Anatomy of a Claim Diagnosing and Treating The Curable Disease of Non - Payment Understanding the Basics of EDI Annela Petrisca

Agenda Welcome Rejections, Rejections, Rejections Visit Anatomy 101 Show Me the Money! Cleaning Up Question and Answer Stump the Presenter

REJECTIONS, REJECTIONS, REJECTIONS Where do the come from and how do I fix them?

Rejections

Rejections - Symptoms Rejected claims are usually a result of setup, enrollment or patient eligibility –Setup is the number one Symptoms in claims not batching correctly or being sent out correctly. Ultimately not being paid at all or correctly! –Enrollment at company or provider level is a big player in claims not being paid –Eligibility is the next contributor to claims not being paid Rejections can be reduced, time can be saved and money can be made!

Rejections - Manifestation Common Batching Rejections –Output Revenue Code is missing –CLIA number is missing –NDC Unit of Measure is missing –Patient Relationship ANSI code is missing –Other payer ID is missing –Procedure Code Qualifier is missing Common Clearinghouse Rejections –Entity is not enrolled: billing or subscriber –Claim is out of balance –Payer Paid Amount missing/invalid

VISIT ANATOMY 101 GETTING TO KNOW YOUR VISIT Back to school, Back to school!

Anatomy 101 Where are the components of my visit coming from? How do I make the right changes? What is my visit supposed to look like? Can I leverage other departments to help reduce rejections?

VISIT INFO TAB Begin at the beginning

Anatomy 101 Visit Info Tab Company Rendering Provider Facility Insurance Carrier Allocation Set Financial Class Benefit Assignment Filing Method

Anatomy 101 Visit Info Company Rendering Provider Facility Insurance Carrier Allocation Set Financial Class Benefit Assignment Filing Method Errors Missing/Invalid NPI Missing/Invalid Billing Taxonomy Code Results – NPI – claim will batch and reject at clearinghouse – Taxonomy Code – claim will batch and reject at the payer or clearinghouse

Anatomy 101 Company - Manifestation –Missing NPI

Anatomy 101 Company - Symptoms –Missing NPI

Anatomy 101 Company - Treatment –Review Company Information and Identification Tab to correct/enter NPI

Anatomy 101 Company Taxonomy - Manifestation –Claim Rejection from Clearinghouse/Payer

Anatomy 101 Company Taxonomy - Symptoms –Missing/Invalid Taxonomy

Anatomy 101 Company Taxonomy - Treatment –Review Company Identification Tab to correct/enter Taxonomy

Missing Provider Row Invalid Taxonomy Invalid Provider NPI Results – Provider ID: Unable to Batch Claim – Invalid IDs/Taxonomy: Clearinghouse/Payer Rejection Anatomy 101 Visit Info Company Rendering Provider Facility Insurance Carrier Allocation Set Financial Class Benefit Assignment Filing Method Errors

Anatomy 101 Rendering Provider - Manifestation –Missing/Invalid Provider ID Row/Enrollment Rejections –Invalid Provider Taxonomy

Anatomy 101 Rendering Provider - Symptoms –Review Provider Information and Identification to correct/enter NPI CPS 12: Administration – Providers and Resources CPS 11: Administration – Edit Responsible Providers –Review Provider Information for correct Specialty Correct Specialty: Administration – List Editor/System/User and Resource/Users

Anatomy 101 Rendering Provider - Treatment –Review Provider Information and Identification to correct/enter NPI –Review Provider Information for correct Specialty

Missing Place of Service Missing/Invalid CLIA Number – Company Level – Single CLIA Number for whole organization Missing Type of Bill Result – Unable to Batch Claims Anatomy 101 Visit Info Company Rendering Provider Facility Insurance Carrier Allocation Set Financial Class Benefit Assignment Filing Method Errors

Anatomy 101 Facility - Manifestation –Missing/Invalid Place of Service –Missing Type of Bill –Missing Facility Type ID

Anatomy 101 Facility - Symptoms –Review Facility Information and Identification to correct/enter NPI

Anatomy 101 Facility - Treatment –Review and Correct Facility or Identification Information

Missing Payer ID Missing Other Payer ID Missing Carrier Type Result – Unable to Batch Claims Anatomy 101 Visit Info Company Rendering Provider Facility Insurance Carrier Allocation Set Financial Class Benefit Assignment Filing Method Errors

Anatomy 101 Insurance Carrier - Manifestation –Payer ID is Missing –Other Payer Primary ID is Missing –Carrier Type is Missing

Anatomy 101 Insurance Carrier - Symptoms –Insurance Carrier EDI Tab –Insurance Carrier Identification Tab –Insurance Carrier Information Tab

Anatomy 101 Insurance Carrier - Treatment –Correct Insurance Carrier EDI Tab –Correct Insurance Carrier Identification Tab –Correct Insurance Carrier Information Tab

Missing Allocation Set Result - Unable to Batch Anatomy 101 Visit Info Company Rendering Provider Facility Insurance Carrier Allocation Set Financial Class Benefit Assignment Filing Method Errors

Anatomy 101 Allocation Set- Manifestation –Missing Allocation Set

Anatomy 101 Allocation Set- Symptoms –Missing Allocation Set Patient Profile –Missing Allocation Set Insurance Carrier –Missing Allocation Set Visit Info Tab

Anatomy 101 Allocation Set- Treatment –Review and Correct Visit Info Tab –Review Patient Information Insurance Tab –Review Insurance Carrier

Missing Financial Class Result – Unable to Batch Anatomy 101 Visit Info Company Rendering Provider Facility Insurance Carrier Allocation Set Financial Class Benefit Assignment Filing Method Errors

Anatomy 101 Financial Class - Manifestation –Missing Financial Class

Anatomy 101 Financial Class - Symptoms –Review Visit Info Tab –Review Insurance Carrier Information –Review Patient Information

Anatomy 101 Financial Class - Treatment –Review and Correct Visit Info Tab –Review and Correct Insurance Carrier –Review and Correct Patient Information

Missing Benefit Assignment Result – Unable to Batch Anatomy 101 Visit Info Company Rendering Provider Facility Insurance Carrier Allocation Set Financial Class Benefit Assignment Filing Method Errors

Anatomy 101 Benefit Assignment - Manifestation –Missing/Invalid Benefit Assignment

Anatomy 101 Benefit Assignment - Symptoms –Review Visit Info Tab

Anatomy 101 Benefit Assignment - Treatment –Review and Correct Visit Info Tab –Review and Correct Insurance Information –Review and Correct Patient Information Review Internal Policy for Benefit Assignment

Missing Filing Method Result – Cannot Approve – Adjustment will not happen – Cannot Batch Claims Anatomy 101 Visit Info Company Rendering Provider Facility Insurance Carrier Allocation Set Financial Class Benefit Assignment Filing Method Errors

Anatomy 101 Filing Method - Manifestation –Either No Plugin or Clearinghouse is Inactive for this this ticket –Cannot Allocate Money to Insurance Carrier

Anatomy 101 Filing Method - Symptoms –Review Visit Info Tab –Review Insurance Carrier

Anatomy 101 Filing Method - Treatment –Review and Correct Visit Info Tab Click Drop Down Click Set Carrier –Review and Correct Insurance Carrier

CHARGES TAB And on to the next…

Fee Schedule Cases Charges Missing Diagnosis Pointer Results – Fee Schedule: Charges are incorrect, missing encounter type – Cases: Incorrect Carrier, Incorrect Fee Schedule – Charges: Incorrect Fees, missing revenue codes – Diagnosis: Claim will not approve Anatomy 101 Charges Fee Schedule Cases Charges Diagnosis Errors

Incorrect Charges Incorrect/Missing Encounter Codes Missing Revenue Codes Anatomy 101 Charges Fee Schedule Cases Diagnosis Charges

Anatomy 101 Fee Schedule - Manifestation –Missing encounter code –Incorrect Fees –Missing adjustments –Missing/Incorrect Revenue Codes

Anatomy 101 Fee Schedule - Symptoms –Incorrect Provider setup –Incorrect Fee Schedule setup

Anatomy 101 Fee Schedule - Treatment –Correct Provider setup –Correct Fee Schedule setup

Incorrect Carrier for Visit Type Incorrect Fee Schedule Incorrect Charges Missing Authorization Numbers Anatomy 101 Charges Fee Schedule Cases Diagnosis Charges Errors

Anatomy 101 Cases - Manifestation –Incorrect Carrier on visit –Incorrect Fee Schedule on visit –Possible Missing Authorizations

Anatomy 101 Cases - Symptoms –Case not setup Patient Registration –Case not attached to the visit

Anatomy 101 Cases - Treatment –Add Case

Approve Failed Claim Result: Cannot Approve Claim Anatomy 101 Charges Fee Schedule Cases Diagnosis Charges Errors

Anatomy 101 Diagnosis- Manifestation –Approve Failed Claim

Anatomy 101 Diagnosis- Symptoms –CPT Code entered before diagnosis –Diagnosis link was deleted

Anatomy 101 Diagnosis- Treatment –Add Linking

Incorrect Charges for Facility Incorrect Charge Setup File Rejected Claims Results: – Do I really know what my visit should look like? Anatomy 101 Charges Fee Schedule Cases Diagnosis Charges Errors

Anatomy 101 Charges - Manifestation –File Rejected –Incorrect Balance –Missing Encounter codes

Anatomy 101 Charges - Symptoms –Incorrect Provider setup –Incorrect Fee schedule / Incorrect Provider setup –Incorrect Fee Schedule setup

Anatomy 101 Charges - Treatment –Correct Provider setup –Correct Fee Schedule setup

Anatomy 101 One saying, one mantra, one thing to live by: “If Patient Registration isn’t Right; Billing isn’t Right!” Correct Administration Setup is just as important! It is the day to day entries from supporting departments that is key!

SHOW ME THE MONEY! Payments, Payments, Where are the Payments?

Missing Check Date Missing Line Information Missing 0.00 Payment Missing COB Anatomy 101 Transactions Payments Filing Secondary Errors

Anatomy 101 Payment Posting - Manifestation –Secondary claims will be out of balance

Anatomy 101 Payment Posting - Symptoms –Primary Posting is not complete or incorrect

Anatomy 101 Payment Posting - Treatment –Electronic Payment Posting –Reconciliation –Add Line Info, COB, 0.00 Payments

Claim Filed is out of balance Anatomy 101 Transactions Payments Filing Secondary Errors

Anatomy 101 Filing Secondary- Manifestation –File Rejected Claim from Clearinghouse Claim is out of balance Missing COB information UPLOADED: TOTAL CLAIM CHARGE AMOUNT (60) DOES NOT EQUAL THE SUM (0) OF OTHER PAYER PAID AMOUNT (0) + ADJUSTMENT AMOUNTS (0) - PRIMARY PAYER

Anatomy 101 Filing Secondary - Symptoms –Primary Posting

Anatomy 101 Filing Secondary - Treatment –Correct Primary Payment Posting

CLEAN UP!! Maid Service Required

Clean Up! EDI Response Management Miscellaneous files What can you archive? May I delete files?

Clean Up! EDI Response Managment Miscellaneous files What can you archive? May I delete files? File Names: MSGU/MSGD - CEDI BST/UGSA – ClaimRemedi RSP – Practice Insight Remit_.txt EOB Type: For Review Only

Clean Up! EDI Response Managment Miscellaneous files What can you archive? May I delete files? Archive Anything! MSGU/MSGD - CEDI BST/UGSA – ClaimRemedi RSP – Practice Insight Remit_.txt EOB For Review Only

Clean Up! EDI Response Managment Miscellaneous files What can you archive? May I delete files? Not in your Best Interest to Delete Anything! Please Don’t Delete Anything! It is Not advisable to Delete Anything!

QUESTION AND ANSWER It’s almost over!

STUMP THE PRESENTER Bring It On!!!

Download all conference presentations at visualutions.com/ug15conference Join our newsletter and stay up to date! visualutions.com/newsletters Thank you.