Aida Anderson and Taz Taylor Support Department / HealthSystems Southeast Centricity User Conference, Callaway Gardens, January 25, 26 and 27, 2007
Agenda Introduction Administration Setup Patient Information Setup Payment Entry Requirements 2
General Requirements For Most Payers Exceptions -There May Be Payer-Specific Exception Payer-Specific Instructions May be Needed in These Situations 3
Administrative Set-Up Transaction Column Sets Line Information Actual Allowed Insurance Carriers EDI Settings Special Medicare Settings 4
Transaction column Sets - Open Administration Select EDIT Choose Transaction Column Sets Search for the Transaction Column Set used with your primary insurance carriers This provides a field for capturing primary payer adjudication information. 5
Transaction column Sets Press the New button to add a new item to the Transaction Column Set. 6
Transaction column Sets Select Line Information from the list. The Name field will default to the same info selected in the Type field. Press OK to add this column. Note: If there is not an Actual Allowed column, repeat these steps to create this column, as well. 7
Insurance Carrier Set-Up on ALL carriers From Administration Select EDIT Choose Insurance Carriers Select and modify the carrier From the Insurance Carrier Select EDI Tab Press the Modify Button for the File Creator Press the Settings button located next to the Claim Creator Plug-in Select the All Payers 2 Tab at the top of this Window *Ensuring the carrier is set up appropriately will help ensure the right information is being transmitted to the secondary payer electronically. **This set-up applies to ALL carriers. 8
Insurance Carrier Set-Up EDI Settings Secondary payers require an AAE Qualifier for Secondary Claim Procedures 9
When MEDICARE is secondary: Medicare Secondary carrier will need to be added in Administration. - This carrier will need to be added as the secondary carrier in Patient Information. *THIS ONLY APPLIES TO MEDICARE 10
Insurance Carrier Set-Up: Special Medicare Instructions Carrier Type for Medicare as a Secondary Payer should be Medicare To insure that the correct Provider and Group ID numbers are sent, select the correct Group. Policy type for Medicare as a Secondary Payer needs to be Other 11
Non-primary Medicare Policy Type is Required From Patient Information: Select the Secondary Payer Press the Details Button 12
Medicare Secondary Policy Type is Required Select the reason that Medicare is not the Primary Payer The options are: - Working Aged Beneficiary or Spouse with Employer Group Health Plan -End-Stage Renal Disease Beneficiary in the 12 month coordination period with an employer's group health plan -No-fault Insurance including Auto is Primary - Worker's Compensation - Public Health Service (PHS) or Other Federal Agency - Black Lung - Veteran's Administration - Disabled Beneficiary Under Age 65 with Large Group Health Plan (LGHP) - Other Liability Insurance is Primary * If NO option is selected claim will batch reject. 13
Payment Entry Requirements Payment Entry Requirements The following items are required by all payers accepting electronic secondary claims: Primary Payment Contractual Adjustment and Actual Allowed Line Adjudication Date Line Adjustments / Associated Codes COB Information Allowed Amount When the primary payment is posted via electronic remittance and the information is received in the remittance file, these fields will be populated during electronic remittance processing. 14
Line Adjudication Information Line Adjudication Information Payment Entry: Enter Primary Payment, within the Transaction Distribution Window Double-Click the Line Information Field Populate: Adjudication Date This information is populated in the 2430 Loop DTP segment. Example: DTP*573*D8*20050608~ Adjustment Amount and Associated Reasons This information is required when the primary payer has paid a different amount that the original charge. It is populated in 2430 Loop CAS segment. Example: CAS*CO*42*5*1*2*5*1~ 15
Payment Entry Transaction Distribution Must enter a Payment, Actual Allowed and Adjustment amount for each procedure; even if value is zero ($0.00). Open Line Information Window 16
Line Information Window Line Adjudication Information Double-Click in the Line Information field of each procedure row. The Adjudication Date is the same as the Date on the EOB Enter the following for procedures containing adjustments: Associated group codes Associated reason codes Adjustment amounts processed for the procedure Units (usually 1 ) 17
Line Information Window Adjustment Codes There are 5 qualifiers that exist for the claim adjustment group codes. These codes will be accompanied by Reason Codes on the Remittance Advice or within the Remittance File. Adjustment Group Codes: CO Contractual Obligation CR Corrections and Reversals OA Other Adjustments PI Payer Initiated Reductions PR Patient Responsibility Sample Reason Codes: 1 Deductible 45 Adjustment Amount 2 Co-insurance 18
Coordination of Benefits (COB) Coordination of Benefits (COB) Payment Entry: Enter Primary Payment, within the Transaction Distribution Window Press the COB Button in the middle of the screen Populate any information required by the secondary payer This information pulls to the 2320 Loop AMT segment Example: AMT*B6*250.00~ 19
Coordination of Benefits (COB) Click COB Information button to open Coordination of Benefits window 20
Coordination of Benefits (COB) Allowed Amount Required Fields: Patient Responsibility Patient Paid Payer Paid to Patient Covered Press COB Button 21
Claim Adjustment Reason Codes List A list of these codes can be obtained by accessing the following website: www.wpc-edi.com Open Internet Explorer In the Address Bar, type www.wpc-edi.com Select Products from the menu on the left Select Claim Adjustment Reason under the heading of Code Lists and Alert Service Select Claim Adjustment Reason Codes 22
EDI rejections for Secondary Filing The following are some common carrier rejections: Medicare: - OTAF Amount Required with CAS/CO (Contractual Obligation) - Claim payer paid amount does not equal sum of line payer paid amounts. AL Medicare: - Edit 377: Paid & Adjustment Amounts do not equal claim charge amount. - Multiple 2420 loops not allowed 23
EDI rejections for Secondary Filing OTAF Amount Required with CAS/CO (Contractual Obligation) Go to the Charge 2 tab of each procedure on the visit. -Click on the Show All button at the bottom of the page - Select Other in the Contract Type field. 24
EDI rejections for Secondary Filing Claim payer paid amount does not equal sum of line COB information must equal total amounts sent. payer paid amounts. NOTE: This example will cause the claim to reject. #1 #1 Equal to Payer Paid Amount #2 Equal to Covered Amount 25
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Multiple 2420 loops not allowed The issue here is anytime there is a tertiary carrier on the visit, the system will create duplicate CAS and AMT records in the file. To avoid these rejections, uncheck the tertiary carrier before you approve and batch the visit. You can check it after you batch the claim. 27
Claim Adjustment Reason Codes List A list of available codes will be displayed. 28
Questions and Answers Thank you for attending! Aida Anderson and Taz Taylor 29