Lesson 5 Testing and Posting the 835 Remittance Advice

2 Lesson 5 Topics Overview of 835 Transaction HIPAA-Compliant Codes Before You Get Started Set Up Electronic Process with Insurers Set Up RPMS Retrieve 835 ERA File from Insurer Load and View 835 ERA File for Batching Process 835 ERA File in Accounts Receivable

3 What is the 835? HIPAA-compliant format that allows for receiving third party reimbursement payments and adjustment information in an electronic format Full name: Health Care Payment & Remittance Advice Also know as Electronic Remittance Advice or ERA Current HIPAA-compliant version – ANSII Standard X Version 4010 Addenda A

4 Benefits of 835 Transaction Retrieved and posted electronically into RPMS system by batch mode – Allows for faster and more accurate posting of payments Contains codes that can be posted directly into RPMS – Standard Adjustment Reason Codes (also called Claims Adjustment Reason Codes) – Remittance Advice Remark codes – NCPDP Reject/Payment codes Denied claims can be manually posted

5 Overview of 835 ERA Process 1.ERA files retrieved from insurer 2.ERA files loaded into RPMS 3.Files batched based on local procedures 4.ERA files posted to Accounts Receivable 5.Payments/adjustments rolled back to RPMS Third Party Billing 6.ERA reconciled with payment received

6 What Does It Mean For You? Site Manager: “The lag time has been cut from weeks to days.”

7 Lesson 5 Topics Overview of 835 Transaction HIPAA-Compliant Codes Before You Get Started Set Up Electronic Process with Insurers Set Up RPMS Retrieve 835 ERA File from Insurer Load and View 835 ERA File for Batching Process 835 ERA File in Accounts Receivable

8 HIPAA-Compliant Codes Three types –Standard Adjustment Reason (also called Claims Adjustment Reason) –NCPDP –Remittance Advice Remark

9 Standard Adjustment Reason Codes Each insurer is required to recognize HIPAA-compliant Standard Adjustment Reason Codes table for implementing 835 ERAs Table standardizes posting and denial codes

10 Local Codes Not Recommended Strongly recommended that sites no longer create or use local codes In past, RPMS Accounts Receivable allowed sites to add new codes specific to their sites With 835 ERA, site-specific codes must be mapped to HIPAA- compliant Standard Adjustment Reason Codes

11 RPMS and Codes IHS OIT has mapped HIPAA- compliant Standard Adjustment Reason Codes to RPMS 100s of RPMS types were added – Adjustment codes were given a 600 or a 700 number – Local codes are 1000 and above See Appendix A of Accounts Receivable Version 1.7 Patch 5 User Manual

12 NCPDP Codes NCPDP Reject/Payment Codes apply to pharmacy claims See Appendix C of Accounts Receivable Version 1.7 Patch 5 User Manual

13 Remittance Advice Remark Codes Used within 835 transaction to: – Convey information about remittance processing – To provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason code This is industry code list – Periodically updated and RPMS modified to include updates

14 Remittance Advice Remark Codes (cont’d) See Appendix B of Accounts Receivable Version 1.7 Patch 5 User Manual

15 Lesson 5 Topics Overview of 835 Transaction HIPAA-Compliant Codes Before You Get Started Set Up Electronic Process with Insurers Set Up RPMS Retrieve 835 ERA File from Insurer Load and View 835 ERA File for Batching Process 835 ERA File in Accounts Receivable

16 What Does It Mean For You? Management Program Analyst: “This is a challenging program... We have to build support systems to address all the issues.”

17 Set Up a Log Keep a log of 835 ERA files and steps completed Two important reasons for this: – There is a lot to remember and it is easy to forget a step – RPMS assigns a 4-digit number to the file when it is imported 4-digit number is utilized throughout 835 ERA auto- posting process Need to be able to associate two files to recall downloading and importing system problems that may occur and there may not be a hard copy to refer to See IHS HIPAA web site for a sample log

18 Lesson 5 Topics Overview of 835 Transaction HIPAA-Compliant Codes Before You Get Started Set Up Electronic Process with Insurers Set Up RPMS Retrieve 835 ERA File from Insurer Load and View 835 ERA File for Batching Process 835 ERA File in Accounts Receivable

19 Testing the 835 Must test 835 process before beginning production – See Lesson 2: Establish a Relationship with the Insurer – See Lesson 3: Test Mode Contact insurer’s EDI department – Request guidance on procedures and documentation requirements before receiving files – Determine test and production requirements –Complete required applications

20 Test Procedures Quick Reference Guide provides procedures for three major insurers – Trailblazer Medicare Part A – Trailblazer Medicare Part B – PNC Bank Procedures for other insurers may be different – Contact local Area IT or IHS OIT to see if those insurers have already been tested

21 Lesson 5 Topics Overview of 835 Transaction HIPAA-Compliant Codes Before You Get Started Set Up Electronic Process with Insurers Set Up RPMS Retrieve 835 ERA File from Insurer Load and View 835 ERA File for Batching Process 835 ERA File in Accounts Receivable

22 Set Up RPMS Must have RPMS Accounts Receivable v1.7 Patch 5 or latest release installed –Check with Site Manager for current version and patch One-time setup required – Through Site Parameter Menu See Quick Reference Guide for setup instructions

23 Lesson 5 Topics Overview of 835 Transaction HIPAA-Compliant Codes Before You Get Started Set Up Electronic Process with Insurers Set Up RPMS Retrieve 835 ERA File from Insurer Load and View 835 ERA File for Batching Process 835 ERA File in Accounts Receivable

24 Retrieve the File Using procedures established with insurer, check regularly to retrieve 835 ERA files – Check every other day – In last week of month, check daily To allow time for month-end reconciliation See Quick Reference Guide for more information

25 Lesson 5 Topics Overview of 835 Transaction HIPAA-Compliant Codes Before You Get Started Set Up Electronic Process with Insurers Set Up RPMS Retrieve 835 ERA File from Insurer Load and View 835 ERA File for Batching Process 835 ERA File in Accounts Receivable

26 Load and View the 835 ERA File for Batching Once retrieved from insurer, electronic 835 ERA files are processed through A/R Menu option Four steps to create batched files to send to Finance –ERA, NEW: Load imported file from established secure directory into RPMS –ERA, RPT: Generate claims report –ERA, View: View file header information –Batch files

27 #1 ERA, NEW To load imported file from established secure directory into RPMS If file is not HIPAA-compliant 835 file: – Error message will display – File will not load

28 #1 ERA, NEW (cont’d) If file is acceptable, RPMS will assign it 4-digit file name – Write this number in your log – You will have to use this 4-digit number throughout 835 auto-posting process System will then import file into RPMS There are four stages to this process – Download process cannot be interrupted or accuracy of file may be corrupted For specific instructions on loading imported file, see Quick Reference Guide

29 #2 ERA, RPT To generate claims report for selected check of 835 file Option used for: –Providing reports for batching purposes –Auto-posting –Reviewing appropriate close out of claims listed under the “Not Match or Match” side of the report

30 #2 ERA, RPT (cont’d) Enter: – List of Claim Status(s) you desire to print – In sequence they should be printed out C - Claim Unmatched R - Reason Unmatched N - Not to Post M - Matched P - Posted X - Claim & Reason Unmatched A - All Categories Example: CRXN Enter response: CRXN Select the type of report: (D/B/S): Summary - Totals Only Select one of the following: P PRINT Output B BROWSE Output on Screen Do you wish to: P// [RET]RINT Output Output DEVICE: HOME//[RET]

31 #2 ERA, RPT (cont’d) Select type of report you want –Detail, Brief or Summary For batching purposes, select –“A” (All Categories) and “D” (Detail). C - Claim Unmatched R - Reason Unmatched N - Not to Post M - Matched P - Posted X - Claim & Reason Unmatched A - All Categories Example: CRXN Enter response: CRXN Select the type of report: (D/B/S): Summary - Totals Only Select one of the following: P PRINT Output B BROWSE Output on Screen Do you wish to: P// [RET]RINT Output Output DEVICE: HOME//[RET]

32 #2 ERA, RPT (cont’d) For unmatched claims you can: – Print a report – Research the information – Then manually post these claims

33 #2 ERA, RPT (cont’d) Set denials and partial payments to “Not to Post” Reasons for setting denials and partial payments to “Not to Post”: –Inappropriate close outs –Differences between amount insurer closed them out to and A/R facility- approved close out –Inability to reverse a close out due to A/R RPMS version installed

34 #2 ERA, RPT (cont’d) See Quick Reference Guide for instructions on generating and viewing reports | ACCOUNTS RECEIVABLE SYSTEM - VER 1.7 | + ERA Posting + | UNSPECIFIED SERVICE UNIT | User: USER,DEMO BUSINESS OFFICE 23-OCT :42 AM NEW Load New Import VIEW View Import Header REV Review Postable Claims PST Post ERA Claims RPT Report ERA Claims Select ERA Posting Option: RPT Select file: 1006_ERA_10/16/2003 ACL partb dt1008.txtCHK: ) CHECK #: BATCH: ** no RPMS match ** ITEM: A/R ACCOUNT: BATCHED AMT: 0.00 BALANCE: 0.00 Please enter the LINE # of the check you wish to REPORT: 1// [RET] Reports for: 1006_ERA_10/16/2003 ACL partb dt1008.txt CHK:

35 #3 ERA, View To view file header information Information in file header –Number of claims in file –Payment amount –Check/EFT numbers –Payee and provider information –Control numbers –Provider-level corrections –Any interest payments or penalty adjustments

36 #3 ERA, View (cont’d) Must view header information in order to verify: – Total Provider Payment – Check Issue/EFT Effective Date – Check or EFT Trace Number (Check #) – Reference Identification (Provider #) Information in this header file only shows what is located on Paper Remittance Advice in header information section

37 #3 ERA, View (cont’d) Header information may vary from insurer to insurer –Each may populate this data differently At minimum, you must find: – Total Provider Payment – Check Issue/EFT Effective (Date) – Check or EFT Trace Number (Check #) – Reference Identification (to show proof of the location of the deposit) – Penalty amounts taken (total amounts only show)

38 #3 ERA, View (cont’d) File header information is very useful when providing report to Finance for batching You can only capture this report by screen-printing necessary data information – You can print whole “View” report but report is long and you don’t need it

39 #3 ERA, View (cont’d) See Quick Reference Guide for instructions on viewing imported file’s header information | ACCOUNTS RECEIVABLE SYSTEM - VER 1.7 | + View Import Header + | LITTLE BUILDING HEALTH CENTER | User: BUSINESS OFFICE 29-JUL :16 PM Select file: ? Answer with A/R EDI IMPORT NAME, or DATE/TIME, or HOST FILE NAME, or CHECK NUMBER, or CHECK/EFT TRACE Choose from: 1001_ERA_02/13/2004 WWH partb dt1008.txt CHK/EFT #: _ERA_03/04/ TEST.txt CHK/EFT #: R _ERA_03/26/ TEST.txt CHK/EFT #: R _ERA_05/17/ Test File. CHK/EFT #: CHK/EFT #: 21443AA0051SY 1005_ERA_07/22/2004 THP00001F_ txt CHK/EFT #: CHK/EFT #: Select file: 1005_ERA_07/22/2004 THP00001F_ txt CHK/EFT #: CHK/EFT #:

40 #4 Batching In order to auto-post successfully, Finance needs to batch checks To do so Finance needs: – Paper Remittance Advice – 835 Report – PNC Daily deposit Business Office provides printed RPT and VIEW report to Finance for batching – Cannot send files to Finance because they will not have capability to retrieve this data information

41 #4 Batching (cont’d) To batch, checks MUST be entered into the Accounts Receivable RPMS Collection Point – This establishes Collection Batch and Item # Check number, payer name, and dollar amount will tie this remittance advice to A/R Collection Batch

42 #4 Batching (cont’d) Your facility should have pre- defined procedures for creating batches Process for creating Collection batch remains unchanged for 835 ERA file posting

43 Warning! If an 835 file is downloaded before batching the payment, the ERA Review and Posting options will not allow the EDI file to identify a unique payment batch for posting. The files will not tie together.

44 #4 Batching (cont’d) See Quick Reference Guide for additional instructions on assembling files for batching

45 Lesson 5 Topics Overview of 835 Transaction HIPAA-Compliant Codes Before You Get Started Set Up Electronic Process with Insurers Set Up RPMS Retrieve 835 ERA File from Insurer Load and View 835 ERA File for Batching Process 835 ERA File in Accounts Receivable

46 Overview of Processing the 835 File in A/R When you receive batch from Finance, review it –Verify that balance available is still outstanding –Highlight any claims that you do not wish to post Best to set following claims as “Not to Post”: –Zero payments –Negative payments –Unusual close outs –Cross over payments that involve “B” or “C” claim (auto-posting will post payment into primary claim and set balance off)

47 Attention If you notice that information you receive from Finance is incorrect, have them fix it before you REV file in RPMS If Finance cannot fix error, follow local procedures for posting these accounts

48 Processing 835 ERA File in A/R Three steps 1.ERA, REV (review postable claims) 2.ERA, PST (initiate auto-post) 3.Master Menu, ROL (roll back bills to third party)

49 #1 ERA, REV Mandatory: Review Postable Claims –Make sure that claims you want auto-posted say “Postable” –Change claims you do no want auto-posted to “Not to Post” ERA, REV only shows claims that can be matched to A/R bill number If claim number could not be matched to bill number: –Claim will not display –Claim will not be posted electronically

50 #1 ERA, REV (cont’d) Reasons for unmatched claims – Payment belongs to another facility – Claim number information is not separated by dashes – Dates of service do not match

51 #1 ERA, REV (cont’d) Option is check number specific –835 ERA file may contain more than one Check/EFT number –So option lists each check number individually System automatically matches Check/EFT numbers to Collection Batches/Items If more than one match is found, system will prompt user to make batch selection

52 #1 ERA, REV (cont’d) Scroll through all claims to validate accuracy If some claims should not be posted, change status to “Not to Post –Manually post later through A/R, PAY Once status on claim has been changed to “not to post,” it cannot be changed back

53 #1 ERA, REV (cont’d) See Quick Reference Guide on how to review postable claims | ACCOUNTS RECEIVABLE SYSTEM - VER 1.7 | + Review Postable Claims + | UNSPECIFIED SERVICE UNIT | User: USER,DEMO BUSINESS OFFICE 20-OCT :22 PM Select file: 1001_ERA_10/01/2003 OKMCD835.txt There are 2 check(s) for the file 1001_ERA_10/01/2003 CHK: 1501 CHK: Now matching check/EFT Trace #’s on ERA to Check # of Collection Batch/Item.. Check 1501 does not match any existing batch/items.?? Check previously match to batch ITSC-MEDICAID-09/29/ Item: 1 A/R Acct: NEW MEXICO MEDICAID for: 1, Bal: Done matching check/EFT Trace # of ERA to check # of collection Batch/Item. Enter Return to continue: [RET] 1) CHECK #: BATCH: ITSC-MEDICAID-09/29/2003 ITEM: 1 A/R ACCOUNT: NEW MEXICO MEDI BATCHED AMT: 1, BALANCE: Please enter the LINE # of the check you wish to REVIEW: 1//

54 #2 ERA, PST Posts payment amounts in an imported and loaded file to matching Accounts Receivable bills Displays information that is relevant to batch and posting results of file

55 #2 ERA, PST (cont’d) PST screen displays reviewed checks For check selected to post, make sure file matches with what was batched: –Check/EFT numbers –Batch name –Item numbers assigned to check number and amount If nothing matches: –System problem due to version on RPMS –Must manually post batch

56 #2 ERA, PST (cont’d) During posting, if system detects that posting to bill will result in negative balance in RPMS system: –Warning message displays –Prompts user to choose whether or not to post that bill If ERA file contains claim cancelled in RPMS Third Party –Cannot be posted electronically

57 #2 ERA, PST (cont’d) Set appropriate time for auto-posting –Only one user can auto-post at a time –If more than one user tries to access same claim within file, RPMS will automatically go into an error mode and sign off all users –Good communication is essential For specific instructions on how to post a payment batch, see the Quick Reference Guide

58 Roll Back Bills to Third Party Rollback must be done every time auto-posting is done Master Menu option Rolls back updates to Third Party Billing package for all posted accounts whose balances are now zero (0)

59 Roll Back Bills to Third Party (cont’d) This option will roll back 50 bills at a time – If your facility does not roll back payments on a timely basis, the older paid bills will be rolled back first See Quick Reference Guide for specific instructions on how to use this Master Menu option

60 After Posting Delete downloaded file from established directory when done Large files quickly fill up space on your drive

61 What Does It Mean For You? Financial Management Officer: “We get them down, we post them, and we walk off. It’s that easy.”

62 Lesson 5 Lessons Learned Overview of 835 Transaction HIPAA-Compliant Codes Before You Get Started Set Up Electronic Process with Insurers Set Up RPMS Retrieve 835 ERA File from Insurer Load and View 835 ERA File for Batching Process 835 ERA File in Accounts Receivable