FISS NAVIGATION - · PDF fileFISS NAVIGATION for clients of: ... Acronyms • Navigate...

COMPREHENSIVE BILLING SERIES - PART 9

FISS NAVIGATION

for clients of:

www.teamtsi.com • 800.765.8998

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COMPREHENSIVE BILLING SERIES-PART 9

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POST-TEST

1. Name three claim status locations?

2. What does RTP mean?

3. What is status location SB6001?

4. The claim error reason code can be found using which function key when in claim corrections?

a. F3 b. F1 c. F8

5. An adjustment claim will default to what bill type?

a. XX3 b. XX4 c. XX7

6. When adjusting claims what two types of codes are required?

7. To log off the DDE system use what combination of letters?

a. CSSF b. CFFS logoff c. CSSF logoff



POST TEST ANSWERS

1. Name three claim status locations? Paid, denied, suspense, return to provider or rejected

2. What does RTP mean?

Return to provider

3. What is status location SB6001? Addition Development Request

4. The claim error reason code can be found using which function key when in claim

corrections? a. F3 b. F1 c. F8

5. An adjustment claim will default to what bill type?

a. XX3 b. XX4 c. XX7

6. When adjusting claims what two types of codes are required?

Condition code and adjustment reason code

7. To log off the DDE system use what combination of letters? a. CSSF b. CFFS logoff c. CSSF logoff


POLARIS GROUP Strategic Solutions For Healthcare www.polaris-group.com©

1

COMPREHENSIVE BILLING SERIES


Acronyms

• Navigate FISS (Fiscal Intermediary Shared System) to follow-up on submitted claims and ensure payment.

2

Acronym Definition

ADR Additional Development Request

ANSI American National Standards Institute

DDE Direct Data Entry

FISS Fiscal Intermediary Standard System

HCPCS Healthcare Common Procedure Coding System

NDC National Drug Code

NPI National Provider Identifier

OIG Office of Inspector General

OSC Occurrence Span Code

RACF ID Resource Access Control Facility Identification

RTP Return to Provider

TOB Type of Bill



Fiscal Intermediary Shared System (FISS) and DDE

• FISS is the designated claims processing system used by Medicare Contractors who process Part A claims.

• DDE is the external application developed for providers claims submission and inquiries.

3


FISS

• The FISS is a menu driven system. The menu item chosen determines the system’s functional capability.

• The Main Menu includes the following submenus:– Inquiry,

– Claim Entry and Attachment,

– Claim Correction

– Online reports. A DDE4



Direct Data Entry

• Medicare provider may perform the following functions electronically:– Submit claims electronically

– Correct originally submitted claim

– View beneficiary eligibility and claim history

– View ADR requests online

– View documentation from Adjudication and Medical Review staff about claim RTP or denial

5


FISS / DDE cont.

• Shows Status/location codes for claims.– Status explains the current standing i.e. paid, rejected,

in processing, etc. of the claim

– Location describes where the claim is in the processing cycle.

6



FISS – How to Get Connected

• To access the Direct Data Entry, Fiscal Intermediary Shared Systems (FISS) and submit claims electronically to CMS the provider must complete an application to use CMS Electronic Data Interchange services and choose an approved connectivity vendor.

• You may also utilize PC-ACE, the free claims processing software offered by CMS specific to your MAC. Free claims transmission software is also available.

7



• Connectivity choices vary. Some providers choose to use a billing clearinghouse to handle claims transmission and connectivity.

• Connectivity to transmit claims DOES NOT give the provider access to DDE.

• You must have software to connect to the DDE and submit the appropriate forms required to obtain log on ID and passwords.

8




Connectivity service:

–http://www.edissweb.com/cgp/software/

Or

Choose any Approved Medicare Vendor:

• Ability

• e-Solutions

• American Health Data

• Axiom etc. 9


EDI

10




• Follow instructions from your MAC to request User IDs

• Set-up and maintain individual passwords. You will also receive a RACF ID. This can be used to reset your password electronically.

• Providers are not permitted to share their RACF ID with ANYONE!

• To gain access to FISS the individual must have their own RACF ID

11


Logon ID

Logon ID belongs to assigned user – even if you quit and go elsewhere Every user of FISS has a unique logon ID Password not to be disclosed to anyone:

• Including supervisors and managers

12



IDs

• Most MACs require providers to certify user access annually. If this recertification information is not verified and returned, access will be terminated.

• DDE User IDs will be revoked and deleted from the system after 30 days of being inactive.

• DDE IDs cannot be re-activated once this has occurred. Notification will not be sent out prior to deletion.

• This issue can be avoided by signing on to DDE at least once every 29 days so that your ID remains active.

13


Changing Passwords

• Password will expire every thirty days.

• On the day after it expires, when you type your password, the system will automatically prompt you to change your password.

• Rules for passwords will usually display on the system when you change your password.

14



Sign On Through Your Vendor

15


Choose Your Jurisdiction

16

Choices will vary by MAC



Sign On

17

Same user name and password


18

Type in FSS0 (zero) or HIQA FSS0 will take you to DDEHIQA will take you to CWF verification



Main Menu


Inquiry Menu

20

The Inquiry Menu gives DDE users access to the following claims information in an inquiry mode:

• Healthcare Common Procedure Coding System (HCPCS) codes• Adjustment reason codes• Diagnoses related grouper (DRG) Revenue codes• International Classification of Diseases (ICD-9 codes)• Diagnosis/procedure codes (ICD-10)• Claims Reason codes• Claim count summary• Check history• American National Standards Institute (ANSI) reason codes

(two-digit codes located on the remittance advice)



Inquiry Menu

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The system will automatically enter your provider number into the Provider field. If the facility has multiple provider numbers, you will need to change the provider number to inquire or input information.

[TAB] to the provider field and type in the appropriate provider number.


Inquiries

22

NOTE: The option 10 – Beneficiary/CWF is no longer updated and the HETS or SPOT should be used to obtain beneficiary information.



Navigation

23

Screen Control/Short Cut (SC) in the upper lefthand corner allows access to another area:• In the ‘SC’ field enter the menu number and

<enter> Tabbing – allows movement between required

fields within the claim/file screen:• Use the tab key versus using the mouse to

move the cursor between required fields ofthe claim/file screen


Function Keys

24



25

Navigation and Page Location


Navigation

• When entering information remember to <TAB> among the fields until you have completed the screen.

• To move on to the next screen/page, press <F8>.

• Depending on the Type of Bill, the cursor will skip fields that are not required.

• If you press <F3> while you are in the middle of data entering your claim before you have ‘stored’ the claim, you will lose all the information you have keyed.

• If, at any time, you press <F4>, you will be bumped totally off the system, and you must sign back on.

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Claims Inquiry

• It is recommended that you use FISS to check your billing transactions at least once a week.

• When you sign on to FISS, you should:– Check Option 56 within the Inquiry Menu to see a quick

summary of claims that are processing in FISS.

– Correct any claims that are in your Return to Provider (RTP) file (T status).

– Check for Additional Development Requests (ADRs).

– Research any claims that have appeared on your Remittance Advice as noncovered or denied.

27


Main Menu



Claim Inquiry - Option 56

• Option 56 gives you a view of your claims currently processing in FISS. It shows you the number of claims and charges submitted by status location and by type of bill. It will not show you which specific claims reside in the status/location.

• You will not see claims that have completed processing (s/loc P B9997, R B9997, & D B9997). You will see claims that have been approved for payment (P B9996) because they have not completed processing.

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Option 56 – Claim Count Summary

Enter 56



Claim Summary Inquiry Screen


Claim Summary Totals



Bill Category

Bill Category Definition

11 – 14 Type of Bill (TOB)

21 – 23 TOB

71 TOB

72 TOB

74 TOB

75 TOB

76 TOB

85 TOB

MP Medical Policy

NM Non-Medical Policy

AD Adjustments

TC Total Count

GT Grand Total


Claims Inquiry – Option 12

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TYPE 12



Claims Inquiry

• Check beneficiary claim Status/Location and history.

• Claims are reflected only for services billed under YOUR provider number.

• Review claim line item detail for paid or denied claims.

• Obtain information on Additional Development Requests (ADRs).

• Number and types of claims shown depending on selection criteria used.

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Claims Inquiry - Tips

• Limit search to reduce numbers of claims shown, but don’t make criteria too narrow so that related claims may not show.

• Selection criteria include:– HIC (Medicare Number)

– From and To dates

– Status/Location (S/LOC field in DDE)

– Type of Bill (TOB)

36



Claim Summary Inquiry

•USE ANY OF THE BELOW SELECTION CRITERIA TO INQUIRE ON CLAIMS

37


Status Locations

• The Status/Location (S/LOC) code for Medicare DDE screens indicates whether a particular claim is paid, suspended, rejected, returned for correction, etc.

• The six-character alphanumeric code is made up of a combination of four sub-codes:

– the claim status,

– processing type,

– location, additional location information.

• Each S/LOC code is made up of two alpha characters followed by four numeric characters.

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PB997

• The first position (position a) is the claim’s current status. “P” indicates the claim has been paid (or partially paid).

• The second position (position b) is the claim processing type. In this example, “B” indicates batch.

• The third and fourth positions (positions cc) are the location of the claim in FISS. In the example, “99” indicates that the session terminated.

• The last two positions (positions dd) are for additional location information. In the example, “97” indicates that the provider’s claim is final on-line.

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Status / Location

• SBxxxx - CLAIM SUSPENDED

– Changes CANNOT be made to claims in this status

– Claims remain in this status until MAC completes the manual processing

– xxxx represents the various location of the claim in the cycle from manual review to adjudication

• SB6001 - Additional Development Requests (ADR) or in the Medical Review process. CHECK FOR CLAIMS IN THIS LOCATION AT LEAST WEEKLY!

40



Common Status / Location

• P B9996 – Claim complete but not on “payment floor”

• P B9997 – Claim completed and paid

–Paid includes claims approved but no money issued, i.e., charges applied to deductible/coinsurance

• R B9997 – Claim rejected – some claims reflecting this status can be ADJUSTED or CANCELED

• T B9997 – RTP return to provider – able to CORRECT claims reflecting this status

• D B9997 – CLAIM DENIED

41


Common Status Locations

42



Specific Claim Selection

• Select specific claim from your claim summary list by placing an “S” on the line to the left of the claim you would like to view.

• The claim will contain at least seven pages to review, plus line item detail charge screens

• REMEMBER: You can ONLY VIEW the claims from the INQUIRY area of the DDE!

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Claim Summary Detail



Claim Page 1


Claim Page 2



Line Item Detail

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• Line item information is available for each revenue and HCPC line on the claim

• Shows payment detail or denial reason codes

• Shows additional modifiers when more than two are present

• Line item denial reason codes may be different from claim denial reason codes

• 3 screens of detail information per line – use F2 (jump Key) or F11 to view detail


Line Level Payment Summary



Line Level Reason Code


Claim Page 3



New MSP Payment Screen


Remarks Page 4



Claim Page 5


Claim Page 6



ADR Info – S/LOC SB6001

55


ADR Info on Screen 7

56



Manual Claims Entry

57


FISS / DDE

58



Claim Entry Screen 1

59



• Screen 1 represents the top of the UB-04 form.

• Enter Dates of Service, Type of Bill

• Part A claim requires DAYS COV, NC (non covered days), CO (co-insurance days)

• Enter demographic information:– HIC #, Beneficiary name, DOB, address, zip code,

sex, marital status, admit date,

– Type, SRC (source code), STAT (status code) are situation specific.

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• ENTER claim specific information:– Condition Codes (ex; 57 SNF readmission)

– Occurrence codes and dates (ex: 22 010112 – Medicare last covered day)

– Span Code & dates (ex: 70 122512 thru 122912 hospital stay dates)

– Value Codes and amount (ex: 09 148.00 co-insurance)

• Press “F6” to move to the next page

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62




• Enter claim detail on this page

• It is very important to use the “tab” key to ensure that the details have the correct placement on the claim

• Use the “ENTER” key to “set” the information after it is entered

• The TOTAL line is entered as REV CODE 0001

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• Part A claims must include:– REV CODE 0022 RUG & Assessment Indicator (ex:

RVB10)

– TOT UNITS (total units of the item)

– COV UNITS (covered units)

– TOT CHARGE (total of the charges – not required for 0022 line)

– NCOV CHARGE (required if non-covered items)

– SERV DATE (service date – required on Part B claims)64




65



• Enter PAYER info on this screen

• Medicare information is entered for PAYER ‘A’– CD - payer code “Z” for Medicare

– ID tab through this field

– PAYER – enter “MEDICARE”

– OSCAR – 6 digit provider ID number

– RI – release of information - enter “Y” (yes) if signed release of information form is on file

– AB – assignment of benefits – enter “Y” (yes) if signed assignment of benefits form is on file 66




• Enter information for supplemental payer if applicable using the appropriate PAYER code.

• TAB down to MEDICAL RECORD NUMBER

– enter number assigned

• TAB to diagnosis codes. Enter codes WITHOUT decimal point. TAB from field to field. Enter ADMITTING diagnosis code.

• TAB to ATT PHYS NPI enter NPI #, Last Name (LN) and First Name (FN) of treating physician

67



68




• REMARKS area is used for entering information that is reflected in the “comments” area of the UB-04. Situation and MAC specific.

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70




• Enter payer specific information for the beneficiary on this page consistent with the information on screen 3.

• Use TAB key to move to the fields

• ENTER on the first line:– recipients last name, first name, sex, DOB then tab

to the next line and enter the REL – relationship (ex: “18” self) and HIC # (Medicare number)

• Enter the information for Payer B if required71



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• No information is entered on this screen.

• Press “F9” to store your claim.

• If claim is accepted, you will get a new “blank” screen to enter another claim.

• If an error exists on the claim, the claim will not “:store” and a denial reason code will be reflected at the bottom left corner.

• Press “F1” for denial information, correct the item and press “F9” again to store the claim.

73


Roster Billing

74



Roster Billing

75


Correcting Claims

76



Correcting RTP’d Claims

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RTP Claim Summary Screen

• Once the selection for the type of claim is entered (SNF “25”) Press Enter again and a summary of all RTP (Returned to Provider) claims, status/location T B9997, will appear.

• Claims in this location can be corrected.

78




• Providers have the option to check claims by sorting them by specific criteria by entering one of the following letters in the DDE SORT field and pressing ENTER:

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80




• The Type of Bill (TOB) field defaults to the first two digits of the TOB for your provider type, which may need to be changed. More than one type of bill may need to be checked, depending on your provider type (example, 22x or 23x claims).

• A provider may key a specific RTP claim by keying the patient’s Health Insurance Claim (HIC) number and the “from and to” dates of service.

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• If no bills appear after pressing Enter, there are no bills for the TOB that need to be corrected.

• Select the claim you want to correct by entering an “S” on the line to the left of the specific claim in the SEL field and press “ENTER”

• Any changes to the claim are made to the appropriate page.

• “F9” stores the claim after corrections are made

82



Reason Codes

• The reason code(s) associated with the error(s) on the claim appears at the bottom left corner on the screen.

• Press “F1” to reveal the narrative for the REASON CODE that is reflected on page 1 of the claim. Use “F6” to scroll forward to read entire narrative.

• Press “F3” to return to the claim from the narrative page.

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Reason Codes



Reason Codes

• If more than 1 reason code is listed on the claim, place the curser on the first digit of the REASON CODE and press “F1” to see the narrative for that code.

• Make the correction and press F9. If the reason code has been corrected, FISS automatically stores the claim. If not, the claim will remain on the screen for further corrections, sometimes other REASON CODES may appear.

85


Correcting Revenue Lines

• If you need to change information on page 2 of the claim to a revenue code line (HCPCS, modifier, units, charges or date of service), delete the incorrect revenue code line and rekey the correct information on a new line.

• Do not type over the incorrect information.

• Use the proper method to delete the revenue code lines!

86



Deleting Revenue Code Lines

• To delete a revenue code detail line: – If rekeying corrected line item, key updated line item

information beneath the 0001 line.

– Enter a D on the line or lines to be removed.

– Press HOME key twice (HOME, HOME)

– Press Enter.

• The selected line(s) will be removed.

• Correct the total amounts on the 0001 line. – Press F9 to submit corrected claim.

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Deleting Revenue Code Lines



Adding Revenue Code Lines

• Key the added revenue code line after the 0001 line. You don’t need to rekey the entire revenue code page.

• Be sure to correct the total charge amount to reflect the addition of the revenue code charge.

• Press Home so that the cursor is placed in the upper right corner of the screen (the Claim Page field).

• Press Enter. FISS will automatically reorder the rev code that you added to appear before the 0001 line.

• Press F9 to submit corrected claim. 89


Correcting a HIC Number

• A HIC number can only be corrected when a claim is in an RTP status/location. To correct a HIC number:

• After selecting the claim by entering “S” in the SEL field:– On claim page 1, press Tab to the Process New HIC

field.

– Type Y in this field. The cursor will move one space to the right after typing Y.

– Enter the correct HIC number. Press F9

90



Suppressing RTP’d Claims

• To SUPPRESS a claim that appears in the TB9997 status and location because the claim is a duplicate or for some other reason does not need to be processed.

– Select the claim form the list of RTP’d claim by placing an “S” in the SEL field.

– On Page 1 of the claim TAB to the SV field and enter a “Y” in the filed. Press F9 to store the claim.

• You CANNOT access claims that have been suppressed.– You can view this claim in claim status inquiry

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How to Suppress a Claim



Cancel Claims

93


Cancel Claims

• To cancel/void paid claims, enter the Claim Cancels option that matches your provider type and press Enter.

• The Claim Summary Inquiry screen will appear.

• The S/LOC field defaults to “P.” Because you are accessing MAP 1741 from the Claim Cancels option, only claims in the “P” (processed) status/location will be displayed. To cancel a Rejected claim enter an ‘R” in the S/Loc field.

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Cancel Claims

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Steps To Complete A Cancel/Void

• Enter the claim change reason code in the first available Condition Code field on claim page 1. Only one code is allowed per claim. Valid claim change reason codes for cancellations are:

– D5 – Cancel only to correct an HIC number or CCN.

– D6 – Cancel only to repay a duplicate payment or correct an error.

• Note: No other changes can be made on a void.

• Press F8 to the REMARKS page

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Cancel Claims

97


Cancel Claim - Page 4

• This page is optional but recommended. Enter a brief description of why the claim is being voided/canceled. There are up to three additional remarks screens available. Press F6 to see additional pages and F5 to page back to the remarks page 1. Press F9 to finalize the void transaction.

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Cancel Claims

• Cancels (voids) can be processed electronically. A bill can only be canceled if it has finalized and is reflected on the remittance advice.

• A cancel claim is sometimes followed with a new corrected bill when an adjustment was not appropriate.

• Providers must be very careful when creating cancels. Once the cancel is created and the F9 key pressed, there is no stopping the cancel. Errors will cause payment to be taken back.

99


Adjustment Claims

• Sometimes a claim may need to be adjusted after it has been paid or rejected to make changes (i.e., add or remove services). Claim adjustments can be made to paid or rejected claims; however, if a claim in “P” status is partially denied due to medical review, the claim cannot be adjusted online.

100



Adjustment Claims

101


Adjustment Claims

• To adjust paid claims from the Claims Correction Menu, key the claims adjustment option that matches your provider type in the Enter Menu Selection field and press Enter.

• The Claim Summary Inquiry screen (MAP 1741) will appear.

102



Adjustment Claim Summary Screen

103


Adjustment Claims

• The S/LOC field defaults to “P” to display claims in a Processed (P) status/location. To display claims in a Reject (R) status/location, type R in the S/LOC field.

• The National Provider Identifier (NPI) is required on in the NPI field.

• Change the type of bill, if necessary. You may also enter the “from” and “through” dates. Press Enter.

104



Adjustment Claims

• To select a claim, press the Tab key until the cursor moves under the SEL field and is to the left of the HIC number of the claim you want to adjust. TypeS in the SEL field and press Enter.

• Only one claim at a time can be selected. After pressing Enter, claim page 1 appears.

105


Adjustment Claims

• The system will automatically default the TOB frequency to XX7 to signify that this is an adjustment claim.

• In addition, the DCN will be automatically inserted by the system on claim page 1. The DCN is the identification number of the original bill. Hard copy UB-04 adjustments must also include the DCN.

106



Adjustment Claims

• Adjustments are a four-step process: – Enter a claim change reason code on claim page 1.

– Enter an adjustment reason code on claim page 3.

– see attachment

• Make your adjustment on the applicable page(s) and add remarks on claim page 4 if necessary.

• Press F9 to save the adjustment.

107


Adjustment Claim Coding 1

108




• Press Tab to the Condition Code field and indicate why the claim is being adjusted by entering the claim change reason code in the first available Condition Code field on claim page 1. Only one code is allowed per claim.

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Valid claim change reason codes are:

• D0 – Changes to service dates.

• D1 – Changes to charges.

• D2 – Changes to revenue codes/HCPCS.

• D3 – Second or subsequent interim PPS bill.

• D4 – Change in clinical codes (ICD) for diagnosis and/or procedure codes.

• D9 – Any other change.

• E0 – Change in patient status 110




111



• Enter the adjustment reason code on claim page 3 in the Adjustment Reason Code field. The adjustment reason code that you select should match the claim change reason in terms of description.

• Adjustment reason codes are specific to each MAC; therefore, providers will need to contact their MAC for valid codes.

112



Adjustment Remarks

113


Adjustment Remarks

• If you are using claim change reason code D9, you must include information in the Remarks field for all of your adjustments. Comments are often helpful in determining what is being adjusted and why.

• Some MACs require SPECIFIC wording on the REMARKS page.

114



Retrieving Offline Claims In Status Location P O9998

• Claims that are in status/location P O9998 are offline. This means that only summary information is available on the online Claims Summary screen and the detail information is stored in offline tape storage.

• Providers may only submit adjustment/cancel requests via DDE for claims that are online in status/location P B9997. Once the claims are in an online status, providers may submit adjustment/cancel requests via DDE.

115


Retrieving Offline Claims

• To retrieve claims from an offline status, go to the FISS Main Menu, type 03 in the Enter Menu Selection field and press Enter. The Claim and Attachments Correction Menu will be displayed.

• Enter the Claim Adjustments or Claim Cancels option matching your provider and bill type. Claim Summary Inquiry will be displayed.

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• Key the HIC number, status/location P O9998, and date of service.

• Put an S in the SEL field for the claim. Press Enter.

• The following message will appear: “Adjustment claim is presently offline – PF10 to retrieve.”

• Press F10 to retrieve claim. Press Enter twice for the retrieval to work.

• The following message will appear: “The offline claim will be retrieved within seven days.”

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• Providers must perform adjustment/cancel requests in DDE within four to six weeks after the status has changed from P O9998 to P B9997.

• If adjustments/cancels are not completed timely, the claim may be returned to offline status. If this occurs, the provider must then retrieve the claim again.

118



Screen Prints

If you want to print a copy of an FISS screen, try one of the following options:

• Select File from the Toolbar and click on Print Screen from the drop down box

• Press ALT+PRINT SCREEN

• Press SHIFT+PRINT SCREEN

• Press ALT+L

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Screen Prints

• All FISS direct data entry (DDE) screens display two lines of information in the top right corner that identifies the region (ACPFAT01), the current date, release number (e.g., C200935E) and the time of day. This information will assist in researching issues when screen prints are provided.

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DDE Information

121


Online Reports



Online Reports

• The Online Report View function allows viewing of certain provider specific reports by the DDE provider.

• The purpose of the reports is to inform the providers of the status of claims submitted for processing and provide a monitoring mechanism for claims management and customer service to use in determining problem areas for providers during their claim submission process.

123


Online Reports

• From the Online Reports Menu you can select R1 for a summary of reports from which you can select.

• R2 to view a report by entering the report number.

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Option R1 - Reports

125


R2 - 201 Report

126



201 Report

• The purpose of the 201 report is to assist providers in accessing information regarding the status of their submitted claims. The report has three main sections: – Summary of pended claims

– Summary of processed claims

– Summary of returned claims

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201 Report

• The pended, processed, and returned claims report lists claims that are pending, claims returned to the provider for correction, and claims processed but not necessarily shown as paid on a remittance advice.

• Each summary section of the report provides a separate count for both original claims and adjustment claims. Each report section is labeled based on type of bill.

128



316 Report

• The Errors on Initial Bills Report is a listing, by provider, of errors received on new claims (claims which were entered into the system for the present cycle.)

• The purpose of this report is to provide a monitoring mechanism for claims management and customer service to use in determining problem areas for Providers during their claim submission process.

129


316 Report

130



Logging Off FISS


Questions?

132


FISS Shortcuts

þ Use your arrow keys and/or TAB key to move between fields. Do not use your ENTER

key. Using the TAB key is preferred, as your arrow keys may not place your cursor in the

correct field position.

þ To move back one data field at a time, press and hold the SHIFT key and then press TAB.

þ To quickly move between claim pages, press your HOME key on your keyboard, which

takes your cursor to the ‘Page’ field. Type the number of the page to which you want to

move, and then press Enter. In FISS, the claim consists of 6 pages. However, two

additional pages, page 7 and page 8, are available for claims in Additional Development

Request (ADR) (status/location S B6001).

þ If you attempt to type in an invalid field, your keyboard will lock, and you will see this

icon in the lower left hand corner of your screen. To “unlock” your

keyboard, try to press the ESC key or the left Ctrl key. The method

used to unlock your keyboard depends on your keyboard set up. You may need to contact

your connectivity vendor for assistance. Once you have unlocked your keyboard, you must

press the TAB key to move your cursor into a valid field.

þ Use the ‘SC’ (Screen Control) field located in the upper left corner (under the ‘Page’ field)

of the FISS screen as a shortcut to information within the Inquiry menu. To access this

field, press the HOME key and then the TAB key. To quickly move to one of the

following options, type the option number (e.g., 13) in the ‘SC’ field and press Enter. Press

F3 to return to the claim page. Refer to the following example.

10 (Beneficiary/CWF) 16 (Adjustment Reason Codes)

13 (Revenue Codes) 17 (Reason Codes)

14 (HCPC Codes) 56 (Claim Count Summary)

15 (Diagnosis/Procedure Codes) 68 (ANSI Reason Codes)

F Example: To move from the Claim Entry screen to the revenue code screen, type 13 in

the ‘SC’ field and press Enter. The Revenue Code Table Inquiry screen appears.

MAP1711 M E D I C A R E A O N L I N E S Y S T E M CLAIM PAGE 01

SC 13 INST CLAIM ENTRY SV:

HIC TOB S/LOC S B0100 OSCAR UB-FORM

NPI TRANS HOSP PROV PROCESS NEW HIC

PAT.CNTL#: TAX#/SUB: TAXO.CD:

STMT DATES FROM TO DAYS COV N-C CO LTR

LAST FIRST MI DOB


STATUS AND LOCATION CODES

CLAIM STATUS WHICH MEANS?

P (PROCESSED/PAID) Claim is approved for payment and is on the

payment floor or claim is paid (full or partial) R (REJECTED) Claim is rejected for reasons such as:

o Medicare eligibility issue

o Billing issues

o Duplicate to a previously submitted claim

S (SUSPENDED) Claim is temporarily paused in FISS for

processing T (RETURN TO PROVIDER) Claim is waiting for correction by the provider

(you) I (INACTIVATED) Claim was inactivated from Return to Provider.

Awaiting final system purge.

Locations further define what is happening to a claim in a particular status.

There are many different locations. Locations are 5-character positions that

follow the status code (e.g., P B9997; where P is the status and B9997 is the

location).


The table below details how claim locations are determined in FISS. This table will be a valuable resource when

reviewing the claims in FISS.

Location Example: B 99 97

(1) (2) (3)


PRINTING FROM FISS

All FISS direct data entry (DDE) screens display two lines of information in the top right corner that identifies the region (ACPFAT01), the current date, release number (e.g.,C200935E) and the time of day. This information will assist in researching issues when screen prints are provided.

S Screen Prints If you want to print a copy of an FISS screen, try one of the following options: Select File from the Toolbar and click on Print Screen from the dropdown box Press ALT+PRINT SCREEN Press SHIFT+PRINT SCREEN Press ALT+L If you are unable to print using the options above, try pressing PRINT SCREEN, which will make a copy of the screen, and then opening a word processing software and pasting the copied image into it. You should then be able to print the word processing document. If none of these options work, and you have consulted with your technical support department with no resolution, please contact your connectivity vendor.


Blank UB04 FISS Roster Billing Sample


Complete Outpatient UB04 FISS Roster Billing Sample


Completed Inpatient UB04 FISS Roster Billing Sample


ADJUST OR CANCEL????…..that is the question

Adjustments

You submit adjustments when information on a processed claim needs to be changed. You may need to submit an adjustment to:

• Change information already recorded on the claim • Add new information • Remove information that was billed incorrectly

Cancellations

You may need to enter a cancellation on a processed claim to:

• Cancel a claim with incorrect information and process a new claim with corrected information

• Cancel a duplicate claim that was entered in error

• Cancel a claim that should not have been submitted

Adjustments and Cancellations affect your payments

Adjustments and cancellations result in either a payment or recoupment and Medicare will initiate a action against the original claim initiate a debit and/or credit transaction and the original claim payment will be recouped by Medicare. For adjustments, payment for the original claim will be recouped. You will receive a payment for the adjusted claim once it finalizes. Carefully review Medicare Remittance Advice for the details of the adjusted or canceled clam..

Limitations: Inappropriate Adjustments and Cancellations

Prior to submitting an adjustment or cancellation, the claim must be finalized in FISS. Cancellations can be made to claims in FISS S/LOC code P B9997. Claim adjustments can be made to paid or rejected claims (status/location code P B9997 or R B9997). If the claim is still processing, wait until the claim finalizes. It is not appropriate to adjust a rejected claim in the following situations.

• Eligibility (entitlement date or date of death)

• HIC number change

• Duplicate

• Untimely claims (past timely filing deadline)

Claims cannot be electronically adjusted if they have been through the medical review process and a partial or full denial was issued. If there is a medically denied line item on a claim and a correction needs to be made to a nonmedically denied line, you would send a hardcopy adjustment for this correction.

If a medically denied line was billed in error, a hardcopy adjustment must also be sent to cancel the claim. Be sure to indicate the reason why you need to cancel the claim and include the correct TOB, XX8 and the appropriate claim change reason code


Step by Step assistance with Adjusting/Canceling Claims

Claims Correction Window

To enter adjustments or cancellations, enter 03 in the Enter Menu Selection field on the FISS Main Menu screen. Press Enter.

Select Provider Type Find the "Claim Adjustments" or the "Cancels" code that matches your provider type. Type the code in the "Enter Menu Selection" field, Press Enter.


Claims Summary Inquiry Screen

The S/LOC (Status/Location) field in FISS identifies the status and location of your claim while it is processing.

This field defaults to P, in order to adjust or cancel paid claims.

To adjust a rejected claim, change the P to R. The TOB (Type of Bill) opens with the default for your provider type. You will need to change this if the claim you need to adjust or cancel is a different type of bill.

Viewing Claims by Beneficiary To find a claim for a beneficiary, press the Shift +Tab keys to move your cursor to the NPI field. Enter your NPI. Tab to the HIC field and enter the beneficiary’s HIC number, you may need to change the TOB field. depending on the type of claim you are adjusting.

Viewing Individual Transactions The system displays paid or rejected claims for the beneficiary.Up to five transactions can be viewed per page. Each has a two-line summary. Use your F5 and F6 keys to scroll through all the claims. Tab to the one you want to adjust, type "S" in the SEL field, press Enter.


FISS Page 01

Now you are viewing the first page (01) of the individual claim. The third number of the TOB field will change to "7" for adjustments or "8" for cancellations. Notice the S/LOC field changes to S B0100 because the claim is now suspended. The DCN (Document Control Number) of the original claim is also automatically inserted by FISS into the adjustment or cancellation claim.

Claim Change Reason Code

Enter a Claim Change Reason Code in the first available COND CODES field. You can only use ONE claim change reason code.

Use the Claim Change Reason Codes that reflects the reason for your adjustment or cancel claim For Adjustments (TOB XX7) D0 Change in service dates D1 Change in charges D2 Change in revenue codes/HCPCS/HIPPS D3 Second or subsequent interim PPS bill - inpatient only D4 Changes in ICD-9 diagnosis and/or procedures D7 Change to make Medicare the secondary payer *Not used in DDE D8 Change to make Medicare the primary payer *Not used in DDE D9 Any other changes (requires remarks) E0 Change in patient status For Cancellations (TOB XX8) D5 Cancel to correct HIC number or provider number D6 Cancel to repay duplicate payment or correct error (or any other reason). Requires a remark


Enter Adjustment Reason Code

Go to Page 03, (enter 03 in the CLAIM PAGE field and press enter.) OR use the F8 key to move through the pages of the claim The Adjustment Reason Code you enter should correspond with the Claim Change Reason Code you entered in the condition code field.

Common Adjustment Reason Codes

Adjustment Reason Codes may vary depending on the reason for the change. Remember, the code you select should match the Claim Change Reason Code you entered earlier. Note: When you are in FISS, you can access a complete listing of Adjustment Reason Codes at any time by typing 16 in the SC field (at the top left corner of any claim page) and pressing enter. F3 will take you back to the claim screen

An Adjustment Reason Code is not required for claim cancellations

Description Adjustment Reason Codes

Change dates of service (use with Claim Change Reason Code D0)

DT

Change charges (use with Claim Change Reason Code D1)

CC

Change revenue codes/HCPCS/HIPPS (use with Claim Change Reason Code D2)

HC

Change in diagnosis and/or procedures or MDS DP or DC

Change to make Medicare primary (use with Claim Change Reason Code D8)

MP

Other change / multiple changes (use with Claim Change Reason Code D9)

OT

Change patient status code (use with Claim Change Reason Code E0)

DS


Enter Changes on Other Screens

You will need to update information on other claim pages (to adjust or remove information) when you complete an adjustment. Move through the claim pages using the F7 and F8 keys. REMEMBER: If you used Claim Change Reason Code D9 or D6 and Adjustment Reason Code OT you must enter

the appropriate REMARKS on screen 04. Some MACs require SPECIFIC language on this screen descriptive of the

changes you have made to the claim.

Saving Your Changes When you are done entering changes, and the appropriate codes press the F9 key to save them and submit the claim for processing. If the change is successful, you should go back to the Map 1741 screen (claim summary). If not, there are additional errors on the claim. Press F1 to see what you need to correct

Viewing Claims The original paid transaction will remain in FISS. Once the cancellation or adjustment has processed (P B9997), you will see the original bill and the changed bill on the Claim Summary Inquiry screen. The original claim will have a date in the CAN DT field. The adjusted claim will reflect a TOB 217, cancelled claim will reflect TOB 218


THINGS TO REMEMBER ABOUT ADJUSTMENT AND CANCEL CLAIMS

Enter 16 in SC field to get help with Adjustment Reason Codes.

Performing an adjustment or cancellation will impact your claim payment.

FISS will initiate a debit and/or credit transaction and the original claim payment will be recouped by Medicare.

For adjustments, the new claim amount will be paid back to you once the adjusted claim finalizes.

When you make an adjustment to a bill, the Type of Bill (TOB) field will change and the third digit will be 7 (e.g. XX7). For cancellations, it will be 8.

Before you can adjust or cancel a claim, it must be processed. The correct S/LOC code to indicate this in FISS is P B9997 or R B9997


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Adjustment Reason Codes

Code DescriptionAA Automated AdjustmentAD Admission Denial - Technical Denial (PRO Review Code - A)AM Admission Denial - No Payment (Medical Denial) (PRO Review Code - A)AR Admission Reversal - Hard Copy AdjustmentAW Admission Denial-Payable Per WaiverCA Cost Outlier ApprovedCB This Reason Code will be to Identify Credit Balance AccountsCC Covered Charges ChangesCD Covered Days Changes (PRO Review Code - B)CO Cost Outlier - No Payment (PRO Review Code - E)CP Cost Outlier Partial ApprovedCR Claim ReconsiderationCW Cost Outlier Denial-Payable Per WaiverDA Day Outlier ApprovedDC Diagnosis Changes (PRO Review Code - C)DD Discharge Destination Code Changes (PRO Review Code - C)DG DRG Change and Day Outlier Denial (PRO Review Code - G)DH DRG Change and Cost Outlier Denial (PRO Review Code - H)DI DRG and Beneficiary Liability Change (PRO Review Code - I)DO Day Outlier Denial - No Payment (PRO Review Code - D)DP Diagnosis and Procedure Changes (PRO Review Code - C)DS Discharge Status ChangeDV DRG Validation (PRO Review Code - C)DW Day Outlier Denial-Payable Per WaiverEF ESRD Adjustment Fix to Correct Original ClaimsFB Beneficiary Liability Change (PRO Review Code - F)FC HHPPS Final claimFD Full Denial (PRO Review Code - A)FR Full Reversal (PRO Review Code - N)FT Full Denial - Technical Denial (PRO Review Code - A)HA Home Health 485/486 Postpayment AuditsHC Home Health Covered Compliance ReviewsHD HMO DisenrollmentHP HMO PayIB PPS Interim Bill

Adjustment reason codes are required on DDE adjustments (TOB XX7) and are entered on page 3. Adjustment Reason Codes are not used on paper or electronic claims.


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Code DescriptionIC Non-Billable Revenue Codes Invalid Revenue CodesID Inpatient or Blood DeductibleJP Deemed Admission Change in Days (PRO Review Code - J)KB Deemed Admission Change in Days (PRO Review Code - J)KD Deemed Admission/Diagnosis Code Change (PRO Review Code - K)KP Deemed Admission/Procedure Code Change (PRO Review Code - K)LD Deemed Admission/Day Outlier Denial (PRO Review Code - L)LI LiabilityLS Length of Stay Denial-No PaymentLW Length of Stay Denial-Payable Per WaiverMC Deemed Admission/Cost Outlier Denial (PRO Review Code - M)NF HHPPS No Final ClaimOC Procedure Codes Changed, Denied, or Added (PRO Review Code - R)OP Day Outlier ApprovedOT Other ChangePC Procedure Changes (PRO Review Code - C)PD Procedural Denial - No PaymentPI Program IntegrityPN Provider Number ChangePP Discharge Status Change (PRO Review Code - P)PR Previous Adjustment Modified (Modifies the PROs Last Action) (PRO Review Code - O)PT Admission Denial and DRG Change (PRO Review Code - T)PW Procedural Denial - Payable Per WaiverQC Procedure Codes (HCPCS) Changed/Deleted/Added (PRO Review Code - R)QD Ancillary Services Denied or Approved (PRO Review Code - Q)QR HCPC Added/Deleted/Changed with Ancillary Change (PRO Review Code-S)RI Recovery Audit Contractor (RAC) Identified OverpaymentRC Complete Reversal of Previous Adjustment (PRO Review Code - N)RP Partial Reversal of Previous Adjustment (PRO Review Code - O)SB Same Benefit PeriodSD Seven Day Readmission DenialSW Seven Day Re-admission Denial - Payable Per WaiverTD Transfer Denial - No PaymentTW Transfer Denial - Payable Per WaiverYA Pacemaker Denial - No DataYB Pacemaker Denial - With ErrorsYC Pacemaker Reversal to DenialYD Pacemaker Reversal to Denial and not going to pay

Adjustment Reason Codes


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