1 Early Intervention Central Billing Office Electronic Claims Submission.

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Early Intervention Central Billing Office

Electronic Claims Submission

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Electronic claims Health Insurance Portability and Accountability Act (HIPAA) How providers can generate HIPAA-compliant Electronic Claims Benefits of electronic claims submission Requirements for submitting electronic claims Factors and considerations Resources

AGENDA

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Electronic claims

Electronic Data Interchange (EDI) applications, including electronic claims have been used for many years.

Electronic claims are an alternative to paper claimsGenerated by computer systemsTransmitted electronically to payers by computer systemsUntil recently (HIPAA), no universal standard has existed

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HIPAA

Among other things, the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA):

Set standard formats for electronic transactions

States that if a provider desires to conduct a “standard transaction” (an electronic transaction in the HIPAA standard format) a payer may not refuse

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Early Intervention Central Billing OfficeElectronic Claims

Pre-HIPAA electronic file layouts:System “A” Field System “B”

Patient First Name 15 characters 1 Date of Service DD/MM/YY

Patient Last Name 25 characters 2 Transaction code 3 numbers

Account Number 40 characters or numbers

3 CPT Code 9 characters

CPT Code 9 numbers 4 Diagnosis Code 6 characters

Diagnosis Code 6 numbers including decimal

5 Account Number 35 numbers

Transaction code 4 characters 6 Patient First Name 12 characters

Date of Service YYY/MM/DD 7 Patient Last Name 23 characters

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Early Intervention Central Billing OfficeElectronic Claims

Simplification of translation or mapping:

Date of Service

Account Number

Patient Last Name

Patient First Name

Procedure Code

Diagnosis Code

Patient First Name

Patient Last Name

Account Number

Procedure Code

Date of Service

Diagnosis Code

System “A” “Standard”

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HIPAA

Impact on the EI-CBO

The EI-CBO upgraded its claims processing system by purchasing a translator that allows the EI-CBO to send and receive electronic transactions in HIPAA-compliant format.

Part of this upgrade, called Rapid Data Entry, has allowed us to significantly reduce turn-around time on paper claims.

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HIPAA

Impact on Providers

Option 1:

Providers can continue to submit claims to the EI-CBO on paper. No changes are required.

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HIPAA

Impact on Providers

Option 2:

Providers may submit electronic claims to the EI-CBO.

This option will require an investment of time and resources.

It is important for you to consider the requirements and costs to submit claims electronically.

The requirements will differ based on which electronic option you elect to pursue.

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Generating HIPAA compliant electronic claims

Use billing or practice management software to:

Submit claims directly to the EI CBO using billing or practice management software that is able to produce claims in HIPAA compliant format.

OR

Submit claims to a clearinghouse using billing or practice management software that is able to convert claims into HIPAA compliant format

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Submit claims directly to the EI CBO

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Submit claims to a clearinghouse

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Clearinghouses

Under HIPAA, a clearinghouse is an entity that does either of the following functions:

Translates data that is not HIPAA-compliant into HIPAA-compliant format.

Translates data that is HIPAA-compliant into a non-compliant format.

Clearinghouses also facilitate the transmission of electronic transactions between payers and providers.

Electronic Claims

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Electronic claims

Some Clearinghouses:

THIN

Envoy/WebMD

McKesson

The EI-CBO has contracted with THIN.

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Requirements For Each Option

Requirements Direct Using THIN

Modem or internet access Yes Yes

Computer Yes Yes

Billing/Practice Management Software

Able to send electronic transactions

Able to create HIPAA compliant transactions

Yes

Yes

Yes

No

Technical and/or software expertise able to assist with configuration and installation of software

Yes Yes

If insurance is to be billed, claims must be mailed with EOB attached.

Yes Yes

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How to determine if you should make this investment to send claims electronically?

Evaluate your current resources, and what you will need to purchase to be able to send claims electronically

Calculate your current operational costs to determine the financial feasibility of automating your business.

Will decrease your total operational costs if invest in the ability to

send electronic claims?

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Evaluate your current resources

Will you need to purchase computer equipment?

Will you need to purchase internet access?

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Will you need to purchase billing or practice management software capable of submitting

electronic claims?

Billing/practice management software packages can range in price from under $2,000 to in excess of

$100,000, depending on the features and capabilities.

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If you currently utilize a billing or practice management system will you need to purchase additional software

to be able to send HIPAA compliant transactions?

Will you need to hire a consultant or do you have a person on staff with a high level of technical

expertise? Consulting fees can run from $75 to $200 per hour.

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How electronic claims submission can benefit you:

decrease postage and paper costs track each claim through a submission report

(see http://www.thinedi.com/hints/thinflow2.pdf for examples of THIN reports)

increase productivity within your organization Claims are checked for completeness - you will know immediately if a claim

has been rejected for mistakes on the claim

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Available resources:

A listing of Practice Management software vendors can be found on the internet. The web addresses for several sites are listed below. The information found in each directory is for informational purposes and is being provided to assist you with your research.

The Health Information Network (THIN) Professional Vendor List. This Professional Vendor List represents a number of available sources for the electronic services. It is in no way an endorsement or recommendation of any single Vendor. The address is:

http://www.bcbsil.com/PDF/professional_vendor_list.pdf

HIPAA.ORG EDI Practice Management System Directory:

http://www.hipaa.org/pmsdirectory

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Thank You!

1 Early Intervention Central Billing Office Electronic Claims Submission.

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