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Practice Insight Instructional Webinar Series Advanced Claim Manager Presented by: Shaun McAnulty – Product Training Specialist.

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Presentation on theme: "Practice Insight Instructional Webinar Series Advanced Claim Manager Presented by: Shaun McAnulty – Product Training Specialist."— Presentation transcript:

1 Practice Insight Instructional Webinar Series Advanced Claim Manager Presented by: Shaun McAnulty – Product Training Specialist

2 Topics to Cover Transfer Files Claim Status Use Selection Criteria Right Click Functionality Editing a Claim

3 Transfer Files Upload Files View complete file in the format is was sent to PI in. See who uploaded claim file. See claim files original uploaded file name. View error messages if Claim File fails to load. File break down showing claim basic stats. Download file if you need. Response Files Repost to SFTP using Right Click if File is missing on PM. (Integrated users) Download file to repost to PM (Manual) Full EOB View Mark ERA responses as Received once they are pulled into PM (Best tracking)

4 File ID: used in selection criteria to locate this group of claims File Name: the original file name for the upload. File Type: what file was uploaded and what format. Staff Name: who uploaded the file. If the claims have any issue loading there will be a message displayed Multi Select Responses Mark ERA responses Received (organizational) See when a response was viewed & who by, when mark received & who by.

5 Filter List Responses Locate responses by File Type, File Name, Date ranges, Description, Status, File ID (File responses came in on), Retrieved ID (What file responses came in on) and Perform a Check Search using the Check Number.

6 Green = Commonly expected Statuses Red = Error or Workable Statuses Yellow = Additional Statuses Claim StatusDefinitionSource VALID Claim Valid (Must be set to READY to SEND to Payer) TESTER /SCRUBBER READY Claim Ready to be Batched and Sent to Payer Auto Processed /Manual Status Override ACK Claim AcknowledgedResponse ACCEPTED Claim Accepted by the PayerPayer Response PAID-ERA Claim Paid by PayerPayer Response (ERA 835) PAID Claim Paid according to a UserManual Status Override/ Received paper EOB Statuses

7 Common Working Statuses Green = Commonly expected Statuses Red = Error or Workable Statuses Yellow = Additional Statuses Claim StatusDefinitionSource INVALID Claim Invalid by Tester or Scrubber TESTER /SCRUBBER REJECTED Claim Rejected by PayerPayer Response DENIED Claim Denied by a PayerPayer Response / Real Time Claim Status (276)

8 Load ClaimValid Claim has no errors found. READY Then Sent ACK Received from Payer ACCEPTED By Payer PAID ERA EOB Claim Flow

9 INVALID Fix in Claim Manager & set to READY. Fix in PM & Rebill, Mark it Delete. REJECTED Fix it Claim Manager set to Ready. Rebill From PM. Mark Complete. ( EX. PT Responsibility ) DENIED Mark Complete. Appeal & send Appeal Letter. Common Working Statuses

10 Claim StatusDefinitionSource APPEALED Claim Appealed by End UserManual Status Override COMPLETE Claim considered Complete by User Manual Status Override DELETE Claim Marked Deleted by a User Manual Status Override, will not show on reports. PAID-PYR Claim Payment Acknowledged by Payer Real Time Claim Status (276) PEND-USR Claim Pended by UserManual Status Override PENDED Claim Pended by PayerPayer Response / Real Time Claim Status (276) Additional Statuses Green = Commonly expected Statuses Red = Error or Workable Statuses Yellow = Additional Statuses

11 PAID-PYR Manual Real Time Check Status was run. Payers decision was to Pay. ERA not delivered yet to change the status to Paid- ERA. PENDED Claim has been manually marked to wait. Status for when claims need to be easily grouped together that are waiting to be worked. APPEALED When the Appeal Letter is marked as Printed the claims status will change to APPEALED. Marked so when a determination is given on the claim it can be easily found. Additional Statuses

12 DELETE Claim will be fixed on the PM & resubmitted. Claims marked Delete will not show on Analytics, or in general searches. History will remain COMPLETE Claim that will not be fixed. Completed claims will show on Analytics. History on claim will remain intact. Organizational Statuses

13 TESTER rejections 1st level of testing Rule-based edits are used to stop claims with missing or invalid data or to flag claims that meet a particular criteria. Double click on rejection to take you to field in error for easy correction Once the claim is corrected in Practice Insight it will retest as VALID then Ready the claim. How we get Invalid Claims EDIFECS rejections 2nd level of testing Runs after claim has batched but before it’s sent to the payer, further tests claims to assure they are ANSI compliant. Correcting the claim WILL NOT make it VALID, Correct then Ready Claim!

14 Second level of testing EDIFECS runs after the claim has batched but before it is sent to the payer EDIFECS further tests claims to assure they are ANSI compliant Correcting the claim WILL NOT make it VALID Once the claim has been corrected, READY the invalid claim EDIFECS rejections How we get Invalid Claims.

15 The same rejection message does not always have the same reason. Look for clues in the rejection message to determine the cause: o Example: Rejection message A7:562:85 is an enrollment rejection. The 85 points to the billing provider. In the ANSI file the billing provider name has a qualifier of 85. See below example of an ANSI file billing provider loop: o EDI ID# in Demo Database Loop 2010AA Billing Provider Name NM1*85*2*GROUP MEDICAL*****XX* How we get Rejected Claims. Payer/Trading Partner Rejections

16 View the ANSI file to see which qualifier the rejection message is referring to: Using the Right Click to View Batch File! Example of common qualifiers referenced in rejection messages: o NM1*85 = billing provider o NM1*82 = rendering provider o NM1*IL = subscriber o NM1*77 = service facility o NM1*DN = referring provider How we get Rejected Claims. Payer/Trading Partner Rejections

17 Selection Criteria Vendor/ CBO Level only: specify customer. Give age buckets, or calendar dates. Then select what date should be used for the selection. Specify an uploaded claim file from Transfer Files. Can narrow selections to specific Providers as well.

18 Narrow claim selections by staff member assigned to. (Hotkey: A on claim) Name or range search, also can use Wildcard Searches. (EX: %ith) Unique Id for specific claim in EDI If Clinical Scrubbing (Extra Service) Edit Id can be entered to locate all claims with error. Returns all claims based on Responsible Payer.

19 Selects claims using PI Payer ID. The Outbound ID # for a Payer If Payer or CH sends back their ID number for the claim it is also searchable. Narrow by Type of Payer. Can group claims with the same Response ID Select claims that contain the same Retrieved ID.

20 F1 ONLINE HELP Using your F1 online help can allow you to better understand the features and functionality of the software. This is the manual with tips and definitions of the fields you see throughout the software. The guide is broken out into categories which allow you to follow the progression of the software to locate the information you’re looking for. When using the F1 key or the Right Click option the system will use your location within the software to locate the information you are currently viewing.

21 CLAIM MANAGER LAYOUT

22 BUTTONS Transfer Files : takes the user to where they can upload and view claims and responses that have come into the software. Print Reports : allows the user to view the Report Manager screen that allows the user to run various WebBrowser and Data Miner reports pertaining to claims.

23 SELECTION CRITERIA Select Claims : Displays claims based upon the criteria the user selects in the fields of the Claim Selection Criteria View. Clear Selections : allows the user to clear all information from the Claim Selection Criteria fields. It's good practice to clear selections before performing a new search. Select Invalids & Rejects : allows the user to select only invalid and rejected claims. Print Claim List : allows the user to print a list of all selected claims.

24 CLAIM LIST VIEW Check Claim Status : Allows the user to check the real time status of an individual claim whose payers name is listed in red. Print Letter : Creates a web-based report on the individual claim selected. Ready Claim : Is used to ready an individual claim. Retest Claim : Re-runs the software's tester on an individual claim. Scrub Claim : Sends one individual claim to the Alpha II Claim Staker to scrub the claim for clinical edits. View Claim Form : Views the claim as it would look on a CMS1500, UB04, or ADA J400 form.

25 STATUS MESSAGE VIEW View Change Log : Displays an audit of all changes made to a selected claim. Print Timely Filing : Generates a letter that displays proof of timely filing by listing all of the statuses that the claim has gone through including the Response File Name that is assigned by the payer or clearinghouse, entity that sent the response, and batch/ File ID. Add Memo : Allows the user to add a memo to the status section of the claim. Edit Memo : Allows the user to edit an existing memo in the status field.

26 TRANSFER FILES Uploaded Files : Shows a full history of files that have been uploaded to the software from the Practice Management System. Response Files : Section shows all of the responses that are received for the selected customer.

27 UPLOADING FILES Integration Allows fluid interaction from the PM to the software. Claim files are automatically brought into the system and Tested. Files can be set to auto ready All accomplished by setting up an SFTP connection, and some PM side working knowledge. Manual Simple process to browse to file location and upload claim files. Allows for full control over when claims are brought into the software. Easy process for users not wanting to setup for integration.

28 LIFE CYCLE OF A CLAIM Claim File Loaded Valid Ready Batched & Sent ACK Accepted PaidDeniedAppeal Complete Rejected Fix Claim Complete Delete*Invalid Make Claim Valid Delete*

29 WORKING CLAIMS Select my invalids & rejects. With Invalids & Rejects displayed I will bring my invalids to the top by sorting on the Status. * All field headings with an asterisk allow for sorting.

30 INVALID CLAIMS With the claim highlighted it will display all of the history for the claim in the Status Messages section. Use the following steps to work Invalid Claims. 1.) Read the Error Message There are multiple ways -Read it in the column -Use the hover text -Or use the Right Click or Hot Key “M” for message. 2.) Based on your workflow fix the claim Remember: On INVALID claims with a TESTER source you can simply double click on the error to take you to the general location of the problem. Fix Now: Add Last Name and Save Fix In PM: Mark Claim Delete and fix it in the PM then resubmit. 3.) When Valid set to Ready.

31 REJECTED CLAIMS Similar to the process of working an invalid claim you would highlight the rejected claim and view the response error to understand the issue. Once you have looked into the rejection then you will refer to your own workflow. “M” Fix it Here Fix it on the PM Nothing to Fix Make the adjustment Ready claim Mark claim deleted Fix on PM and resubmit Mark claim complete

32 RIGHT CLICK OPTIONS Claim Selection View Status Message View Standard Functions Claim Related Functions Views of Claim Reports Functions for All Claims

33 Claim Related Functions

34 Editing Claim Have the capability to pass change log back to PM. Eliminating dual work Easy, logical layout to work claims. Change transaction sequence easily moving their order. Hover text displays ANSI coordinates. Assisting you in locating the potential problem the payer or tester may be flagging.

35 Views of Claim Reports

36 View Inbound File View EXACTLY what PM sent. To research & fix invalid claims. Views Entire file. View Outbound File (Batch) View EXACTLY what was sent to PAYER. To research & fix Rejected or Denied claims. Views individual claim. Get Inbound File Downloads full Inbound claim file. Same as Downloading file in Transfer Files. Inbound or Outbound Files?

37 Functions for ALL SELECTED Claims

38 Status Message View Options

39 Additional Functionality Ctrl+C: With a line item (Claim list view, or Status message view) highlighted, the user can copy and paste values. When CTRL+C is used a clipboard of the data will appear, to copy data simply double click on value desired. Ctrl+B: Displays what the claim would look like on a potential batch. Allowing you to view the potential Ansi data you would send to the payer. Delete Key: If user has permissions, using the delete key can delete highlighted selection (i.e. Claim, Uploaded File). Space Bar: Clears radio selections when no radio selection is needed. F4: (for use in Selection Criteria fields) Displays search tool or multi select dialogue box for fields.

40 Question and Answer


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