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 of insurance claims on paper (CMS-1500, UB04, etc). From the Main Menu: Select Insurance Processing and the Insurance Processing Menu will be displayed. Select Electronic Claims Interface. A screen will appear asking, Do you wish to generate new electronic claims which have not been previously filed? Selecting Yes will cause the software to check the Unfiled Insurance Claims report for new electronic claims to generate, while selecting No will simply load the Electronic Claims System without generating new claims. Any new claims that are generated will be placed in the Edit Claim File in preparation of being filed electronically to your clearinghouse. The Electronic Claims System menu will appear: You may print a Claims Edit List (See Option 4 - Print Claims Edit List) to view a listing of the claims generated or regenerated. These claims may be removed from the claim file prior to compression and transmission. (See Option 1 - Edit Claim File.). NOTE: See Chapter 5 - Medical Management System for conditions that must be met in order to generate insurance claims. You also must have the ECI Carrier field in the Insurance Master Update set to the file type that you are going to be transmitting.
6-2 Electronic Claims Processing Module Edit Claim File [1] will display a list of the claims in the current batch which have already been generated or regenerated. From this list, you may view the detail of the claim, delete individual line items from a claim, or delete claims from the batch. Select All - Check marks all claims in the batch to allow you to remove them. Deselect All - Unchecks all claims that might be check marked. COB Info - Allows you to enter payment information for secondary claims transmissions. View Detail - This option will open the following window with detail on the selected claim: The Claim Detail window allows you to view the detail on a claim, remove selected procedure lines, and enter resubmission information. To remove a procedure line, check mark it by clicking the box at the far left of the line(s) you wish to delete then click Remove Line Item(s). Remove Selected Claims - Deletes selected claims from the claim batch. This does not change or delete the original transaction. + TIP: From the above two windows, you may click on the column headers to sort the data by that column.
Electronic Claims Processing Module 6-3 COB Info: If you have any secondary claims that have been generated or regenerated, the COB info will be populated with the primary insurance payment information as entered at the payment entry screen for each service line (see Chapter 5). To access this information for viewing or updating purposes, highlight the claim and press the COB Info button. The following screen will appear. There are three tabs that contain the COB information: Payer Amounts tab: Payer Adjustments tab: Payer Procedure tab: After entering this information, click the Save button. If this information is not entered, the claim will not compress into the file that will be sent to your electronic claims carrier.
6-4 Electronic Claims Processing Module Ansi Transmissions [2] allows you to send claims to the Gateway EDI Clearinghouse through their website in a standard electronic file format called ANSI. (Most clearinghouses accept this file type. Contact AMS Technical Support for further clarification if choosing any other clearinghouse but Gateway EDI.) Submitter Information [1]- This must be completed in full before compressing claims into an ANSI file. It needs to be set up once before transmitting claims for the first time, and will not need to be updated unless specified by Gateway EDI or AMS Technical Support. The following screen will appear: Default Gateway Settings When submitting claims to Gateway EDI clearinghouse, click this option to populate the Receiver fields per Gateway EDI s specifications. ISA-06 Submitter Id Assigned by your clearinghouse. For Gateway EDI users this is your Gateway Site ID. ISA-08 Receiver Id Assigned by your clearinghouse, Gateway EDI users can click the Default Gateway Settings button to fill this in automatically.
Electronic Claims Processing Module 6-5 Submitter Id Assigned by your clearinghouse. For Gateway EDI users this is your Gateway Site ID. Receiver Id Assigned by your clearinghouse, Gateway EDI users can click the Default Gateway Settings button to fill this in automatically. Submission Number Number assigned by AMS and increments each time you compress. DO NOT CHANGE THIS NUMBER! Submission Contact Name of user in your office who is the primary electronic claims user who may be the contact for electronic claims. Batch Number Number assigned by AMS and increments each time you compress. DO NOT CHANGE THIS NUMBER! Person/Non-Person Entity of this Submitter s Information. Sender Name, etc Billing name and address, same as name that prints in Block 33 of CMS. Sender Address 1 Billing address, same as address that prints in Block 33 of CMS. Sender Address 2 Billing address line 2, same as address that prints in Block 33 of CMS. Sender City Billing City, same as city that prints in Block 33 of CMS. Sender State Billing State, same as state that prints in Block 33 of CMS. Sender Zip Billing Zip, same as zip that prints in Block 33 of CMS. Sender Phone Billing Phone Number. Pay to Provider Address - ANSI 5010 Only: If your sender address does not comply with the requirements for ANSI 5010 (ie. has a PO Box or does not have ZIP+4) you may fill in this information in to send alternative pay-to provider information. Pay To Addr1 Pay-to Provider Address Line 1 Pay To Addr2 Pay-to Provider Address Line 1 Pay To City Pay-to Provider City Pay To State Pay-to Provider State Pay To Zip Pay-to Provider ZIP Don t delete claim files when compressing: When unchecked (default), previously created electronic claim files will be deleted when claims are compressed. If you wish to check this box you MUST have the files deleted upon upload to Gateway by selecting Delete the File in the file path settings on Gateway EDI s website. Prev [Record#] Next Corresponds with the Insurance Personalization Records as defined in Chapter 5 and is used for insurance carriers who require payment be made to a different Billing Name and/or Address. For example, Medicare may prefer to make checks payable to the doctor who rendered the service (Person), but Blue Cross Blue Shield may prefer the Group and/or Practice Name (Non-Person).
6-6 Electronic Claims Processing Module Remittance tab: This must be completed in full by clicking the options that apply if you choose to automatically post remittances for claims processed by Gateway EDI. Pend/Generate Secondary per Remittance file Pend/Generate Secondary per Remittance file. Unless Balance is <= Zero Always Pend Secondary when Patient has Secondary Always Generate Secondary when Patient has Secondary and Pend Secondary When Insurance Payment is Zero and Deductible is > 0, Post Payment and Adjustment Post All Zero Dollar Insurance Payments Check this option to Pend or Generate Secondary Claim according to the Primary Remittance Check this option to Pend or Generate Secondary Claim according to the Primary Remittance unless the bill balance is now zero Check this option to always Pend a Secondary Claim but not Generate one. Check this option to always Pend and Generate a Secondary claim. Check this option to always post a zero dollar payment and the adjustment when the deductible is greater than zero according to the Primary Remittance Check this option to automatically post all zero dollar payments. Post Secondary, Tertiary, Quatern Insurance Check this option to automatically post Payments Secondary, Tertiary, and Quatern Insurance Payments according to all options selected.
Electronic Claims Processing Module 6-7 Do Not Post Negative Insurance Payments Check this option to not automatically post any Insurance Payments with a negative amount. Use EOB Check Date as Payment Date Will post the payments with using the check date as the payment date. Select a Payment Code for Posting Blue Cross/Blue Shield Payments from the drop down list provided. Select a Payment Code for Posting HMO/PPO Payments from the drop down list provided. Compress Claims [2]- Compressing claims will put the claims in a file that Gateway EDI will be able to read. A window will appear stating, Compressing claims will transfer the file into a format that will be transmitted. Once compressed, the file cannot be edited again. Are you sure you wish to do this? Click Yes. If there are any secondary claims in this file that do not have COB Info attached, you will be notified of the number of claims that will be skipped and not compressed into this file. Click Yes to continue, or you may choose No to return to the Edit Claim File to attach the information. It is very important that once you Compress your claims, you send them before Compressing again or the file that was Compressed first will have to be regenerated or retrieved from the Archived Claims Folder of your AMS directory. The Don t delete claim files when compressing checkbox under Submitter Information will prevent this from occurring when checked. Gateway EDI Transmission [3] allows you to send claims to the Gateway EDI Clearinghouse through their website or by dialing directly in to them via a modem.
6-8 Electronic Claims Processing Module Submitter Information NSF [1] Submitter Information tab: This must be completed in full before compressing claims into an NSF File. It needs to be set up once before transmitting claims for the first time, and will not need to be updated unless specified by Gateway EDI or AMS Technical Support. The following screen will appear: Submitter Id Assigned by your clearinghouse. For Gateway EDI users this is your Gateway Site ID. Submission Number Number assigned by AMS and increments each time you compress. DO NOT CHANGE THIS NUMBER! Submission Contact Name of user in your office who is the primary electronic claims user who may be the contact for Gateway EDI. Batch Number Number assigned by AMS and increments each time you compress. DO NOT CHANGE THIS NUMBER! Provider Specialty Specialty code for provider. Provider License Provider s license number. Sender Name, etc Billing name and address, same as name that prints in Block 33 of CMS. Sender Address 1 Billing address, same as address that prints in Block 33 of CMS. Sender Address 2 Billing address line 2, same as address that prints in Block 33 of CMS. Sender City Billing City, same as city that prints in Block 33 of CMS. Sender State Billing State, same as state that prints in Block 33 of CMS. Sender Zip Billing Zip, same as zip that prints in Block 33 of CMS. Sender Phone Billing Phone Number.
Electronic Claims Processing Module 6-9 Prev [Record#] Next Corresponds with the Insurance Personalization Records as defined in Chapter 5 and is used for insurance carriers who require payment be made to a different Billing Name and/or Address. For example, Medicare may prefer to make checks payable to the doctor who rendered the service, but Blue Cross Blue Shield may prefer the Group and/or Practice Name. Don t delete claim files when compressing: When unchecked (default), previously created electronic claim files will be deleted when claims are compressed. If you wish to check this box you MUST have the files deleted upon upload to Gateway by selecting Delete the File in the file path settings on Gateway EDI s website. Remittance tab: This must be completed in full by clicking the options that apply if you choose to automatically post remittances for claims processed by Gateway EDI. Pend/Generate Secondary per Remittance file Pend/Generate Secondary per Remittance file. Unless Balance is <= Zero Always Pend Secondary when Patient has Secondary Always Generate Secondary when Patient has Secondary and Pend Secondary When Insurance Payment is Zero and Deductible is > 0, Post Payment and Check this option to Pend or Generate Secondary Claim according to the Primary Remittance Check this option to Pend or Generate Secondary Claim according to the Primary Remittance unless the bill balance is now zero Check this option to always Pend a Secondary Claim but not Generate one. Check this option to always Pend and Generate a Secondary claim. Check this option to always post a zero dollar payment and the adjustment when the
6-10 Electronic Claims Processing Module Adjustment Post All Zero Dollar Insurance Payments deductible is greater than zero according to the Primary Remittance Check this option to automatically post all zero dollar payments. Post Secondary, Tertiary, Quatern Insurance Check this option to automatically post Payments Secondary, Tertiary, and Quatern Insurance Payments according to all options selected. Do Not Post Negative Insurance Payments Check this option to not automatically post any Insurance Payments with a negative amount. Use EOB Check Date as Payment Date Will post the payments with using the check date as the payment date. Select a Payment Code for Posting Blue Cross/Blue Shield Payments from the drop down list provided. Select a Payment Code for Posting HMO/PPO Payments from the drop down list provided. Submitter Information Ansi [2]- Same as Submitter Information under ANSI Transmission. Compress Claims [3]- Compressing claims will put the claims in a file that Gateway EDI will be able to read. A window will appear stating, Compressing claims will transfer the file into a format that will be transmitted. Once compressed, the file cannot be edited again. Are you sure you wish to do this? Click Yes. It is very important that once you Compress your claims, you send them before Compressing again or the file that was Compressed first will have to be regenerated or retrieved from the Archive Claims Folder of your AMS directory. Unless the Do Not Delete Claim Files When Compressing option is selected under the Submitter Information menu. Gateway EDI Webclaims [4]- This menu option will take you directly to Gateway EDI s log in screen on their webpage. (Internet Connection Required) Gateway via Windows Modem (Tapi) [5]- This option will allow you to dial directly in to Gateway EDI s bulletin board system to send claims. The following screen will appear:
Electronic Claims Processing Module 6-11 Modem Settings must be setup prior to transmitting claims for the first time: Method - Three methods are available: Send (used to send claims and receive reports and remittance), Receive (used to receive reports and remittance only), and Remittance (used to download and post remittance to patient accounts). Protocol - Initially the protocol will be set to 0 - Zmodem. This option should only be changed at instruction of Technical Support to enhance modem connections. Comm Port/Modem - Click the arrow to the right of this field to choose the modem attached to your computer. (It will usually be the last option in the drop down box.) Number to Dial - This is the number the modem will dial to connect with Gateway EDI. This should be set to 18009891526. No dashes are needed. If you need to dial another number before the phone number, type that first, followed by a comma (ex. 9,18009891526). User Name/Code - For Gateway EDI, the User Name/Code is your four digit Site ID. Password - Gateway EDI will also assign a password to sign in to their bulletin board system. Click the Send button to connect with Gateway EDI. Your claims will be transferred and any reports and remittance available will download automatically.
6-12 Electronic Claims Processing Module Post Remittance [6]- This option will post all remittance files which have been downloaded from Gateway EDI. It will ask you for the payment date for posting this remittance file before you will see a blue screen appear stating Processing Occurring and the remittance report will begin printing. The right hand side of this report will indicate whether there were payments issues that were not automatically posted, and then you will need to post them manually. The payments will be posted into your system as Temporary transactions (not yet processed). If you would like to review the payments that were posted, you may view or print the Edit List. (Post Remittance must be checked under Submitter Info NSF on the Remittance Tab for you to be able to post remits.) + TIP: Since all payments that are autoposted will have a Username of AMSREMIT and a Session ID of AMS, the Edit List discussed in Chapter 5 can be limited to show only payments posted by session ID AMS (as long as no other users who post payments are using this as their session ID ) to quickly balance the payments that were just autoposted. You will still need to review the right hand side of the report that prints immediately after autoposting for anything that will need to be manually posted (such as $0 payments). Print Claims Edit List [4] shows all claims that have been generated or regenerated since the last time claims were compressed. You may select one of three ways to sort the claims on the list - by Claim Number, by Record Type/Provider/Insurance Carrier, or alphabetically by Patient s Last Name. The Claims Edit List shows the type of file generated, claim number, account number, patient name, service date, insurance carrier code, diagnosis, procedure, and amount. At the end are totals for each claim type, and a grand total of all claims. File Types are: AN - Ansi File (recommended). This standard should work regardless of clearinghouse. GW - Gateway EDI NSF GU - Gateway EDI UB92 or 04
Electronic Claims Processing Module 6-13 Batch Eligibility [5] allows you to create a file for a patient(s) that you specify or for an appointment date range of scheduled patients (if using this in conjunction with Appointment Scheduling System). The file can then be uploaded to Gateway EDI and the results imported to verify insurance coverage and eligibility information before a patient is seen. Patients can be added to a Batch Eligibility inquiry by entering their information and clicking SAVE or by clicking on Add from Appointments. You may receive a warning that issues need to be resolved before the record may be compressed and sent. Any record with issues that need resolved will appear with a yellow warning ( ). Double click the record to resolve any issues with required information denoted by the red asterisk (*). After you complete any of the required corrections you must click SAVE to apply those changes. When finished you must compress the requests to be able to transmit them to Gateway EDI. Record ID Automatically assigned to each Batch Eligibility Inquiry. Inquiry Date Date that you are submitting this Batch Eligibility Inquiry. Gateway Site ID This is your Gateway EDI site ID, and is set under Patient Eligibility. Pt No Patient ID Number SSN Patient Social Security number Last Name/ Patient Name First Name/MI Insured ID Patient s Insured ID Date of Birth Patient s Date of Birth Provider Provider for this inquiry. By default this is the patient s default provider or the provider on the appointment if request was added by using Add from Appointments. Facility Facility for this inquiry. By default this is the patient s default facility or the facility attached to the appointment if request was added by using Add from Appointments.
6-14 Electronic Claims Processing Module Insurance Carrier Insurance Carrier for this inquiry. This is the patient s default insurance from the Patient Master but you may select from any of the patient s insurance records. Allows you to edit the Insurance Payor ID, Batch Eligibility Payor ID and Batch Eligibility Carrier Status. Ins d No Insurance holder for patient s insurance. SSN Insurance holder s Social Security number. Last Name/ Insurance holder s Name First Name/MI Ins d Date of Birth Date of birth for the insurance holder. Refresh Transactions - Refreshes the list of Batch Eligibility Requests. Inbound/271 - Imports eligibility requests that were previously downloaded from Gateway EDI s website that can be viewed from the Eligibility Report (see Chapter 5). The following screen will appear allowing you to specify the location to import the file from: Select All - Check marks all patients who have the required demographic and insurance information on file that is necessary to perform an eligibility request ( ). You will need to double click to resolve all items with a yellow warning ( ) which indicates that there is information missing that is necessary to perform the request for this patient and/or insurance (such as birth date, payor ID, or batch eligibility indicator). Compress - Compressing the results displayed on screen will create an eligibility request file with the patient demographic and insurance information that Gateway EDI can read. It is important that once a file is compressed, it is uploaded to Gateway EDI s website before compressing again or you will have to add the patients again to compress another file. Add from Appointments - This option will allow you to verify eligibility for patients who are scheduled per the date range that you specify (if using this in conjunction with Appointment Scheduling System). If adding to this on a per patient basis and not per an appointment date range, enter the patients number or search for your patient by name and choose Save to add them to this file prior to compressing. Clear - Clears the patient demographic and insurance information displaying on the screen when adding or resolving a patient. Save - Saves the current Record. Delete - This option will remove the patient(s) that is check marked from the list so that it is not included in the request for eligibility file once compressed. Exit - This option will exit the screen. If you have not compressed an eligibility request file with the patients that are displayed on the screen, they will remain in the list and be included in the next file that is compressed.
Electronic Claims Processing Module 6-15 - Choosing this option will take you directly to Gateway EDI s log in screen on their webpage. You must already have an internet connection before choosing this option. Regenerate Electronic Claims [6] should be selected if you wish to regenerate claims for retransmission to your clearinghouse. Transaction Number - You may select the Transaction Number if you would like to regenerate just one claim. To search for a transaction number for a particular patient, click the button. The following screen will appear: If you select a Transaction Number, the rest of the screen will be filled out for you. Click the Regenerate Claims button. Transaction Dates - To regenerate by transaction date, you may select from a range of dates or enter a specific date. The Transaction Date must be used, not the Service Date. Regenerate All Claims Unpaid by Insurance - To generate only those claims that do not have an insurance payment made to them, place a check mark in this box. (This will only work when payments have an insurance type payment posted to them.)
6-16 Electronic Claims Processing Module Regenerate Only Claims Pending Insurance - To generate only claims that have the Pending Insurance indicator set, check mark this option. With this selected, any transactions that are due by the patient (not the insurance) will not be regenerated. Regenerate Claims with Any/Primary/Secondary Status - With Any selected, claims will regenerate no matter what status they have. If you have Primary selected, the claim would need to have status P in order to regenerate. And if you have Secondary selected, the claim would need to have status S in order to regenerate. Regenerate by Patient/Carrier/Provider - You may select a specific patient, insurance carrier, or provider. If you do not know the patient number, carrier number, or provider number you may search by name. All three of these selections do not need to be selected. (For example, if you would like to regenerate a claim for a particular patient, just select the patient, and you may leave the carrier and provider blank.) Any / Primary Claims / Secondary Claims - This option will only appear when a patient is selected. This option will allow you to pick whether you would like to regenerate the primary claim(s) for this patient or the secondary claim(s) for this patient. STEPS NECESSARY TO TRANSMIT GATEWAY EDI ELECTRONIC CLAIMS From Medical Office Management: 1. Select Insurance Processing, or press Alt + I simultaneously. 2. Select Electronic Claims Interface. 3. A box will appear asking, Do you wish to generate new electronic claims which have not been previously filed? If you have processed daily transactions and do want to generate new claims, click Yes. When this is done, a box will appear telling you the total number of claims and the total claim amount. If you want to just regenerate past claims, click No. 4. If you need to regenerate claims, Select Option 6 - Regenerate Electronic Claims. 5. Print a Claims Edit List. Option 4 - Print Claims Edit List. 6. Check the claims through the Edit Claim File screen, Option 1 - Edit Claim File. You may delete lines or claims and attach COB information to secondary claims. Changes cannot be made to claims from this screen. Corrections must be made through the Charge screen. They can then be regenerated into the Electronic Claims System. 7. Select Option 3 - Gateway EDI Transmission. 8. From the Gateway EDI menu, select 3. Compress Claims. A window will appear stating, Compressing claims will transfer the file into a format that will be transmitted. Once compressed, the file cannot be edited again. Are you sure you wish to do this? Click YES. If there are any secondary claims in this file that do not have COB Info attached, you will be notified of the number of claims that will be skipped and not compressed into this file. Click Yes to continue, or you may choose No to return to the Edit Claim File to attach the
Electronic Claims Processing Module 6-17 information It is very important that once you Compress your claims, you send them before Compressing again or the file that was Compressed first will have to be regenerated unless the option Don t delete claim files when compressing is selected. 9. Choose 4. Gateway EDI Webclaims to upload your file. 10. Exit back to the Insurance Processing Menu. You are now ready to process paper claims. You may optionally view the Unfiled Insurance Claim Report first. This will give you a list of all claims that need to be sent on paper. This can be printed and is helpful if your printer jams. It will help you know exactly which claims still need to be processed. 11. Print the Insurance Claims not previously printed, if you have any. From the Insurance Processing menu, select Generate Insurance Forms for all Claims not Previously Printed.
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