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CREATIVE PLAN BUILDING PRESENTED BY: FRED PORTER, YONETTE BOWEN AND CHARLEEN MULLANEY.

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Presentation on theme: "CREATIVE PLAN BUILDING PRESENTED BY: FRED PORTER, YONETTE BOWEN AND CHARLEEN MULLANEY."— Presentation transcript:

1 CREATIVE PLAN BUILDING PRESENTED BY: FRED PORTER, YONETTE BOWEN AND CHARLEEN MULLANEY

2 AGENDA Episode Records Pre-Certification Requirements Benefit Plan Setup Adjudication Logic Setup ICD9 and ICD10 Category Definitions Dental Logic Copay by DOS Out of Network payment options (Creatively!)

3

4 ELIGIBILITY/ENROLLMENT

5 OPTIONS/UTILITIES

6 INDIVIDUAL/PATIENT EPISODES

7 If any exist a list will appear

8 CREATING RECORDS Select (A)dd to create new record. Patient information will populate

9 EPISODE RECORD HIGHLIGHTS Pricing methods

10 PRICING OPTIONS NORMAL PRICING Allows you to attach multiple Providers to a single episode EVENT PRICING Allows you to attach a single Provider to a single episode CASE PRICING No Providers are attached to the episode

11 ADDING PROVIDERS Search for Provider to add.

12 ADDING PROVIDERS Can add single or multiple Providers. Depending on Case Price Method

13 ACTIONS/REASON Exceed Except is most common. Will create EXC when conditions of Pre-Cert are not met.

14 PROVIDER VALIDATION Can select all Providers with same TIN or a Single Provider assigned by System ID

15 NETWORK MATCHING NOT for forcing In-Network

16 PENALTY OPTIONS Network, Penalty or Force the Network?

17 ACCEPTANCE OF THE RECORD Exact matching or “some” matching

18 REV AND DIAGNOSIS CODES Enter your codes required for this Episode

19 ICD, HCPCS AND CPT CODES Add other necessary Service Codes here

20 CODE RANGES Always put “from” and “through”.

21 OTHER INFORMATION Authorized/Accumulated and Comments

22 PRICING OPTIONS Command line options of pri(C)ing

23 PRICING OPTIONS Can price claim differently for each Episode

24 ACCESS IN CLAIMS Can access Episode to view during Claims Processing

25 EXISTING EPISODE RECORDS Can Identify Case Record vs. Manual Episodes

26

27 PRE-CERT VIA BENEFIT PLAN Per Benefit Plan setup. Plan details.

28 DEFINED SERVICES Can add multiple Categories requiring Pre-Cert

29 CATEGORY DEFINITIONS F4 will allow for searching Categories

30 DENY NON-PRECERTED CLAIMS Can auto-deny if needed

31 SEPARATE PRICING OPTIONS Can apply separate pricing if needed.

32 PRICING OPTIONS

33 CAN USE SEPARATE SCHEDULE

34 SEPARATE BENEFIT SCHEDULE If enter “Y”, will see different schedule option

35 BENEFIT EXCEPTION PENALTIES Can apply Non-Precert Penalties

36 BENEFIT EXCEPTION PENALTIES Can Penalize by percentage or flat dollar

37 CAN PEND AT EXCEPTION LEVEL Can choose to Pend even if no Penalty set

38

39 ADJUDICATION LOGIC Same Benefit Code can be set two ways

40 ADJUDICATION LOGIC Same code Pend if no Pre-Cert

41 ADJUDICATION LOGIC

42

43 CATEGORY DEFINITIONS ICD9 and ICD10 options on same Category

44 ICD9 DIAGNOSIS CODES Same options for both codes

45 ICD9 CODE ENTRY Separate ranges for ICD9 codes

46 ICD10 DIAGNOSIS CODES

47 Separate ranges for ICD10 codes

48 HCFA FORM Same options for HCFA form

49 HCFA FORM ICD9 Code ranges

50 HCFA FORM ICD10 code ranges

51

52 WHAT CAN DENTAL LOGIC DO? Dental logic is by Group. If it is set up, it is used. Ability to do multiple things on one ADA code Ability to change ADA codes or use a particular Benefit Code as in regular Adjudication Logic. Multiple variations on Tooth, Arch, Quadrant and Provider. Patient Age Limitations Limitations base on services Reported With, History of or Without History.

53 DENTAL LOGIC All U/W, Groups within single U/W or single Group

54 DENTAL LOGIC Rules are set per ADA Code

55 DENTAL LOGIC Multiple options for what to do with the Code

56 DENTAL LOGIC

57 Age based limitations without using Benefit Exceptions

58 DENTAL LOGIC Multiple rules for same Code

59 DENTAL LOGIC Dental Claims Processing. Entered D1120

60 DENTAL LOGIC Switches ADA Code to D1110

61 DENTAL LOGIC Also ensures use of Benefit Code 902

62 DENTAL LOGIC Conditional exception without using Benefit Exceptions

63 DENTAL LOGIC One issue: Can’t use “Pay as MM” option in Group Master set up.

64

65 COPAY DEFINITIONS Add Office Visit and Lab Categories and designate Inpatient Codes

66 TABLE OF CONTENTS-BILL TYPE Bill Type defines In-Patient Confinement

67 BILL TYPE Control Flag equal to “I” for Inpatient

68 COPAY PLAN SET UP Set at each Basic Policy Information screen

69 COPAY BY DOS Warning will appear on initial set up

70 COPAY BY DOS Inpatient can be Day or Stay

71 CORE REQUIREMENTS Type of Service Code input for Inpatient and Office Visits

72 CORE REQUIREMENTS F4 for list of 270/271 Service Types

73 DEDUCTIBLE OPTIONS New in !!

74 LAB CLAIM OPTIONS What to do when Lab claim comes in before Office Visit?

75 COPAY EXCEPTIONS

76 DEDUCTIBLE OPTIONS Exception options for Deductible

77

78 EXEMPT CATEGORY OPTION Penalize…”except when…”

79 EXEMPT CATEGORY OPTION Can add categories such as Emergency or Ambulance.

80 EXEMPT PRICING OPTION Separate pricing if needed

81 Any Questions?


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