LIFE OF A CLAIM PRESENTED BY: JANE PLANT, NANCY FEE & PATTY LAVIGNE.
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Transcript of LIFE OF A CLAIM PRESENTED BY: JANE PLANT, NANCY FEE & PATTY LAVIGNE.
LIFE OF A CLAIM
PRESENTED BY: JANE PLANT, NANCY FEE & PATTY LAVIGNE
P R E S E N TAT I O N OV E RV I E W
• HCFA and UB changes released in 4.11.00
including ICD9/ICD10
• Upcoming Out of Pocket and Deductible changes
4.11.00 and 4.11.01
• Claim flow and Adjudication Control Rules
• Episode Records what else can they be used
for?
HCFA/UB CHANGES
H C FA : C H A N G E S
page 4 • Confidential
F I E L D 1 9 - A D D I T I O N I N F O R M AT I O N - LO C AT I O N
Located on Page 1 of the HCFA form
• Also gives advice on how to work certain exceptions
page 5 • Confidential
F I E LD 1 9 - P U R P O S E
• HCFA field 19 was previously a reserved field but is available now for Additional Claim information that can be required by payers. NUCC has defined a list of qualifiers that are used in the 5010A1 format.
• The information is written into the RPC_ADDCLINFO field the qualifier code and the identifier are joined into one entry.
• The information populated in this field will be populated within the 837 5010 outbound transaction.
TA B L E S A N D C O DE S
• THE NEW 302 TABLE WITHIN THE TABLE OF CONTENTS
CONTAINS THE AVAILABLE QUALIFIERS.
page 7 • Confidential
F I E L D - 2 1 – D I A G V E R S I O N A N D A D D I T I O N A L I C D C O D E S - LO C AT I O N
F I E LD - 2 1 - P U R P O S E
• HCFA field 21 is for diagnosis code entry and
previously allowed for four diagnosis codes to be
entered. This has now been expanded to allow for up
to twelve diagnosis code entries. A new field was
added to handle the ICD version indicator.
F I E LD 2 1
• Logic added to the form equals if ICD Version
indicator is populated the code is assumed to be that
version, if ICD Version is blank the version will be
determined by the code.
• ICD9 and ICD10 mixing on a claim is not allowed.
• ICD Version indicator can be found in the RPC_67A
and in 4.11.01 it will be added to the claim record in
a new field CLM_ICDV.
F I E L D - 2 2 R E S U B M I SS I O N C O D E A N D O R I G I N A L R E F E R E N C E N U M B E R - LO C AT I O N
F I E LD 2 2 - P U R P O S E
• Resubmission Code will be an optional field and will allow for a one byte numeric code of either “7” or “8”
• The value entered will be written to the RPC_ADJAC field.
• If the value is equal to 7 the HI ADJ exception
will be triggered.
• If the value is equal to 8 the HI VOD exception
will be triggered.
F I E LD 2 2 - P U R P O S E
• Original REF No. will be an optional field and will allow for up to 18 alpha numeric codes.
• A new RPC field was created to store this information – RPC_REFNR.
F I E L D - 2 3 E - D I AG N O S I S P O I N T E R
• Page 2 of the HCFA form is now for service line.
• Location has not changed however -
• Diagnosis pointers have been changed from numeric values to alpha values A-L.
• If numeric is entered the system will switch to Alpha.
F I E L D - 2 4 G - DAY S / U N I T
• Location has not changed however -
• The existing Days/Units field has been expanded to accept up to 7 bytes as required by the NUCC.
S E RV I C E L I N E S C R E E N
UB -CHANGES
• Only the UB04 form has been changed!
• Field 66 – ICD Version Indicator
• Follows the same logic as the HCFA Form.
• Field 46 – Units
• Has been expanded to now accept up to 7 bytes
4.11.01OUT OF POCKET AND DEDUCTIBLE CHANGES
P LA N B U I LD I N G - S C H E DU L E S -P LA N DE TA I L S - C H A N G E S
• New Combine Out of Pocket With field modeled off the current Combine Deductible with field.
P L A N B U I L D I N G – B A S I C P L A N – O U T O F P O C K E T C A L C U L AT I O N - C H A N G E
• Upon entering this area you will be presented with a new selection.
• You will have the ability to set one calculation method or many.
• You will be required to build at least the default.
• Once built you will be able to see all the calculation methods used for each schedule on one screen.
C H A N G E F O R F U L L A M O U N T O F D E D U C T I B L E F R O M T H E A C C U M U L AT O R S A C R O SS P R O D U C T S .
• When the Deductible amount for the service line is
calculated if the combined deductible flag is set for
multiple products the deductible accumulators will
be read for all products indicated.
• The amount read from the accumulators will be
written into the new field on the claim record
“Accumulator DED”.
• Clients can request changes to EOB’s to use this new
field to show combined deductibles.
N E W C O PAY M E N T S – C H A N G E F O R O U T O F P O C K E T
• Changes to New Copayment Only.
• Both the Standard and Exception Copayment area a new field will be added – Suppress Copayment from Out of Pocket.
• Options will be Y or N
H O W D O E S I T W O R K ?
• If Suppress Copayment from OOP flag is set to Y and
Out of Pocket Calculation Method indicates
Copayment as part of the Out of Pocket.
• Copayment will not be added to the Out of
• If Suppress Copayment from OOP flag is set to Y and
Out of Pocket Calculation Method indicates
Copayment is not part of the Out of Pocket.
• Copayment will not be added to the Out of
• If Suppress Copayment from OOP flag is set to N and
Out of Pocket Calculation Method indicates
Copayment as part of the Out of Pocket.
• Copayment will be added to the Out of
• If Suppress Copayment from OOP flag is set to N and
Out of Pocket Calculation Method indicates
Copayment is not part of the Out of Pocket.
• Copayment will not be added to the Out of
N E W C O PAY M E N T S – C H A N G E F O R DE DU C T I B L E
• Changes to New Copayment Only.
• The Standard Copayment area has two new fields:
• Apply to Deductible
• Continue Taking Copayment After Deductible Met
• Options will be Y or N
S C R E E N C H A N G E
H O W DO E S I T W O R K ?
• Apply to Deductible• If equal to Y the amount the copayment will show
on the claim as deductible and the amount will be
written to the appropriate Deductible based on
plan setup.
• If equal to N the copayment will show as a
copayment and does not write to the deductible
bucket.
• Continue Taking Copayment after Deductible Met• If equal to Y the copayment when taken will show
on the claim as a copayment and the amount will
not be written to the deductible bucket.
• If equal to N the copayment will not be taken on
the claim.
CLAIM FLOW
ADJUDICATION CONTROL RULES
• Adjudication Logic – The Adjudication Logic which is stored
on the Adjudication Control Rules is actually read at the
time the logic is applied..
• Patient Not Eligible – Compares claim earliest date of
service to the patient eligibility. If patient is terminated or
not active at the earliest date of service rule applies.
• Question in Exceptions – Questions are only allowed at the
Benefit Exception and the application will always pend to
allow a user response.
• Unable to Find Occurrence - Occurrence benefits can be on
either a DGN or Benefit Exception and again the system
will always pend for user intervention.
• Pend if COB Flag Set – If the COB flag on the patients
eligibility record is set to Y the rule will apply.
• Group Not Paid Up to Date - If the COB flag on the patients
eligibility record is set to Y this rule will apply.
• When Claim/Accum Locked - If for example two examiners
are attempting to update the same accumulator at the
same time the claim will pend. Once the claim is unpended
all benefit limits will recalculate and the accumulators will
be updated.
• Hold When Payment Exceeds – Designed to control the
ability to review claims that exceed a specific gross
payment amount. Claim is compared to dollar limit on the
user and dollar limit in the control rules and the lessor
amount wins.
• Other Insurance Plan – If set on the HCFA template it will
be read but it is not set at 837.
• Condition of Employment – Reads the flag Employment on
the HCFA template.
• Related to Auto Accident – Reads the flag Auto Accident o
the HCFA template.
• Related to Other Accident – Reads the flag Other Accident
on the HCFA template.
• Set by 837 – Loop 2300>Segment CLM>Position 11-1,11-2, or 11-3> AA
equal Auto Accident, OA equal Other Accident and EM equals
Employment. The state for the Auto Accident is 11-4.
• Enable Capitation – If set allows the plan to apply Managed
Care Capitation.
• Add Encountered to Accums – If set the encountered value
from the claim will write to the accumulators.
• Change in Elig Since –Compares patient's eligibility to each
service line of the claim. Applies when there are spanned
dates of service on the claim and a change in eligibility
status.
• Pre-Authorization –Pertains to only Dental Pre-D claims so
it is only read on Dental Template Claims. * Upcoming
change Pre-D claims will apply eligibility denials before
determining benefits*
• Pend EDI Attachment – Will allow claims to pend when the
837 PWK segment indicates an attachment.
• Allow Zero Charge Claim –If yes the system accepts zero as
a valid charge on claims. If no the system will create a BD
ZRO exception when a claim has zero charge if keyed or
edi.
• Adjustment Claim –All adjusted claims pend during claims
processing.
• Enable Provider Withholds –If Yes, applies the provider
withhold , a contractual amount withheld from provider's
payment that should not be billed to the patient . If No,
does not apply a withhold from the claim, even if the
provider is set to apply a withhold.
•
• Deductible Carryover - Only active if the plan has a carry
over deductible provision. If three conditions are met, the
claim applies the selected action, though pend is
recommended.
• Claim is for the prior plan year
• Charges would have applied to the carry over deductible
• Deductible for the next year has already been satisfied
• Example -The plan year is the calendar year, set for three month
carry over on the benefit schedule. The individual deductible of
$100 has been satisfied for 2013. A claim for November 2012
which would have applied to the 2012 deductible and would have
carried over and applied 2013 deductible. ECI recommends
pending this claim for review.
• EXT Pricing on COB Claim -If COB flag in
employee/dependent coverage is set to Yes, and this
option is No, the claim is placed in exception status with
the code PTCOB before adjudication. This is done by
checking for COB in the eligibility record during pricing.
You can create a workflow rule to route claims with PTCOB
to a user defined queue.
• If COB flag is set to No in patient's eligibility, and this
option is also No, the system functions as usual.
• If this option is set to Yes, the system functions as usual
D E N I A L S T H AT D O N ’ T S H O W D I S C O U N T• Age edits
• Patient not Eligible
• Other Ins Plan
• Condition of Employment
• Related to Auto Accident
• Related to Other Accident
• Dup Checking Denial
• PreCert Denial
EPISODE RECORDS
LO G I C A N D E P I S O D E R E C O R D S - P R E - C E RT
• In adjudication logic when you are looking for Pre-Cert any episode that has CM, UR, PC, PA or WC in the Case Type Field will be read.
LO G I C A N D E P I S O D E R E C O R D S - R E F E R R A L
• In adjudication logic when you are looking for Referral the Case Type Field must have RF.
U S I N G E P I S O D E S F O R N E G O T I AT E D P R I C I N G
• Patient needs a wheelchair and there are no In Network DME providers available in his area. I was able to negotiate a price on the wheel chair he needs.
Once Complete select Pricing
Set the Action as Exceed Except
I F T H E P R O V I D E R B I L L S F U L L C H A R G E S
• Claim applies the exceed except rule because the full
charge was billed.
S E RV I C E L I N E
• Shows the difference in U&C due to claim being Penalty
M O D I F I C AT I O N M AY B E R E Q U I R E D F O R S E R V I C E L I N E
• You may be required to correct the placement of the disallowed if you want this to show as not patient responsibility.
• If the provider bills the negotiated amount this will not be an issue.
TA K I N G A P E R C E N T D I S C O U N T U S I N G E P I S O D E R E C O R D
• Patient needs an out of network MRI that I was able to get the provider to agree to a Discount if it is paid as In Network.
Set to
Force
Network that will be
used
Negotiated Price
Pricing set to pay by
Episode
U S I N G E P I S O D E S
• Episodes can be used to control unit limitations within your benefit plan requirements.
U S I N G E P I S O D E S T O C O N T R O L U N I T L I M I T S
Any Questions?