Presentation on theme: "CREATIVE PLAN BUILDING PRESENTED BY: FRED PORTER, YONETTE BOWEN AND CHARLEEN MULLANEY."— Presentation transcript:
CREATIVE PLAN BUILDING PRESENTED BY: FRED PORTER, YONETTE BOWEN AND CHARLEEN MULLANEY
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!)
If any exist a list will appear
CREATING RECORDS Select (A)dd to create new record. Patient information will populate
EPISODE RECORD HIGHLIGHTS Pricing methods
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
ADDING PROVIDERS Search for Provider to add.
ADDING PROVIDERS Can add single or multiple Providers. Depending on Case Price Method
ACTIONS/REASON Exceed Except is most common. Will create EXC when conditions of Pre-Cert are not met.
PROVIDER VALIDATION Can select all Providers with same TIN or a Single Provider assigned by System ID
NETWORK MATCHING NOT for forcing In-Network
PENALTY OPTIONS Network, Penalty or Force the Network?
ACCEPTANCE OF THE RECORD Exact matching or “some” matching
REV AND DIAGNOSIS CODES Enter your codes required for this Episode
ICD, HCPCS AND CPT CODES Add other necessary Service Codes here
CODE RANGES Always put “from” and “through”.
OTHER INFORMATION Authorized/Accumulated and Comments
PRICING OPTIONS Command line options of pri(C)ing
PRICING OPTIONS Can price claim differently for each Episode
ACCESS IN CLAIMS Can access Episode to view during Claims Processing
EXISTING EPISODE RECORDS Can Identify Case Record vs. Manual Episodes
PRE-CERT VIA BENEFIT PLAN Per Benefit Plan setup. Plan details.
DEFINED SERVICES Can add multiple Categories requiring Pre-Cert
CATEGORY DEFINITIONS F4 will allow for searching Categories
DENY NON-PRECERTED CLAIMS Can auto-deny if needed
SEPARATE PRICING OPTIONS Can apply separate pricing if needed.
CAN USE SEPARATE SCHEDULE
SEPARATE BENEFIT SCHEDULE If enter “Y”, will see different schedule option
BENEFIT EXCEPTION PENALTIES Can apply Non-Precert Penalties
BENEFIT EXCEPTION PENALTIES Can Penalize by percentage or flat dollar
CAN PEND AT EXCEPTION LEVEL Can choose to Pend even if no Penalty set
ADJUDICATION LOGIC Same Benefit Code can be set two ways
ADJUDICATION LOGIC Same code Pend if no Pre-Cert
CATEGORY DEFINITIONS ICD9 and ICD10 options on same Category
ICD9 DIAGNOSIS CODES Same options for both codes
ICD9 CODE ENTRY Separate ranges for ICD9 codes
ICD10 DIAGNOSIS CODES
Separate ranges for ICD10 codes
HCFA FORM Same options for HCFA form
HCFA FORM ICD9 Code ranges
HCFA FORM ICD10 code ranges
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.
DENTAL LOGIC All U/W, Groups within single U/W or single Group
DENTAL LOGIC Rules are set per ADA Code
DENTAL LOGIC Multiple options for what to do with the Code
Age based limitations without using Benefit Exceptions