Transcript Document
Practice Insight Instructional Webinar Series Advanced Claim Manager
Presented by: Shaun McAnulty – Product Training Specialist
Topics to Cover
• • • • • Transfer Files Claim Status Use Selection Criteria Right Click Functionality Editing a Claim
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)
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.
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.
Claim Status VALID
Statuses
Definition
Claim Valid (Must be set to READY to SEND to Payer)
Source
TESTER /SCRUBBER
READY
Claim Ready to be Batched and Sent to Payer Claim Acknowledged Auto Processed /Manual Status Override Response
ACK ACCEPTED
Claim Accepted by the Payer Payer Response
PAID-ERA
Claim Paid by Payer
PAID
Claim Paid according to a User Payer Response (ERA 835) Manual Status Override/ Received paper EOB
Green
= Commonly expected Statuses
Red
= Error or Workable Statuses
Yellow
= Additional Statuses
Common Working Statuses
Claim Status INVALID Definition
Claim Invalid by Tester or Scrubber
Source
TESTER /SCRUBBER
REJECTED
Claim Rejected by Payer Payer Response
DENIED
Claim Denied by a Payer Payer Response / Real Time Claim Status (276)
Green
= Commonly expected Statuses
Red
= Error or Workable Statuses
Yellow
= Additional Statuses
Common Working Statuses 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.
Additional Statuses
Claim Status APPEALED Definition
Claim Appealed by End User
Source
Manual Status Override
COMPLETE DELETE PAID-PYR
Claim considered Complete by User Manual Status Override Claim Marked Deleted by a User Manual Status Override, will not show on reports.
Claim Payment Acknowledged by Real Time Claim Status (276) Payer
PEND-USR
Claim Pended by User Manual Status Override
PENDED
Claim Pended by Payer Payer Response / Real Time Claim Status (276)
Green
= Commonly expected Statuses
Red
= Error or Workable Statuses
Yellow
= Additional Statuses
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.
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.
Organizational Statuses
COMPLETE
• Claim that will not be fixed.
• Completed claims will show on Analytics.
• History on claim will remain intact.
DELETE
• Claim will be fixed on the PM & resubmitted.
• Claims marked Delete will not show on Analytics, or in general searches.
• History will remain
• • • •
TESTER rejections
1st level of testing How we get Invalid Claims 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.
• • •
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!
How we get Rejected Claims.
Payer/Trading Partner Rejections
• • 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# 131415021 in Demo Database
Loop 2010AA Billing Provider Name NM1* 85 *2*GROUP MEDICAL*****XX*1234567890
How we get Rejected Claims.
Payer/Trading Partner Rejections
• • 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
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.
Narrow claim selections by staff member assigned to. (Hotkey: A on claim) Unique Id for specific claim in EDI Returns all claims based on Responsible Payer.
Name or range search, also can use Wildcard Searches.
(EX: %%ith) If Clinical Scrubbing (Extra Service) Edit Id can be entered to locate all claims with error.
If Payer or CH sends back their ID number for the claim it is also searchable.
Can group claims with the same Response ID Selects claims using PI Payer ID.
The Outbound ID # for a Payer Narrow by Type of Payer.
Select claims that contain the same Retrieved ID.
RIGHT CLICK OPTIONS
Claim Selection View Standard Functions Claim Related Functions Status Message View Views of Claim Reports Functions for All Claims
Claim Related Functions
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.
Views of Claim Reports
Inbound or Outbound Files?
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.
Functions for ALL SELECTED Claims
Status Message View Options
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.