Anatomy of a ClaimDiagnosing 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 take time and time is money!!!

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 TABBegin 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 TABAnd 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 ANSWERIt’s almost over!

STUMP THE PRESENTERBring It On!!!

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