.0 5/20/11 Original 1.1 6/14/11 Added within the timeframes required by applicable law to page 32. Minor edits
More informationThe benefits of electronic claims submission improve practice efficiencies
The benefits of electronic claims submission improve practice efficiencies Electronic claims submission vs. manual claims submission An electronic claim is a paperless patient claim form generated by computer
More informationAdministrative Services of Kansas
Administrative Services of Kansas ANSI X12N 837D V4010A1 Health Care Claim Companion Guide - Dental, INC BlueCross BlueShield of Western New York BlueShield of Northeastern New York Last Updated March
More informationElectronic Transaction Manual for Arkansas Blue Cross and Blue Shield FEDERAL EMPLOYEE PROGRAM (FEP) Dental Claims
Electronic Transaction Manual for Arkansas Blue Cross and Blue Shield FEDERAL EMPLOYEE PROGRAM (FEP) Dental Claims HIPAA Transaction Companion Document Guide Refers to the X12N Implementation Guide: 005010X224A2:
More informationICD-10 Frequently Asked Questions
ICD-10 Frequently Asked Questions ICD-10 General Overview... 3 What is ICD-10?... 3 Why are we adopting ICD-10?... 3 What are the benefits of the ICD code expansion?... 3 What does ICD-10 compliance mean?...
More informationHIPAA Compliance. Saeed Rajput
HIPAA Compliance 1 What is HIPAA 26 cents of each health care dollar is spent on administrative overhead Health Insurance Portability & Account- ability Act - 1996 Public Law 104-191 191 To reform the
More informationEDI Solutions Your guide to getting started -- and ensuring smooth transactions empireblue.com/edi
EDI Solutions Your guide to getting started -- and ensuring smooth transactions empireblue.com/edi 00175NYPEN Rev. 12/11 This brochure is a helpful EDI reference for both new and experienced electronic
More information835 Health Care Claim Payment/Advice Companion Guide
835 Health Care Claim Payment/Advice Companion Guide HIPAA/V5010X221A1/835 Version: 1.2 Company: Blue Cross of Idaho Created: 07/18/2014 1.1 Disclaimer Blue Cross of Idaho (BCI) created this Companion
More informationHIPAA Transactions and Code Set Standards As of January 2012. Frequently Asked Questions
HIPAA Transactions and Code Set Standards As of January 2012 Frequently Asked Questions Version 20 Rev 11222011 Frequently Asked Questions: HIPAA Transactions and Code Set Standards One of the most prominent
More informationBILLING COMPANY STANDARDS
BILLING COMPANY STANDARDS ASSESSING PRACTICE VALUE OF OUTSOURCING Cost Saving Efficiencies gained Improved collections Compliance Once a decision to out source is made the following due diligence should
More informationFrequently Asked Questions about ICD-10-CM/PCS
Frequently Asked Questions about ICD-10-CM/PCS Q: What is ICD-10-CM/PCS? A: ICD-10-CM (International Classification of Diseases -10 th Version-Clinical Modification) is designed for classifying and reporting
More informationMolina Healthcare of Ohio, Inc. PO Box 22712 Long Beach, CA 90801
Section 9. Claims As a contracted provider, it is important to understand how the claims process works to avoid delays in processing your claims. The following items are covered in this section for your
More information5010 Gap Analysis for Dental Claims. Based on ASC X12 837 v5010 TR3 X224A2 Version 2.0 August 2010
5010 Gap Analysis for Dental Claims Based on ASC X12 837 v5010 TR3 X224A2 Version 2.0 August 2010 This information is provided by Emdeon for education and awareness use only. Even though Emdeon believes
More informationWEEK CHAPTER OBJECTIVES ASSIGNMENTS & TESTS 19-20 6A medical necessity as it ICD-9-CM Coding. relates to reporting diagnosis codes on claims.
HEALTH INSURANCE & CODING Textbook: Understanding Health Insurance: A Guide to Billing and Reimbursement 11 th edition Website Activities: StudyWARE Online Practice Software linked to the book. SimClam:
More informationACS DOL. Electronic Submission Standard Changes. Provider Training X12N 5010
ACS DOL Electronic Submission Standard Changes Provider Training X12N 5010 AGENDA Purpose Acronyms and Definitions What is an Electronic Submission? Electronic Submission Overview What s New? Submission
More informationARIZONA FOUNDATION FOR MEDICAL CARE ANSI X12 837 V.5010 COMPANION GUIDE. 1 Arizona Foundation for Medical Care
ARIZONA FOUNDATION FOR MEDICAL CARE ANSI X12 837 V.5010 COMPANION GUIDE 1 Arizona Foundation for Medical Care TABLE OF CONTENTS EDI Communication...3 Getting Started...3 Testing...4 Communications...4
More informationCompensation and Claims Processing
Compensation and Claims Processing Compensation The network rate for eligible outpatient visits is reimbursed to you at the lesser of (1) your customary charge, less any applicable co-payments, coinsurance
More informationICD-10 Action Plan: Your 12-Step Transition Plan for ICD-10. Written by the AMA CPT Medical Informatics Department
ICD-10 Action Plan: Your 12-Step Transition Plan for ICD-10 Written by the AMA CPT Medical Informatics Department P R A C T I C E T O O L S E P T E M B E R 2 0 1 2 This resource is for educational purposes
More informationBlueCross BlueShield of Tennessee Electronic Provider Profile
Date: Business Name: SECTION 1 PURPOSE FOR PROFILE Please PLACE A CHECK MARK using blue or black ink by the purpose for completing the. The chart below indicates with an X the sections that need to be
More informationMedicare-Medicaid Crossover Claims FAQ
Medicare-Medicaid Crossover Claims FAQ Table of Contents 1. Benefits of Crossover Claims... 1 2. General Information... 1 3. Medicare Part B Professional Claims and DMERC Claims... 2 4. Professional Miscellaneous...
More informationCMS. Standard Companion Guide Transaction Information
CMS Standard Companion Guide Transaction Information Instructions related to the 837 Health Care Claim: Professionals based on ASC X Technical Report Type 3 (TR3), version 00500A Companion Guide Version
More informationBLUE CROSS AND BLUE SHIELD OF LOUISIANA DENTAL CLAIMS COMPANION GUIDE
BLUE CROSS AND BLUE SHIELD OF LOUISIANA CLAIMS Table of Contents I. Introduction... 3 II. General Specifications... 4 III. Enveloping Specifications... 5 IV. Loop and Data Element Specifications... 7 V.
More informationInsurance 101. Infant and Toddler Coordinators Association. July 28, 2012 Capital City Hyatt. Laura Pizza Plum Plum Healthcare Consulting
Insurance 101 Infant and Toddler Coordinators Association July 28, 2012 Capital City Hyatt Laura Pizza Plum 1 Agenda Basics of Health Insurance Frequently Asked Questions Early Intervention and working
More informationINTERMEDIATE ADMINISTRATIVE SIMPLIFICATION CENTERS FOR MEDICARE & MEDICAID SERVICES. Online Guide to: ADMINISTRATIVE SIMPLIFICATION
02 INTERMEDIATE» Online Guide to: CENTERS FOR MEDICARE & MEDICAID SERVICES Last Updated: February 2014 TABLE OF CONTENTS INTRODUCTION: ABOUT THIS GUIDE... i About Administrative Simplification... 2 Why
More information837 Professional Health Care Claim Encounter. Section 1 837P Professional Health Care Claim Encounter: Basic Instructions
Companion Document 837P This companion document is for informational purposes only to describe certain aspects and expectations regarding the transaction and is not a complete guide. The details contained
More informationOptimizing Your Billing System to Produce Clean Claims
Optimizing Your Billing System to Produce Clean Claims Chris Peters, ACL Laboratories Road to Billing Optimization Missing Billing Information Missing test modifiers Wrong billing address Insurance coverage
More informationHorizon Blue Cross and Blue Shield of New Jersey
Horizon Blue Cross and Blue Shield of New Jersey Companion Guide for Transaction and Communications/Connectivity Information Instructions related to Transactions based on ASC X12 Implementation Guides,
More informationEnrollment Guide for Electronic Services
Enrollment Guide for Electronic Services 2014 Kareo, Inc. Rev. 3/11 1 Table of Contents 1. Introduction...1 1.1 An Overview of the Kareo Enrollment Process... 1 2. Services Offered... 2 2.1 Electronic
More informationEDI Solutions Your guide to getting started -- and ensuring smooth transactions bcbsga.com/edi
EDI Solutions Your guide to getting started -- and ensuring smooth transactions 00175GAPENBGA Rev. 12/11 This brochure is a helpful EDI reference for both new and experienced electronic submitters. It
More informationImagine that your practice could submit
What the HIPAA Transactions and Code Set Standards Will Mean for Your Practice If there s a silver lining to the HIPAA regulations, it s here. These standards can save your practice time and money. David
More informationChapter 5 Claims Submission Unit 1: Benefits of Electronic Communication
Chapter 5 Claims Submission Unit 1: Benefits of Electronic Communication In This Unit Topic See Page Unit 1: Benefits of Electronic Communication Electronic Connections 2 Electronic Claim Submission Benefits
More information2011 Provider Workshops. EDI Presents
2011 Provider Workshops EDI Presents 1 Electronic Transaction Exchange The electronic format you exchange with BCBSLA today is referred to as: ANSI 4010A1, HIPAA 4010A1 or 4010 Changes have been made and
More informationCoventry receives claims in two ways:
Coventry receives claims in two ways: Paper Claims Providers send claims to the specific Coventry PO Box, which are keyed by our vendor and sent via an EDI file for upload into IDX. Electronic Claims -
More informationReal Time Adjudication
Real Time Adjudication THE HOLY GRAIL or NOT? Market Trends AMA 2009 Cost Survey Report With 2008 Data 9.9% fewer procedures Nunber of patients dropped 11.3% Multi-specialty practices bad debts increased
More informationSECTION 4. A. Balance Billing Policies. B. Claim Form
SECTION 4 Participating Physicians, hospitals and ancillary providers shall be entitled to payment for covered services that are provided to a DMC Care member. Payment is made at the established and prevailing
More informationOverview on Claims Submission Requirements, Electronic Billing Options, and Provider Website Features
Overview on Claims Submission Requirements, Electronic Billing Options, and Provider Website Features Magellan Direct Submit Electronic and Contracted Claim Submission Clearinghouses Webinar Session for
More informationICD-10 Post Implementation: News from the Front Lines
ICD-10 Post Implementation: News from the Front Lines Presented by: Paula Kleiman, RHIA, CPC, AHIMA ICD-10-CM Trainer CEO/President, Creatively HIM Consulting Services, Inc. Agenda ICD-10 Post Implementation
More informationTo submit electronic claims, use the HIPAA 837 Institutional transaction
3.1 Claim Billing 3.1.1 Which Claim Form to Use Claims that do not require attachments may be billed electronically using Provider Electronic Solutions (PES) software (provided by Electronic Data Systems
More informationPROSPECT MEDICAL GROUP DOWNSTREAM PROVIDER NOTICE CLAIMS SETTLEMENT PRACTICES AND DISPUTE RESOLUTION MECHANISM
PROSPECT MEDICAL GROUP DOWNSTREAM PROVIDER NOTICE CLAIMS SETTLEMENT PRACTICES AND DISPUTE RESOLUTION MECHANISM As required by Assembly Bill 1455, the California Department of Managed Health Care has set
More informationBasics of the Healthcare Professional s Revenue Cycle
Basics of the Healthcare Professional s Revenue Cycle Payer View of the Claim and Payment Workflow Brenda Fielder, Cigna May 1, 2012 Objective Explain the claim workflow from the initial interaction through
More informationFAQ ICD 10. Categories: Compliance Billing General Claims Testing COMPLIANCE: Q. When is the ICD 10 compliance deadline? A.
FAQ ICD 10 Categories: Compliance Billing General Claims Testing COMPLIANCE: Q. When is the ICD 10 compliance deadline? A. October 1, 2015 Q. What does ICD 10 compliance mean? A. IDC 10 compliance means
More informationPreparing Your Revenue Cycle for ICD-10. Carrie Aiken, CHC Compliance and Consulting Manager
Preparing Your Revenue Cycle for ICD-10 Carrie Aiken, CHC Compliance and Consulting Manager Today s Presenter Carrie Aiken SVA Healthcare Services, LLC 608.826.2451 aikenc@sva.com 1 Objectives Seeing Revenue
More informationMolina Healthcare of Puerto Rico (MHPR) Non-Participating Provider Information
Molina Healthcare of Puerto Rico (MHPR) Non-Participating Provider Information Please refer to Carta Normativa 15-0326 Re Transicion for details regarding the ASES-established Transition of Care and Reimbursement
More informationHow To Use An Electronic Data Exchange (Edi)
Electronic Data Interchange Companion Document HIPAA...3 Getting Started with EDI...4 When You Are Set Up for EDI...4 When You Are Ready to Go Live...5 Specifications for 837P Transactions...6 Transaction
More informationThis information is current as of the training dates.
Welcome to this training on Billing Basics for Washington State Local Health Jurisdictions. This training will help you understand basic principles and processes needed for billing private insurance. This
More informationNational Electronic Data Interchange Transaction Set Companion Guide Health Care Claims Institutional & Professional 837 ASC X12N 837 (004010X096)
National Electronic Data Interchange Transaction Set Companion Guide Health Care Claims Institutional & Professional 837 ASC X12N 837 (004010X096) DMC Managed Care Claims - Electronic Data Interchange
More informationHIPAA EDI Companion Guide For 270/271 Eligibility Inquiry & Response Companion Guide Version: 3.0
HIPAA EDI Companion Guide For 270/271 Eligibility Inquiry & Response Companion Guide Version: 3.0 ASCX12N National Electronic Data Interchange Transaction Set Implementation and Addenda Guides, Version
More informationHealthcare Management Boot Camp November 3-7, 2014 in Anaheim, California
2014 Healthcare Management Boot Camp November 3-7, 2014 in Anaheim, California Coding / Auditing / Billing / Compliance / Practice Management 32 AAPC Approved CEUs for Core A, CPCO, CPMA and CPPM Course
More informationHIPAA X 12 Transaction Standards
HIPAA X 12 Transaction Standards Companion Guide 837 Professional/ Institutional Health Care Claim Version 5010 Trading Partner Companion Guide Information and Considerations 837P/837I June 11, 2012 Centene
More informationChildren s Long Term Support (CLTS) Waiver Third Party Administration (TPA) Claims Processing
Children s Long Term Support (CLTS) Waiver Third Party Administration (TPA) Claims Processing Wisconsin Department of Health Services Division of Long Term Care Bureau of Long-Term Support 1 Third Party
More informationABC1234567 1478940520. Ex. Blue Shield Plan ID
Health Care Service Corporation (HCSC) and its operating divisions, BCBS IL, NM, OK and TX, have taken deep strides to educate and update its providers on the impending changes related to the National
More informationProfessional Coders Role in Compliance
Professional Coders Role in Compliance Sponsored by 1915 N. Fine Ave #104 Fresno CA 93720-1565 Phone: (559) 251-5038 Fax: (559) 251-5836 www.californiahia.org Program Handouts Monday, June 8, 2015 Track
More informationFrequently Asked Questions About Quality Data Reporting
Why am I being asked to submit claims for all of my patients if SQCN does not have any payer contracts? SQCN is a Clinical Integration (CI) network. The success of our network will depend upon our CI program
More informationQ4. Is BCBSAZ going to update the HIPAA Version 5010 Companion Guide??
An Independent Licensee of the Blue Cross and Blue Shield Association ICD-10 FAQs General Questions Q1. What are ICD-10-CM and ICD-10-PCS? A1. ICD-10-CM is the International Classification of Diseases,
More informationEZClaim Advanced 9 ANSI 837P. Capario Clearinghouse Manual
EZClaim Advanced 9 ANSI 837P Capario Clearinghouse Manual EZClaim Medical Billing Software December 2013 Capario Client ID# Capario SFTP Password Enrollment Process for EDI Services 1. Enroll with the
More informationUPMC HEALTH PLAN. HIPAA EDI Companion Guide For 837 Institutional Claims File
UPMC HEALTH PLAN HIPAA EDI Companion Guide For 837 Institutional Claims File Companion Guide Version: 0.1 Refers to the Implementation Guide Based on X12 Version 005010X223A1 ~ 1 ~ Overview Batch File
More informationBelow are some frequently asked questions that may assist your practice.
Dear Providers: With the recent announcement in the delay for the implementation for ICD-10-CM/PCS we wanted to provide an update on Blue Cross and Blue Shield of Vermont s (BCBSVT) implementation. We
More informationManagement Report Services. Staff Training and Education Services
Management Report Services Your management team will receive reports that are clear, well defined and serve as a tool for increased performance. These include a brief description emphasizing how the information
More informationNational Provider Identifier (NPI) NPI 201 Claims Filing Instructions
*NOTE: This reference guide was developed specifically to assist providers with claim submission during the dual identifier acceptance phase. At the time of original publication, this NPI 201 material
More informationSECTION E Molina Healthcare CLAIMS
SECTION E Molina Healthcare CLAIMS CLAIMS CLAIM SUBMISSION (Refer to Section J, Claims, in the 2007 Provider Manual for detailed information) Professional Fees Claims must be submitted on a CMS (Centers
More informationEDI Solutions Your guide to getting started -- and ensuring smooth transactions anthem.com/edi
EDI Solutions Your guide to getting started -- and ensuring smooth transactions anthem.com/edi 00175CEPEN (04/12) This brochure is a helpful EDI reference for both new and experienced electronic submitters.
More informationIntroduction to ICD-10-CM and PCS. ICD Background. ICD Use ICD Codes are reported on the hospital/physician claim form
Introduction to ICD-10-CM and PCS Sheila Goethel, RHIT, CCS Coding Consultant and AHIMA ICD-10 Certified Trainer Rural Wisconsin Health Cooperative June 2011 ICD Background The INTERNATIONAL CLASSIFICATION
More informationMountain Park Health Center Billing Services. Request for Proposal
Mountain Park Health Center Billing Services Request for Proposal Mountain Park Health Center 2702 North 3 rd Street, Suite 4020 Phoenix, AZ 85004 Page 1 of 8 I. Purpose of Request Mountain Park Health
More informationAt the End of the Day Does the Pipeline Deliver: Cerner / WellPoint ICD-10 Pilot Test Collaboration
At the End of the Day Does the Pipeline Deliver: Cerner / WellPoint ICD-10 Pilot Test Collaboration Elaine O Bleness MBA, RHIA, CHP, AHIMA-approved ICD-10 CM/PCS Trainer Cerner Revenue Cycle Executive
More informationHIPAA: AN OVERVIEW September 2013
HIPAA: AN OVERVIEW September 2013 Introduction The Health Insurance Portability and Accountability Act of 1996, known as HIPAA, was enacted on August 21, 1996. The overall goal was to simplify and streamline
More informationWelcome. ICD-10 Road to Ten : ICD-10 Implementation Guidance
Welcome ICD-10 Road to Ten : ICD-10 Implementation Guidance Jean Stevens, RHIT, CCS-P AHIMA ICD-10 Ambassador and OSMA education consultant Melissa Little, Medicaid Health Systems Administrator, Ohio Medicaid
More informationWhat Every Medical Practice Must Do to Optimize Workflow and Maximize Revenue While Decreasing Costs
What Every Medical Practice Must Do to Optimize Workflow and Maximize Revenue While Decreasing Costs Don t just trust that your staff is maximizing time and revenue. It is up to you to monitor, analyze
More informationPOST ACA REVENUE CYCLE TRANSFORMATION
POST ACA REVENUE CYCLE TRANSFORMATION Agenda Intro Revenue cycle features ACA impact areas What did we expect? UDS and PMG data analytics Top to-do items Summary WWW.GOPMG.COM ICD 10 Update* Encounters
More informationBilling and Claim Billing and Claim Submission Boot Camp Submission Boot Camp Beverly Remm Beverly Remm
Billing and Claim Submission Boot Camp Presented by: Beverly Remm Orion Healthcare Technology Billing and Claim Submission Boot Camp Presented by: Beverly Remm Orion Healthcare Technology The presentation
More informationWhat s Up Wednesday. Together Let s Get ICD-10 Ready. Date: July 15, 2015 Time: 2 3 p.m. Phone Number: 800-882-3610 Pass code: 5411307
What s Up Wednesday Together Let s Get ICD-10 Ready Date: July 15, 2015 Time: 2 3 p.m. Phone Number: 800-882-3610 Pass code: 5411307 Presented by the Pennsylvania Blues Plans 2 What s Up Wednesday and
More information. NOTE: See Chapter 5 - Medical Management System for conditions that must be met in CHAPTER 6. ELECTRONIC CLAIMS PROCESSING MODULE
Electronic Claims Processing Module 6-1 CHAPTER 6. ELECTRONIC CLAIMS PROCESSING MODULE Processing claims electronically is an option that may be selected in place of or in conjunction with the processing
More informationHIPAA Administrative Simplification and Privacy (AS&P) Frequently Asked Questions
HIPAA Administrative Simplification and Privacy (AS&P) Frequently Asked Questions ELECTRONIC TRANSACTIONS AND CODE SETS The following frequently asked questions and answers were developed to communicate
More informationICD-10 Compliance Date
ICD-10 Implementation Frequently Asked Questions Updated September 2015 ICD-10 Compliance Date The U.S. Department of Health and Human Services (HHS) issued a rule on July 31, 2014 finalizing October 1,
More informationArkansas Blue Cross Blue Shield EDI Report User Guide. May 15, 2013
Arkansas Blue Cross Blue Shield EDI Report User Guide May 15, 2013 Table of Contents Table of Contents...1 Overview...2 Levels of Editing...3 Report Analysis...4 1. Analyzing the Interchange Acknowledgment
More informationSTATE OF MARYLAND KIDNEY DISEASE PROGRAM UB-04. Billing Instructions. for. Freestanding Dialysis Facility Services. Revised 9/1/08.
STATE OF MARYLAND KIDNEY DISEASE PROGRAM UB-04 Billing Instructions for Freestanding Dialysis Facility Services Revised 9/1/08 Page 1 of 13 UB04 Instructions TABLE of CONTENTS Introduction 4 Sample UB04
More informationICD-10. New Mexico Medicaid. Presenter: Xerox State Healthcare LLC Provider Field Representative
ICD-10 New Mexico Medicaid Presenter: Xerox State Healthcare LLC Provider Field Representative Purpose This training will provide an overview ICD-10 and what providers should do to prepare for the transition
More informationMake the most of your electronic submissions. A how-to guide for health care providers
Make the most of your electronic submissions A how-to guide for health care providers Enjoy efficient, accurate claims processing and payment Reduce your paperwork burden and paper waste Ease office administration
More informationMedicaid Managed Care Program (STAR) and Children s Health Insurance Program (CHIP) FQHC/RHC Claims and Billing Training
Medicaid Managed Care Program (STAR) and Children s Health Insurance Program (CHIP) FQHC/RHC Claims and Billing Training 2012 Provider Training Rev 030512 A Division of Health Care Service Corporation,
More information276/277 Health Care Claim Status Request and Response Transactions
276/277 Health Care Claim Status Request and Response Transactions IBC/KHPE 276/277 Trading Partner Companion Guide V4.0 Rev. 12..06-1 - Disclaimer This Independence Blue Cross and Keystone Health Plan
More informationHow To Submit 837 Claims To A Health Plan
UPMC HEALTH PLAN HIPAA EDI Companion Guide For 837 Professional Claims File Companion Guide Version: 0.1 Refers to the Implementation Guide Based on X12 Version 005010X222A1 ~ 1 ~ Overview Batch File Submissions
More informationHOW TO PREVENT AND MANAGE MEDICAL CLAIM DENIALS TO INCREASE REVENUE
Billing & Reimbursement Revenue Cycle Management HOW TO PREVENT AND MANAGE MEDICAL CLAIM DENIALS TO INCREASE REVENUE Billing and Reimbursement for Physician Offices, Ambulatory Surgery Centers and Hospitals
More informationClaim Status Request and Response Transaction Companion Guide
Claim Status Request and Response Transaction Companion Guide Version 1.2 Jan. 2015 Connecticut Medical Assistance Program Disclaimer: The information contained in this companion guide is subject to change.
More information