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LIFE OF A CLAIM PRESENTED BY: JANE PLANT, NANCY FEE & PATTY LAVIGNE.

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Presentation on theme: "LIFE OF A CLAIM PRESENTED BY: JANE PLANT, NANCY FEE & PATTY LAVIGNE."— Presentation transcript:

1 LIFE OF A CLAIM PRESENTED BY: JANE PLANT, NANCY FEE & PATTY LAVIGNE

2 PRESENTATION OVERVIEW HCFA and UB changes released in 4.11.00 including ICD9/ICD10 Upcoming Out of Pocket and Deductible changes 4.11.00 and 4.11.01 Claim flow and Adjudication Control Rules Episode Records what else can they be used for?

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4 HCFA: CHANGES page 4 Confidential

5 FIELD 19- ADDITION INFORMATION -LOCATION Located on Page 1 of the HCFA form Also gives advice on how to work certain exceptions page 5 Confidential

6 FIELD 19 - PURPOSE HCFA field 19 was previously a reserved field but is available now for Additional Claim information that can be required by payers. NUCC has defined a list of qualifiers that are used in the 5010A1 format. The information is written into the RPC_ADDCLINFO field the qualifier code and the identifier are joined into one entry. The information populated in this field will be populated within the 837 5010 outbound transaction.

7 TABLES AND CODES THE NEW 302 TABLE WITHIN THE TABLE OF CONTENTS CONTAINS THE AVAILABLE QUALIFIERS. page 7 Confidential

8 FIELD-21 –DIAG VERSION AND ADDITIONAL ICD CODES- LOCATION

9 FIELD-21 - PURPOSE HCFA field 21 is for diagnosis code entry and previously allowed for four diagnosis codes to be entered. This has now been expanded to allow for up to twelve diagnosis code entries. A new field was added to handle the ICD version indicator.

10 FIELD 21 Logic added to the form equals if ICD Version indicator is populated the code is assumed to be that version, if ICD Version is blank the version will be determined by the code. ICD9 and ICD10 mixing on a claim is not allowed. ICD Version indicator can be found in the RPC_67A and in 4.11.01 it will be added to the claim record in a new field CLM_ICDV.

11 FIELD -22 RESUBMISSION CODE AND ORIGINAL REFERENCE NUMBER-LOCATION

12 FIELD 22 -PURPOSE Resubmission Code will be an optional field and will allow for a one byte numeric code of either “7” or “8” The value entered will be written to the RPC_ADJAC field. If the value is equal to 7 the HI ADJ exception will be triggered. If the value is equal to 8 the HI VOD exception will be triggered.

13 FIELD 22 -PURPOSE Original REF No. will be an optional field and will allow for up to 18 alpha numeric codes. A new RPC field was created to store this information – RPC_REFNR.

14 FIELD-23E-DIAGNOSIS POINTER Page 2 of the HCFA form is now for service line. Location has not changed however - Diagnosis pointers have been changed from numeric values to alpha values A-L. If numeric is entered the system will switch to Alpha.

15 FIELD- 24G-DAYS/UNIT Location has not changed however - The existing Days/Units field has been expanded to accept up to 7 bytes as required by the NUCC.

16 SERVICE LINE SCREEN

17 UB -CHANGES Only the UB04 form has been changed! Field 66 – ICD Version Indicator Follows the same logic as the HCFA Form. Field 46 – Units Has been expanded to now accept up to 7 bytes

18 4.11.01 OUT OF POCKET AND DEDUCTIBLE CHANGES

19 PLAN BUILDING-SCHEDULES- PLAN DETAILS- CHANGES New Combine Out of Pocket With field modeled off the current Combine Deductible with field.

20 PLAN BUILDING –BASIC PLAN – OUT OF POCKET CALCULATION - CHANGE Upon entering this area you will be presented with a new selection. You will have the ability to set one calculation method or many. You will be required to build at least the default. Once built you will be able to see all the calculation methods used for each schedule on one screen.

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22 CHANGE FOR FULL AMOUNT OF DEDUCTIBLE FROM THE ACCUMULATORS ACROSS PRODUCTS. When the Deductible amount for the service line is calculated if the combined deductible flag is set for multiple products the deductible accumulators will be read for all products indicated. The amount read from the accumulators will be written into the new field on the claim record “Accumulator DED”. Clients can request changes to EOB’s to use this new field to show combined deductibles.

23 NEW COPAYMENTS – CHANGE FOR OUT OF POCKET Changes to New Copayment Only. Both the Standard and Exception Copayment area a new field will be added – Suppress Copayment from Out of Pocket. Options will be Y or N

24 HOW DOES IT WORK? If Suppress Copayment from OOP flag is set to Y and Out of Pocket Calculation Method indicates Copayment as part of the Out of Pocket. Copayment will not be added to the Out of Pocket If Suppress Copayment from OOP flag is set to Y and Out of Pocket Calculation Method indicates Copayment is not part of the Out of Pocket. Copayment will not be added to the Out of Pocket

25 If Suppress Copayment from OOP flag is set to N and Out of Pocket Calculation Method indicates Copayment as part of the Out of Pocket. Copayment will be added to the Out of Pocket If Suppress Copayment from OOP flag is set to N and Out of Pocket Calculation Method indicates Copayment is not part of the Out of Pocket. Copayment will not be added to the Out of Pocket

26 NEW COPAYMENTS – CHANGE FOR DEDUCTIBLE Changes to New Copayment Only. The Standard Copayment area has two new fields: Apply to Deductible Continue Taking Copayment After Deductible Met Options will be Y or N

27 SCREEN CHANGE

28 HOW DOES IT WORK? Apply to Deductible If equal to Y the amount the copayment will show on the claim as deductible and the amount will be written to the appropriate Deductible based on plan setup. If equal to N the copayment will show as a copayment and does not write to the deductible bucket.

29 Continue Taking Copayment after Deductible Met If equal to Y the copayment when taken will show on the claim as a copayment and the amount will not be written to the deductible bucket. If equal to N the copayment will not be taken on the claim.

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35 Adjudication Logic – The Adjudication Logic which is stored on the Adjudication Control Rules is actually read at the time the logic is applied.. Patient Not Eligible – Compares claim earliest date of service to the patient eligibility. If patient is terminated or not active at the earliest date of service rule applies. Question in Exceptions – Questions are only allowed at the Benefit Exception and the application will always pend to allow a user response. Unable to Find Occurrence - Occurrence benefits can be on either a DGN or Benefit Exception and again the system will always pend for user intervention.

36 Pend if COB Flag Set – If the COB flag on the patients eligibility record is set to Y the rule will apply. Group Not Paid Up to Date - If the COB flag on the patients eligibility record is set to Y this rule will apply. When Claim/Accum Locked - If for example two examiners are attempting to update the same accumulator at the same time the claim will pend. Once the claim is unpended all benefit limits will recalculate and the accumulators will be updated. Hold When Payment Exceeds – Designed to control the ability to review claims that exceed a specific gross payment amount. Claim is compared to dollar limit on the user and dollar limit in the control rules and the lessor amount wins.

37 Other Insurance Plan – If set on the HCFA template it will be read but it is not set at 837. Condition of Employment – Reads the flag Employment on the HCFA template. Related to Auto Accident – Reads the flag Auto Accident o the HCFA template. Related to Other Accident – Reads the flag Other Accident on the HCFA template. Set by 837 – Loop 2300>Segment CLM>Position 11-1,11-2, or 11-3> AA equal Auto Accident, OA equal Other Accident and EM equals Employment. The state for the Auto Accident is 11-4.

38 Enable Capitation – If set allows the plan to apply Managed Care Capitation. Add Encountered to Accums – If set the encountered value from the claim will write to the accumulators. Change in Elig Since –Compares patient's eligibility to each service line of the claim. Applies when there are spanned dates of service on the claim and a change in eligibility status. Pre-Authorization – Pertains to only Dental Pre-D claims so it is only read on Dental Template Claims. * Upcoming change Pre-D claims will apply eligibility denials before determining benefits*

39 Pend EDI Attachment – Will allow claims to pend when the 837 PWK segment indicates an attachment. Allow Zero Charge Claim –If yes the system accepts zero as a valid charge on claims. If no the system will create a BD ZRO exception when a claim has zero charge if keyed or edi. Adjustment Claim –All adjusted claims pend during claims processing. Enable Provider Withholds –If Yes, applies the provider withhold, a contractual amount withheld from provider's payment that should not be billed to the patient. If No, does not apply a withhold from the claim, even if the provider is set to apply a withhold.

40 Deductible Carryover - Only active if the plan has a carry over deductible provision. If three conditions are met, the claim applies the selected action, though pend is recommended. Claim is for the prior plan year Charges would have applied to the carry over deductible Deductible for the next year has already been satisfied Example - The plan year is the calendar year, set for three month carry over on the benefit schedule. The individual deductible of $100 has been satisfied for 2013. A claim for November 2012 which would have applied to the 2012 deductible and would have carried over and applied 2013 deductible. ECI recommends pending this claim for review.

41 EXT Pricing on COB Claim -If COB flag in employee/dependent coverage is set to Yes, and this option is No, the claim is placed in exception status with the code PTCOB before adjudication. This is done by checking for COB in the eligibility record during pricing. You can create a workflow rule to route claims with PTCOB to a user defined queue. If COB flag is set to No in patient's eligibility, and this option is also No, the system functions as usual. If this option is set to Yes, the system functions as usual

42 DENIALS THAT DON’T SHOW DISCOUNT Age edits Patient not Eligible Other Ins Plan Condition of Employment Related to Auto Accident Related to Other Accident Dup Checking Denial PreCert Denial

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44 LOGIC AND EPISODE RECORDS- PRE-CERT In adjudication logic when you are looking for Pre-Cert any episode that has CM, UR, PC, PA or WC in the Case Type Field will be read.

45 LOGIC AND EPISODE RECORDS- REFERRAL In adjudication logic when you are looking for Referral the Case Type Field must have RF.

46 USING EPISODES FOR NEGOTIATED PRICING Patient needs a wheelchair and there are no In Network DME providers available in his area. I was able to negotiate a price on the wheel chair he needs.

47 Once Complete select Pricing Set the Action as Exceed Except

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49 IF THE PROVIDER BILLS FULL CHARGES Claim applies the exceed except rule because the full charge was billed.

50 SERVICE LINE Shows the difference in U&C due to claim being Penalty

51 MODIFICATION MAY BE REQUIRED FOR SERVICE LINE You may be required to correct the placement of the disallowed if you want this to show as not patient responsibility. If the provider bills the negotiated amount this will not be an issue.

52 TAKING A PERCENT DISCOUNT USING EPISODE RECORD Patient needs an out of network MRI that I was able to get the provider to agree to a Discount if it is paid as In Network.

53 Set to Force Network that will be used Negotiated Price

54 Pricing set to pay by Episode

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56 USING EPISODES Episodes can be used to control unit limitations within your benefit plan requirements.

57 USING EPISODES TO CONTROL UNIT LIMITS

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62 Any Questions?


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