EZ-CAP Claimshop Interface Sanjay Goel · 15. PEN –“Parenteral and Enteral Nutrition” 16. ORF...
Transcript of EZ-CAP Claimshop Interface Sanjay Goel · 15. PEN –“Parenteral and Enteral Nutrition” 16. ORF...
EZ-CAP Claimshop Interface
Sanjay Goel
Manager, Software Development
Daren DeBow
Account / Sales Support Manager
Welcome!
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What is Claimshop?Why use Claimshop?EZ-Steps on pricing and getting Edits via
Claimshop.EZ-CAP Claimshop Configurations.Processing information and results.Claimshop changes in Auto Adjudication
and Workflow.Q&A
What is Claimshop?
• Pricing Hospital and Professional Claims using MedAssets managed care insurance pricing.• Get Contract and Copay values for the successfully priced claims.
• Show DRG grouper details for Hospital Inpatient Claims.
• Show APC details for each detail line for Hospital Outpatient Claims.
• Send various processing information.
• CCI Edits Hospital (Outpatient) and Professional Claims using MedAssets CCI Edits.• NCD, LCD, Policy, Age Gender, Modifier and many more.
• Show Trigger Code, Excluded Code and Description for each detail line for Hospital Outpatient and Professional Claims.
• DRG Claims (Hospital Inpatient Claims) not applicable for CCI Edits as they are included as part of pricing.
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Why Claimshop?
• More accurate Pricing/Edits based on Medicare.
• Beats manual pricing and Edits.
• Seamless integration from EZ-CAP saves time.
• Interface already included with EZ-CAP 651 onwards. Only activation is needed.
• No server installation and updates.
• Web service is hosted by MedAssets on their server with the latest changes always included.
• 99.9% up time.
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Pricing Supported by Claimshop
1. IPPS (MS-DRG) – all aspects and variations including CAH, SCH, EACH, MDH, RRP,VBP, low volume, and the rest
2. OPPS – including APC, all four fee schedules, and reasonable cost (SI = F or L)3. Physician RBRVS – includes all localities4. LTCH – including SSO and VSSO5. SNF6. ASC7. Ambulance8. Inpatient psych9. Inpatient rehab10. ESRD11. Hospice – both inpatient and outpatient12. RHC13. DME – everything except “portable oxygen”, which requires a series of “if-then”
decisions14. POS – “Prosthetics, Orthotics and Surgical Supplies”15. PEN – “Parenteral and Enteral Nutrition”16. ORF – “Outpatient Rehabilitation Facility”17. CORF – “Comprehensive Outpatient Rehabilitation Facility”18. CMHC – “Community Mental Health Center”19. HH- Home Health
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Claims Pricing/Edits Processing
• Two ways to price/Edit claims -1. Batch claims based on filter criteria for
multiple claims processing and scheduling.
2. On-Demand for individual claims.
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EZ Steps for Processing Claims
1. Assign an NPI or Medicare 1C to provider identification.
2. Create a claim with all mandatory fields.
3. Configuration (Global/Company/Reimbursement) if required. (For
CCI Edits these are not required).
• Global level.
• Company level at Health Plan, Option.
• Copay/Coinsurance, Allowed Amounts calculations.
• Reimbursement Value calculations.
4. Process the claim.
• Batch.
• On – Demand.
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Step 1 for Processing Claims
Add Provider NPI
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Step 1 for Processing Claims
Or Medicare ID as 1C Identification Type
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Step 1 for Processing Claims
Zip Code for Professional Claims
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Step 2 for Processing Claims
Create a claim with all mandatory fields entered
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Step 3 for Processing Claims
Create Configuration (Global/Company/Reimbursement) if required
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Processing Claims - Batch
Company ID, Batch Description and Batch Information.
Add a criteria to the Filter.
Pick Price, CCI Edit or both.
Preview the claim result with the criteria.
Create the Batch.
Process Batch with Claimshop or schedule the Batch to run later.
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Processing Claims - Batch
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Processing Claims – On Demand
Right-click Menu > Utilities > Price Via Claim Shop or CCI Edits or Price and CCE Edits
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Processing Claims –
Results
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Processing Claims –
Results
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Processing Claims –
Results
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Processing Claims –
Reports
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Processing Claims –
Reports
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Claimshop Configuration
Claim Adjustment handling
Copay/Coinsurance Calculation (Inpatient/Outpatient)
Allowed Amount determination (Hospital/Professional)
Global – Applies to all Claimshop processed claims
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Claimshop Configuration
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Company Healthplan Healthplan Option
Claimshop Configuration
Reimbursement
Apply Percent to Priced Amount coming from Claim Shop. Default is 100%.
Setup just like Fee Set Assignments.
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Edits Supported by Claimshop
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Included Edits in DRG and APC Groupers (UB)IOCE (Outpatient Facility) Includes, but not limited to the following:
Inpatient procedure conflict with TOB
Age/Gender
Invalid Procedure
Inpatient Procedure
Procedure and Gender Conflict
MCE – Medicare Code Edits (Inpatient Facility) Includes, but not limited to the following:
Inpatient specific validation
Invalid diagnosis or procedure code
Age/Gender
Non-covered procedures
NCCI – National Correct Code Initiatives
Other Edits (UB and 1500)• NCD –National Coverage Determination
• LCD – Local Coverage Determination
• NCCI – National Correct Code Initiatives
• Diagnosis code Validation
• Age Edits
• Gender Edits
• Modifier Edits
• Advance Beneficiary Notice of Non-coverage (ABN) edits
• History Edits/Global Pricing
• ICD9 Manifestation Edits
• ICD9 Unacceptable Principal Diagnosis
• ICD9 Validation Edits (for DOS)
• MUE – Medically Unlikely Edits
• CPT Validation Edits (for DOS)
• CPT Place of Service Edits
• CPT EM Surgical Edits with proper Modifiers
• RVU functionality/Edits
• Diagnosis Validation
• History Edits/Global Billing
Claim Shop Bill Types
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Auto Adjudication & Workflow
Elements added for Claim Shop with new pend codes for Auto Adjudication
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Auto Adjudication & Workflow
And Workflow
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Auto Adjudication & Workflow
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AUTO ADJUDICATION CRITERIA Value Description
CLAIM SHOP PRICE STATUS 0 TO 6 Various status returned by Claim Shop
IS CLAIM PRICED BY CLAIM SHOP? YES/ NO
IS CLAIM EDITED BY CLAIM SHOP? YES/ NO
PEND CODE MASTERS
P25 PSU PRICE SUSPENDED
P25 PNR PRICE NEEDS REVIEW
P26 EDF EDIT FAILED
PEND CODE DETAIL
DP23 CEF CLAIMSHOP EDIT FAIL
WORK FLOW RULESCLAIM SHOP PRICE STATUS 0 TO 6 Various status returned by Claim
ShopIS CLAIM PRICED BY CLAIM SHOP? YES/ NO
IS CLAIM EDITED BY CLAIM SHOP? YES/ NO
PEND CODE MASTERS
P25 PSU PRICE SUSPENDED
P25 PNR PRICE NEEDS REVIEW
P26 EDF EDIT FAILED
PEND CODE DETAIL
DP23 CEF CLAIMSHOP EDIT FAIL
Pricing, Edits and Benefits
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After the claim is priced via Claim Shop, the claim will still hit the EZ-CAP Benefits, Auto Adjudication and Workflow.
Copay and Coinsurance can be calculated based on benefit setup. Non-covered services will not be paid and an Adjustment Code will be applied.
Summary
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Claims can be Priced, sent for Edits or Priced and Edited together.
Batched or per claim.No installation is required.NPI is required for Hospital Claims and Zip Code is
required for Professional Claims. Both Auto Adjudication and Workflow include
Claimshop elements.All required information for pricing and edits are
stored in the claim.Activation key is required to process claims which
can be received from MedAssets and OrangeMZI.
EZ-CAP Claimshop Interface
Questions?
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