Presentation on theme: "Practice Insight Instructional Webinar Series Advanced Claim Manager"— 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 FunctionalityEditing a Claim
3 Transfer Files Upload Files Response 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.Repost to SFTP using Right Click if File is missing on PM. (Integrated users)Download file to repost to PM (Manual)Full EOB ViewMark 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 Staff Name: who uploaded the file.File Name: the original file name for the upload.If the claims have any issue loading there will be a message displayedFile Type: what file was uploaded and what format.Multi Select ResponsesMark ERA responses Received (organizational)See when a response was viewed & who by, when mark received & who by.
5 Filter List ResponsesLocate 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 Statuses VALID READY ACK ACCEPTED PAID-ERA PAID Claim Status DefinitionSourceVALIDClaim Valid (Must be set to READY to SEND to Payer)TESTER /SCRUBBERREADYClaim Ready to be Batched and Sent to PayerAuto Processed /Manual Status OverrideACKClaim AcknowledgedResponseACCEPTEDClaim Accepted by the PayerPayer ResponsePAID-ERAClaim Paid by PayerPayer Response (ERA 835)PAIDClaim Paid according to a UserManual Status Override/ Received paper EOBGreen= Commonly expected Statuses Red= Error or Workable StatusesYellow= Additional Statuses
7 Common Working Statuses Claim StatusDefinitionSourceINVALIDClaim Invalid by Tester or ScrubberTESTER /SCRUBBERREJECTEDClaim Rejected by PayerPayer ResponseDENIEDClaim Denied by a PayerPayer Response / Real Time Claim Status (276)Green= Commonly expected Statuses Red= Error or Workable StatusesYellow= Additional Statuses
8 Claim Flow Load Claim Valid Claim has no errors found. READY Then Sent ACKReceived from PayerACCEPTEDBy PayerPAIDERAEOB
9 Common Working Statuses INVALIDFix in Claim Manager & set to READY.Fix in PM & Rebill, Mark it Delete.REJECTEDFix it Claim Manager set to Ready.Rebill From PM.Mark Complete. (EX. PT Responsibility)DENIEDMark Complete.Appeal & send Appeal Letter.
10 Additional Statuses Claim Status Definition Source APPEALED COMPLETE Claim Appealed by End UserManual Status OverrideCOMPLETEClaim considered Complete by UserDELETEClaim Marked Deleted by a UserManual Status Override, will not show on reports.PAID-PYRClaim Payment Acknowledged by PayerReal Time Claim Status (276)PEND-USRClaim Pended by UserPENDEDClaim Pended by PayerPayer Response / Real Time Claim Status (276)Green= Commonly expected Statuses Red= Error or Workable StatusesYellow= Additional Statuses
11 Additional Statuses 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.PENDEDClaim has been manually marked to wait.Status for when claims need to be easily grouped together that are waiting to be worked.APPEALEDWhen 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.
12 Organizational Statuses DELETEClaim will be fixed on the PM & resubmitted.Claims marked Delete will not show on Analytics, or in general searches.History will remainCOMPLETEClaim that will not be fixed.Completed claims will show on Analytics.History on claim will remain intact.
13 How we get Invalid Claims TESTER rejections1st level of testingRule-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 correctionOnce the claim is corrected in Practice Insight it will retest as VALID then Ready the claim.EDIFECS rejections2nd level of testingRuns 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 How we get Invalid Claims. EDIFECS rejectionsSecond level of testingEDIFECS runs after the claim has batched but before it is sent to the payerEDIFECS further tests claims to assure they are ANSI compliantCorrecting the claim WILL NOT make it VALIDOnce the claim has been corrected, READY the invalid claim
15 How we get Rejected Claims. Payer/Trading Partner RejectionsThe same rejection message does not always have the same reason.Look for clues in the rejection message to determine the cause: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:EDI ID# in Demo DatabaseLoop 2010AA Billing Provider NameNM1*85*2*GROUP MEDICAL*****XX*
16 How we get Rejected Claims. Payer/Trading Partner RejectionsView 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:NM1*85 = billing providerNM1*82 = rendering providerNM1*IL = subscriberNM1*77 = service facilityNM1*DN = referring provider
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 Name or range search, also can use Wildcard Searches. 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 EDIIf 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. If Payer or CH sends back their ID number for the claim it is also searchable.Selects claims using PI Payer ID.The Outbound ID # for a PayerNarrow by Type of Payer.Can group claims with the same Response IDSelect claims that contain the same Retrieved ID.
20 F1 ONLINE HELPUsing 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.Currently the best kept secret the F1 online help guide is a wealth of information, this is the official manual for the software and is updating along with the program to display new features and functionality as well as best use practices and common how to’s.
21 Claim Selection Criteria CLAIM MANAGER LAYOUTClaim Selection CriteriaClaim List ViewClaim Manager is where you can Manage, Select, Research, and Work your claims. It contains and displays a multitude of Claim Data. The main display is broken into three windows:The Claim Selection Criteria: Using these fields the user can choose a single criteria for basic searches or add multiple criteria to view a more advanced specific group of claims.Claim List View: Once a search is run, using the above, the Claims that fulfil the request are displayed here in a easy to view format. Displaying the specific claim data in a readily accessible easy to see view.Lastly Status Message View: When a claim is focused on the History of that claim is then displayed in this lower section, allowing the user to research the claim further. Any responses, ERAs or Messages as well as Claim Status History will display. As well as any informational messages or Memos that may have been added by users.Status Message View
22 BUTTONSTransfer 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 CRITERIASelect 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 VIEWCheck 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 VIEWView 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 FILESUploaded 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.Transfer Files is where you can view and manage all inbound claim files, as well as all the subsequent responses from Payers. The responses will vary from Payer, to ERA, to initial uploads. Think of transfer files as the one main informational hub where the Data comes in.
27 UPLOADING FILES Integration Manual 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 readyAll accomplished by setting up an SFTP connection, and some PM side working knowledge.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 AcceptedPaidDeniedAppealCompleteRejectedFix ClaimDelete*InvalidMake Claim ValidLIFE CYCLE OF A CLAIM
29 Select my invalids & rejects. WORKING CLAIMSSelect 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.In Claim Manager I will simply use the Select Invalids & Rejects so I can easily access all of my claims that are time sensitive and important.
30 INVALID CLAIMSRemember: 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.There are multiple waysRead it in the columnUse the hover textOr use the Right Click or Hot Key “M” for message.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.Working Invalids first is my personal choice simply because they have not been out of our system yet. Working an invalid claim you should first read the Error, we have multiple options on how to view the message the easiest being using your M key on your keyboard with the Error Message highlighted and you will see a report view allowing you to see the entire message. Once the message is read and understood you can either fix the problem right here in the software by double clicking on the error which will take you to the general location of the problem and fixing it on the claim, saving the work, and once it retests and is set to valid mark the claim ready! Or if your workflow is to make all adjustments at your PM level than you can mark this invalid as delete by using your Delete Key on your keyboard.1.) Read the Error Message3.) When Valid set to Ready.Fix Now: Add Last Name and Save2.) Based on your workflow fix the claimFix In PM: Mark Claim Delete and fix it in the PM then resubmit.
31 REJECTED CLAIMS“M”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.Fix it HereMake the adjustmentReady claimFix it on the PMMark claim deletedFix on PM and resubmitNothing to FixMark claim complete
32 RIGHT CLICK OPTIONS Status Message View Claim Selection View Standard FunctionsClaim Related FunctionsStatus Message ViewWhere your focus is will affect the options that you have for that specific item. In the Claim Selection View you have more options in your right click functions than you do for the Status Message View area.Views of Claim ReportsFunctions for All Claims
34 Editing Claim Have the capability to pass change log back to PM. Eliminating dual workEasy, 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.
36 Inbound or Outbound Files? View Inbound FileView 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 FileDownloads full Inbound claim file.Same as Downloading file in Transfer Files.
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.