CREATIVE PLAN BUILDING PRESENTED BY: FRED PORTER, YONETTE BOWEN AND CHARLEEN MULLANEY

AGENDA Episode Records Pre-Certification Requirements Benefit Plan Setup Adjudication Logic Setup ICD9 and ICD10 Category Definitions Dental Logic Copay by DOS Out of Network payment options (Creatively!)

ELIGIBILITY/ENROLLMENT

OPTIONS/UTILITIES

INDIVIDUAL/PATIENT EPISODES

If any exist a list will appear

CREATING RECORDS Select (A)dd to create new record. Patient information will populate

EPISODE RECORD HIGHLIGHTS Pricing methods

PRICING OPTIONS NORMAL PRICING Allows you to attach multiple Providers to a single episode EVENT PRICING Allows you to attach a single Provider to a single episode CASE PRICING No Providers are attached to the episode

ADDING PROVIDERS Search for Provider to add.

ADDING PROVIDERS Can add single or multiple Providers. Depending on Case Price Method

ACTIONS/REASON Exceed Except is most common. Will create EXC when conditions of Pre-Cert are not met.

PROVIDER VALIDATION Can select all Providers with same TIN or a Single Provider assigned by System ID

NETWORK MATCHING NOT for forcing In-Network

PENALTY OPTIONS Network, Penalty or Force the Network?

ACCEPTANCE OF THE RECORD Exact matching or “some” matching

REV AND DIAGNOSIS CODES Enter your codes required for this Episode

ICD, HCPCS AND CPT CODES Add other necessary Service Codes here

CODE RANGES Always put “from” and “through”.

OTHER INFORMATION Authorized/Accumulated and Comments

PRICING OPTIONS Command line options of pri(C)ing

PRICING OPTIONS Can price claim differently for each Episode

ACCESS IN CLAIMS Can access Episode to view during Claims Processing

EXISTING EPISODE RECORDS Can Identify Case Record vs. Manual Episodes

PRE-CERT VIA BENEFIT PLAN Per Benefit Plan setup. Plan details.

DEFINED SERVICES Can add multiple Categories requiring Pre-Cert

CATEGORY DEFINITIONS F4 will allow for searching Categories

DENY NON-PRECERTED CLAIMS Can auto-deny if needed

SEPARATE PRICING OPTIONS Can apply separate pricing if needed.

PRICING OPTIONS

CAN USE SEPARATE SCHEDULE

SEPARATE BENEFIT SCHEDULE If enter “Y”, will see different schedule option

BENEFIT EXCEPTION PENALTIES Can apply Non-Precert Penalties

BENEFIT EXCEPTION PENALTIES Can Penalize by percentage or flat dollar

CAN PEND AT EXCEPTION LEVEL Can choose to Pend even if no Penalty set

ADJUDICATION LOGIC Same Benefit Code can be set two ways

ADJUDICATION LOGIC Same code Pend if no Pre-Cert

ADJUDICATION LOGIC

CATEGORY DEFINITIONS ICD9 and ICD10 options on same Category

ICD9 DIAGNOSIS CODES Same options for both codes

ICD9 CODE ENTRY Separate ranges for ICD9 codes

ICD10 DIAGNOSIS CODES

Separate ranges for ICD10 codes

HCFA FORM Same options for HCFA form

HCFA FORM ICD9 Code ranges

HCFA FORM ICD10 code ranges

WHAT CAN DENTAL LOGIC DO? Dental logic is by Group. If it is set up, it is used. Ability to do multiple things on one ADA code Ability to change ADA codes or use a particular Benefit Code as in regular Adjudication Logic. Multiple variations on Tooth, Arch, Quadrant and Provider. Patient Age Limitations Limitations base on services Reported With, History of or Without History.

DENTAL LOGIC All U/W, Groups within single U/W or single Group

DENTAL LOGIC Rules are set per ADA Code

DENTAL LOGIC Multiple options for what to do with the Code

DENTAL LOGIC

Age based limitations without using Benefit Exceptions

DENTAL LOGIC Multiple rules for same Code

DENTAL LOGIC Dental Claims Processing. Entered D1120

DENTAL LOGIC Switches ADA Code to D1110

DENTAL LOGIC Also ensures use of Benefit Code 902

DENTAL LOGIC Conditional exception without using Benefit Exceptions

DENTAL LOGIC One issue: Can’t use “Pay as MM” option in Group Master set up.

COPAY DEFINITIONS Add Office Visit and Lab Categories and designate Inpatient Codes

TABLE OF CONTENTS-BILL TYPE Bill Type defines In-Patient Confinement

BILL TYPE Control Flag equal to “I” for Inpatient

COPAY PLAN SET UP Set at each Basic Policy Information screen

COPAY BY DOS Warning will appear on initial set up

COPAY BY DOS Inpatient can be Day or Stay

CORE REQUIREMENTS Type of Service Code input for Inpatient and Office Visits

CORE REQUIREMENTS F4 for list of 270/271 Service Types

DEDUCTIBLE OPTIONS New in !!

LAB CLAIM OPTIONS What to do when Lab claim comes in before Office Visit?

COPAY EXCEPTIONS

DEDUCTIBLE OPTIONS Exception options for Deductible

EXEMPT CATEGORY OPTION Penalize…”except when…”

EXEMPT CATEGORY OPTION Can add categories such as Emergency or Ambulance.

EXEMPT PRICING OPTION Separate pricing if needed

Any Questions?