physician practice solutions - mckesson medisoft clinical emr
TRANSCRIPT
Revenue Management Guide
for Medisoft
McKesson Provider Technologies
Physician Practice Solutions
1145 Sanctuary Parkway, Suite 200
Alpharetta, GA 30009
1.800.334.4006
Physician Practice Solutions
Revenue Management
Guide for Medisoft
Copyright Notice
Copyright © 2010 McKesson Corporation and/or one of its subsidiaries. All rights reserved.
Use of this documentation and related software is governed by a license agreement. This documentation and related software
contain confidential, proprietary and trade secret information of McKesson Corporation and/or one of its subsidiaries and are
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duplication or disclosure is subject to restrictions as set forth in contract subdivision (c)(1)(ii) of The Rights in Technical Data and
Computer Software clause at DFARS 252.227-7013 or subparagraphs (a) through (d) of the Commercial Computer Software
Restricted Rights clause at 48 CFR 52.227-14, as applicable, in addition to the limitations set forth in the license agreement
governing this software. Manufacturer is listed below. Unpublished rights are reserved under the copyright laws of the United States.
The software described in this documentation cannot substitute for the knowledge, skill and experience of the competent medical
personnel who are its intended users. Its use as such a substitute is prohibited.
No part of this document may be copied or reproduced in any form or by any means without the express prior written consent of
McKesson Corporation.
Information in this document is subject to change without notice and does not represent a commitment on the part of McKesson
Corporation.
All other brand and product names are trademarks or registered trademarks of their respective companies.
Publication date
September 2010
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TABLE OF CONTENTS
1.0 REVENUE MANAGEMENT OVERVIEW ................................................................................................. 1
Product Features........................................................................................................................................................................ 1
Dependencies ............................................................................................................................................................................ 1
Practice and Workstations Limitations ...................................................................................................................................... 1
1.1 Best Practices ................................................................................................................................................................... 2
1.2 Software 14-day Updates ................................................................................................................................................. 3
1.3 Revenue Management Edits............................................................................................................................................. 4
2.0 REVENUE MANAGEMENT INSTALLATION, CONFIGURATION, AND REGISTRATION .......... 5
2.1 Launching Revenue Management on the first computer ........................................................................................... 5
2.2 Revenue Management Registration ........................................................................................................................ 10
2.3 Configuring the first practice ................................................................................................................................... 12
Add Practice ............................................................................................................................................................................. 12
Connection Wizard .................................................................................................................................................................. 13
Existing Receivers..................................................................................................................................................................... 15
Configure New Receivers? ....................................................................................................................................................... 17
Additional Receiver Information and Identification Details .................................................................................................... 17
Revenue Management Practice List ........................................................................................................................................ 20
Claims Editor Database Update ............................................................................................................................................... 21
Downloading File ..................................................................................................................................................................... 22
2.4 Configuring “Preferences” .......................................................................................................................................... 23
2.5 Claims editor wizard ................................................................................................................................................ 30
3.0 SENDING CLAIMS ..................................................................................................................................... 35
Claims – Receiver ..................................................................................................................................................................... 35
To Check the Claims ................................................................................................................................................................. 36
Checking Claims- Building Dataset ........................................................................................................................................... 37
Building Claims ........................................................................................................................................................................... 2
4.0 REVIEWING REPORTS .............................................................................................................................. 4
To Access Reports ...................................................................................................................................................................... 4
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4.1 Report Archive .......................................................................................................................................................... 7
5.0 REVENUE MANAGEMENT ELIGIBILITY .............................................................................................. 9
5.1 Set up ........................................................................................................................................................................ 9
Existing Receivers..................................................................................................................................................................... 11
New Receivers ......................................................................................................................................................................... 12
Configuring Receivers .............................................................................................................................................................. 13
Edit Receivers ........................................................................................................................................................................... 14
Associating Eligibility Receiver with Payer Code ...................................................................................................................... 17
Insurance List ........................................................................................................................................................................... 19
3.2 Sending eligibility requests ...................................................................................................................................... 19
Eligibility through Office Hours ................................................................................................................................................ 19
Eligibility through Patient Cases .............................................................................................................................................. 27
6.0 REVENUE MANAGEMENT REMIT SET UP ........................................................................................ 31
Requirements .......................................................................................................................................................................... 31
6.1 Remittance setup .................................................................................................................................................... 31
6.2 Posting Remittance advice ...................................................................................................................................... 38
Assigning Patients and Service Lines ....................................................................................................................................... 45
6.3 Exporting Remittances Received in RM for viewing in Medicare Remittance Easy Print (MREP) ............................. 47
7.0 SMART SCREENS ...................................................................................................................................... 54
7.1 Importing Smart Screens ......................................................................................................................................... 54
7.2 Verifying the Smart Screen Connection ................................................................................................................... 55
7.3 Purchasing a Smart Screen ...................................................................................................................................... 56
7.4 Importing a smart screen......................................................................................................................................... 57
7.5 Configuring the EDI Receiver ................................................................................................................................... 60
7.6 Utilizing the Smart Screen ....................................................................................................................................... 67
8.0 REVENUE MANAGEMENT EDITS ......................................................................................................... 68
8.1 Configuring the claim edits ...................................................................................................................................... 68
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8.2 Purchasing the edits ................................................................................................................................................ 68
8.3 Enabling the edits for the insurance carriers ........................................................................................................... 68
8.4 Customizing the edits .............................................................................................................................................. 69
8.5 Creating a new rule set ............................................................................................................................................ 71
8.6 Assigning your new edits on an insurance carrier .................................................................................................... 75
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1.0 REVENUE MANAGEMENT OVERVIEW
This section describes the product features, dependencies and limitations of Revenue Management.
The specifications to function properly within Medisoft practice management software are not limited to
the dependencies and limitations listed.
Product Features
The serial number indicates what products, connections, and types of transactions are attached to each
installation based on what the customer purchased. The serial number can only be registered once.
The connections store the Implementation Guides that are used, receiver information, and the
communication sessions. Each of these particular items is stored in the Revenue Management
Database.
The Connection Wizard only allows access to the connections, products, and destinations associated
with the serial number. To order additional connections for an installation or existing serial number, the
order must come from within Revenue Management.
Dependencies
The following must be met for the software to be licensed and function properly:
1. The time and date at the customer network server must be accurate (within minutes).
2. Windows Management Interface Scripting must be enabled.
3. All .net framework updates must be installed from the Windows Updates web site.
4. All computers with Revenue Management installed must have internet access.
Practice and Workstations Limitations
The following number of practices and workstations are the limitations as defined by Revenue
Management.
1. Revenue Management Advanced product is used to connect to RelayHealth only:
a. Revenue Management Advanced is limited to:
i. Two (2) practices
ii. Unlimited workstations
b. Advanced for Billing Services is limited to:
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i. Unlimited practices on the same physical network
ii. Unlimited workstations on the same physical network
2. Revenue Management Direct products are used to connect to anything besides RelayHealth:
a. Revenue Management Direct is limited to:
i. Two (2) practices
ii. Unlimited workstations
b. Direct for Billing Services is limited to:
i. Unlimited practices on the same physical network
ii. Unlimited workstations on the same physical network
1.1 BEST PRACTICES
System Requirements
Supported Operating Systems: Windows XP Professional Service Pack 2 or higher, Windows Vista Business Edition, Windows 2000, Windows Server 2003 Service Pack 2 or higher, Windows Server 2008, and Windows 7 Professional. Home editions, XP Media Center, and Ultimate are not supported as Revenue Management will not run as expected on them.
Pentium 4 2.4 GHz or higher CPU.
1 GB of RAM (2 GB strongly recommended for smooth performance).
2 GB available hard disk space.
56k dial-up modem installed and phone line attached if sending claims over a dial-up type connection (NOT cable or DSL modem).
Windows Vista, Before the installation, log into Windows using the ADMINISTRATOR account.
To ensures full permission to read and write certain files for a thorough installation. After the
install is complete, before opening Revenue Management for the first time, right click the Medisoft
icon on the desktop and click the option in the pop-out list that reads “Run as Administrator”
This must be done if even if they are still logged in as ADMINISTRATOR. Once Medisoft is
opened, proceed to open Revenue Management as described in the later sections of this guide,
the administrator‟s permissions will carry over into Revenue Management.
Practice management software requirements:
Supported Practice Management Systems: Medisoft 15 Service Pack 1 or higher or Medisoft 16.
Practice information accurately filled-out.
Insurance companies present in Medisoft and accurately filled-out.
Providers and referring providers present in Medisoft and accurately filled-out.
Patients, insured, and guarantors present in Medisoft and accurately filled-out.
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Procedure codes and fee schedules imported in Medisoft and ready for use.
Services or charges entered and claims created with patient and insured information.
The Medisoft practice database name cannot contain apostrophes or underscores.
Try as much as possible to ensure there are no special punctuation characters, such as apostrophes,
colons, parenthesis, etc., present in any practice, provider, referring provider, patient, or guarantor
information. These are special characters reserved for use by the ANSI standard when building the claim
file and can cause entire files to reject from the payor or clearinghouse.
Networking requirements:
Revenue Management requires a shared folder on the server. This folder must be accessible to all computers that will use Revenue Management. We recommend this folder to be named “RMData”.
Revenue Management requires access to the internet to check for program and license updates.
Firewalls and antivirus programs must allow Revenue Management to read, write, and access files in the shared folder.
1.2 SOFTWARE 14-DAY UPDATES
The current version of Revenue Management software contacts the website and looks for any new
updates every 14 days. The customer can choose to check for updates or not to check for updates.
If updates are available, the Customer can choose to install the update or not to install the update. To
install the update, the following must happen.
The user must be logged in to the computer as the administrator.
Medisoft on the computer running the update on must be closed.
Revenue Management must be closed on all workstations.
There are two different types of updates for Revenue Management; Program Updates and Edits
Updates.
The Program Updates are updates to the core Revenue Management software. This includes
updates for Implementation Guides, Receivers, Communication Sessions, and Revenue
Management processes.
Edits Updates are updates to the Edits database for Revenue Management. This includes
updated diagnosis codes, updated CPT/HCPC codes, common edit rules, CCI edits, global
period updates, and Medicare Coverage Database updates.
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1.3 REVENUE MANAGEMENT EDITS
There are several types of edits with Revenue Management. The types of edits are:
ANSI Edits – included at no cost
Medicare Policy Edits – Annual subscription required
Check DX codes – Annual subscription required
Check CPT codes – Annual subscription required
Global Periods – Annual subscription required
CCI Edits – Annual subscription required
Common Edits – included at no cost
User Defined Edits – included at no cost Most of the edits can be turned on or turned off based upon the insurance carrier.
ANSI Edits – ANSI edits are included in Revenue Management free of charge. These edits are
displayed on the claim preview window. The implementation guide determines ANSI Edits. Typically,
the ANSI edits will cause either the file or claim to be rejected.
Medicare Policy Edits – Medicare Policy Edits are available with Revenue Management for an
additional cost. These edits check the Procedure Codes on a claim to see if they are listed in the
coverage topics selected in preferences. If they are listed, the Diagnosis Codes on the claim are
checked against the supported/not supported list of diagnosis codes for the coverage topic. The
coverage topics are selected in the preferences inside of Revenue Management.
Check Diagnosis Codes – The Check Diagnosis Codes edits are available with Revenue Management for an additional cost. If enabled, the Diagnosis Codes on a claim are checked against the valid codes stored in the MCD database. Check CPT Codes – The Check CPT Codes edits are available with Revenue Management for an additional cost. If enabled, the Procedure Codes on a claim are checked against the valid codes stored in the MCD database. Global Periods – Global Period edits are available with Revenue Management for an additional cost. A global Period is when a specific procedure is performed, the follow up visits or procedures are considered to be part of the original procedure. The length of most Global Periods is same day, ten days, thirty days, sixty days, or ninety days from the date of the original procedure. CCI Edits – CCI Edits are available with Revenue Management for an additional cost. These check for mutually exclusive codes (ones that cannot normally be billed together) and comprehensive/component codes (also called "bundled" codes, this means that one code is considered to be part of another code, and they cannot normally be billed at the same time). Common Edits – Common Edits are included in Revenue Management free of charge. These edits are
displayed when checking claims. The Common Edits are a predefined set of common checks loaded
when the Revenue Management Database is created. The Common Edits can be edited, imported, or
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exported. These edits are designed to catch common data entry mistakes. The edit message text and
the edit message level can be edited and changed.
User Defined Edits –Revenue Management gives users the ability to make user defined edits free of
charge. These edits are displayed on the claim preview window. User defined edits are made in the
configure edits editor. User Defined Edits can be edited, imported, or exported. These edits are
designed to catch common data entry mistakes. The edit message text and the edit message level can
be edited and changed.
2.0 REVENUE MANAGEMENT INSTALLATION, CONFIGURATION, AND
REGISTRATION
The following section provides the steps to perform the set up for Revenue Management connections
within Medisoft. Revenue Management is automatically installed when Medisoft 2009 SP 2 or newer
is installed. When Revenue Management is launched for the first time, the following steps are
required.
The Revenue Management Practice List database (RMDBList) location must be set.
Revenue Management must be registered.
The Revenue Management practice database(s) must be configured.
2.1 LAUNCHING REVENUE MANAGEMENT ON THE FIRST COMPUTER
Open Revenue Management from within Medisoft following the below steps:
From the Menu bar, click Activities
Click Revenue Management
Click Revenue Management
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The first time Revenue Management is launched on a computer, the Revenue Management Practice
List dialog window is displayed. The Revenue Management Practice List database (RMDBlist)
location must be set from this window.
If Revenue Management has not been registered or if this is the first computer this step is being
performed on, then a new Revenue Management Practice List database must be created.
Click the Create button.
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Browse for Folder
You will be required to create a new folder under the MediData folder. This will be located
either on a server or on a workstation in your office.
IMPORTANT NOTICE: If you are on the server, you MUST use a UNC path (ex:
\\servername\Medidata) or a mapped drive. If you are using a mapped drive, make sure
that all workstations are using the same drive letter as this information is linked to the
connection. When browsing this path, please browse through the entire network path by
selecting My Network Places > Entire Network > Microsoft Windows Network; and then
select the domain or workgroup and the server.
Note: If launching Revenue Management for the first time on a network, click „Create‟
on the first PC. When launching Revenue Management on additional PC‟s, click
„Connect‟ and browse the path to the RMData folder (created in the next step).
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With the MediData folder highlighted, click Make New Folder.
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Name the new folder RMData and click OK.
Creating MCD
Creating DB List
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Copying MCD
DB List Upgrade - This is going to create the database list
Click OK
Upgrading RM DBList
2.2 REVENUE MANAGEMENT REGISTRATION
Registration Screen - Please take a moment to register your copy of Revenue Management.
1. Serial Number- (The customer would have received the serial number through the mail or email) 2. Enter the Serial number in field indicated 3. Enter Company Name or Practice name *Please note: data entered in this field prints as the
footer of your reports* 4. Enter Address 5. Enter City 6. Enter State 7. Enter Zip 8. Enter Phone 9. Click Register using my Internet Connection.
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10. Registration Complete
Click OK
Note: This step will only need to be completed once during the installation. Once the
program is registered on the first PC, additional PC‟s will not have to complete this
step.
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2.3 CONFIGURING THE FIRST PRACTICE
Add Practice
User‟s will be required to select the practice to add into Revenue Management
Highlight the practice you wish to add and click OK to continue
Database Upgrade – This will update the actual practice database
Click OK to continue
NOTE: DO NOT EDIT THIS PATH UNLESS INSTRUCTED BY MCKESSON OR YOUR
SYSTEM ADMINISTRATOR.
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Upgrading Practice
Users will be required to login
Configure?
Click OK to configure the new practice now
Connection Wizard
Welcome to Connection Wizard
Click Next to continue
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Enter the same login and password you entered earlier when adding the practice and click OK.
Connection Wizard
Users will be required to choose the connection they wish to configure.
Multiple connections may be in the list, however they must be configured one at a time using the configuration wizard
Place a check mark next to the connection you wish to configure and click Next.
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Existing Receivers
This screen displays receivers already configured in the practice management system
If users have an existing RelayHealth receiver, select receiver on this screen then click Next
If user does not have an existing RelayHealth receiver, select nothing click Next
See the following example for a user who is not an existing RelayHealth customer
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New Receivers
This screen should ONLY be used if you marked (NONE) in the previous step or if you wish to add an additional receiver.
If user selected an existing RelayHealth receiver, do not select RelayHealth on the New Receiver screen
If user did not select an existing RelayHealth receiver, select RelayHealth on the New Receiver screen
Click Next to continue
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The following example indicates a NEW receiver for RelayHealth
Configure New Receivers?
Click OK to continue
Additional Receiver Information and Identification Details
Group Practice: Not used.
Primary Contact: Enter the customer contact information
Type: Select telephone.
Number: Enter the contacts phone number
Secondary Contact: leave blank
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Identification Details
ISA/GS Submitter ID: Enter the EMF Login (p + existing submitter id)
1000A Submitter ID: Enter the Billing ID + Submitter ID
Taxonomy: Not used
User ID: Enter the EMF Login (p + existing submitter id)
Password: Enter the EMF Password
Click Next
Note: Test mode: Select this to mark the claims as test mode in the ISA15 for testing/validation
purposes.
Configuring Receivers
Click Next
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Edit Receivers - At this screen, the only values that may need to be changed unless instructed otherwise
are as follows:
Suppress Legacy: RelayHealth customers uncheck this option.
Send Drug Loop: Select this option if you send drug claims with NDC Codes.
If you need to further edit the EDI receivers, this is where you will need to complete the edits
Click Next
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Click Finish
Revenue Management Practice List
If you have multiple practices this is where you may switch between the practices
If you have more than one connection or receiver, highlighting the practice and clicking configure will invoke the Connection Wizard to configure the next receiver/connection.
Highlight the practice click Select
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Login
Claims Editor Database Update
- Click Next
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Update Available
- Click Next
Downloading File
When the download completes, you will have to re-launch Revenue Management.
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2.4 CONFIGURING “PREFERENCES”
Click Configure and then Preferences to configure the practice preferences.
Medisoft Tab
A. Security – Contains two sub items for auto logoff.
i. Auto Log Off – Enable this option to have the Revenue Management program logoff after so
many minutes of inactivity.
ii. Log Off Minutes – Specify the number of minutes here to tell Revenue Management when to
logoff.
B. Claims – Contains two sub items regarding billing out claims.
i. Create Billing Notes – Enable this option to have Medisoft create a billing note as a
comment in Transaction Entry when the claim is sent out.
ii. Billing Note Code – If the top option is enabled, specify the code here that you would like to
use.
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Note: These two sets of options are also available inside the Medisoft program, found under the “File”
button on the main toolbar and “Program Options” in the drop-down list. Security items can be found on
the “HIPAA” tab and Claims items can be found on the “Billing” tab. If these options are already
configured in Medisoft, they will be reflected here inside Revenue Management.
Revenue Management Tab
A. Claim Prefix – If a Claim prefix is desired, enter it here. This will put 3 letters in front of the claim number in the claim file. This can be helpful for billing services.
B. Show Service Date – This will show the first date of service for each claim in Revenue Management Claims Editor. Normally, this checkbox is not selected. Selecting this option will slow the performance of Revenue Management.
C. Write Log File – Checking this box will have Revenue Management create log entries in the application event log in Windows. Only check this box if instructed to check it by Revenue Management support.
D. Auto Login from Medisoft – Checking this box will turn on the ability for Revenue Management to automatically log in when launching from Medisoft. With this checked, you will need to enter the username and password in the box below, and you will not be prompted for a login when launching Revenue Management.
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E. Auto Login from Medisoft – User and Password – Enter the username and password to be used to Auto-Login from Medisoft. If no username and password are entered, then the end user will be prompted to enter their user and password when Revenue Management is launched from Medisoft.
F. Global Settings – If the submitter has submitted claims previously with the current Submitter IDs, then increase the Group and Interchange numbers. Typically, increase it 1000 for each year of use per practice.
Revenue Management Tab – Report Settings Tab
A. Remit Export Folder – This is used to specify a location to export Electronic Remittance Advice files (835 ERA) to.
B. Use Common Report Folder – This check box determines whether Revenue Management uses the common Archive, Download and Reports folder or the individual Archive, Download and Reports folder located under the Revenue Management practice database. If a Submitter ID is used by more than 1 practice, this check box must be checked.
C. Report Import Folders - Alternate locations for Revenue Management to import reports from can be specified by adding the paths in this list. Usually, this is not used.
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Revenue Management Tab – Archive Options Tab
A. Auto Archive – This check box determines whether Revenue Management automatically archives files. Normally, this check box should be checked.
B. Archive Files over ## months old. – This setting determines how old files must be before Revenue Management will archive the files. Normally, this is set to 12 months. Files archived will be moved into a zipped file in the corresponding archive folder.
C. Make a new archive every ## months – This setting determines how often Revenue Management makes new archive files. Normally, this is set to 12 months. New archive files will be made according to the setting selected.
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Revenue Management Tab – Remit Posting Options Tab
This tab is explained in section 6.0 (Revenue Management Remit Set Up)
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Click the Claims Editor tab and click Next to start the Claims Editor Wizard.
Select the state or states of which the services are provided and click Next.
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2.5 CLAIMS EDITOR WIZARD
Select the contractor (carrier or intermediary) the practice sends the Medicare claims to. If necessary,
select more than one contractor. Click Next.
Select the coverage topics for services that the practice bills Medicare for. Only check coverage topics
that apply. Checking extra coverage topics will subject the claims to unnecessary edits.
Suppress DX Warnings – This check box makes Revenue Management suppress warnings when a
diagnosis is not specifically listed on the medical policy. McKesson recommends to check this box if the
Physical Therapy coverage topic was selected.
Click Next.
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CCI Edit Type – Select the CCI Edit Type for the practice. Choose Physician or Hospital.
Global Period Option – Select the Global Periods Option for the practice. McKesson recommends
setting this option to All Cases.
Click Next.
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Click Finish to complete the Claims Editor Wizard.
Click Save when finished. This will close the Preferences window.
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Remittance Codes Tab
This tab is explained in section 4.0 (Revenue Management Remit Set Up)
Assign Posting Codes Tab
This tab is explained in section 4.0 (Revenue Management Remit Set Up)
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Status Codes Tab Status Codes – Displays a list of all healthcare claim status codes used to convey the status of an entire
claim or a specific service line.
Status Categories – Displays a list of all claim status category codes used to indicate the general
category of the status (accepted, rejected, additional information requested, etc.) which is then further
detailed in the Claim Status Codes.
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3.0 SENDING CLAIMS
Click Process then click Claims.
Claims – Receiver
Click the receiver to expand the selection
Once the selection is expanded, there will be a drop down list of all claims ready to be sent.
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To Check the Claims
Click Check Claims and then choose the receiver
Revenue Management will now check your claims against Common and User Defined edits as well as
the medical policy edits, CCI, and global periods if the advanced edits have been purchased.
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Checking Claims- Building Dataset
Note: If you did not purchase MCD and CCI edits, a series of error messages may
display. Click OK to pass these messages. Once Revenue Management has finished
checking your claims, the „Edit Status‟ flags will be updated to show the check
claims result.
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System will check claims:
Green Flags indicate that claims are ready to go and have passed.
Red Flags indicate that there are critical errors on the claims.
Yellow Flags indicate that there are warnings.
Blue Flags indicate that there is an informational message
The claims that indicate Green flags will have a check mark in the send column.
The claims that indicate Red flags or Yellow flags will not have a check mark in the send column.
The claims with errors should be corrected in Medisoft and re-checked.
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To view the error on red flagged claims, click the plus sign in the „Send‟ column.
Once the selection is expanded, click the „Edits‟ tab to see the error.
Reports can be printed showing any claims with errors and the error message. To print this report, follow
the steps below:
Click Print and select Edits.
This report only prints claims with errors.
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Click OK
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The system will display the claim edits report
You may print, save, or export the file into PDF Click the red „X‟ when you are done with the report
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Build the Claim File Once the claims have been checked, they must be built into a claim file. To build the claims into a claim
file, follow the steps below:
Select Send, choose Claims then, select the receiver
Revenue Management will now gather the claim information from Medisoft and check the claims for
HIPAA errors.
Note: Revenue Management will only send claims that have the Send checkbox
checked.
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Building Claims
If there are any ANSI errors on the „Claim Preview‟ screen, a red “X” will display on the claim line, the transaction set tab, and on the file totals. Any claims with errors at this point should be removed from the file.
To remove the claim with errors:
Select the claim that has the errors on it and click the Remove Claims button.
Note: The removed claims will not be sent to the Clearinghouse. In addition, the errors on the claim must be corrected and the claim re-built for submission.
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The claim preview report may also be viewed from this screen. To view, click Report.
The next screen provides the option to choose a summary or detail report. Make your selection and click OK.
The system will display the claim preview report. You may print, save, or export the file into PDF Click the red „X‟ when you are done with the report
Once the report is closed, you will then be taken back to the claim preview screen to proceed with sending the claims transmission.
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Click the Send button to proceed with your claims transmission.
4.0 REVIEWING REPORTS
To Access Reports
Click Process then click Reports.
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The report viewer will open. When reports are downloaded, they are automatically placed in the download folder. To view a report, double click it or highlight it and choose the Open button.
You will be provided the option to select the report format for the claim response. Click OK.
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The system will display the report.
You may print, save, or export the file into PDF
Click the red „X‟ when you are done with the report
Once you close the report, you will be asked if you want to post the report. If you select YES, Revenue Management will change the claim status to rejected for all claims contained in a rejected transaction set. If the claims were accepted, no changes will be made.
Note: The claim status will change on rejected claims on 997 reports, RelayHealth
machine readable reports, and Availity machine readable only.
The claim status will change on rejected claims on 997 reports for RelayHealth and
Availity clearinghouses only.
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You will then be asked if you are finished with this report. If you select Yes, the report will be removed
from the report viewer and into the archives. If you select No, the report will remain in the report viewer
so that it can be previewed later.
4.1 REPORT ARCHIVE
Click File then Archive
Note: Plain text reports are human readable, and can not be posted. These reports
will automatically move to the Archive.
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In the „Archive Manager‟, click File, Open Folder then, and Downloads to extract downloaded reports.
You will then see a list of the downloaded archived files.
If you wish to extract a file, highlight the file, click the Extract File button or simply double-click the file in the grid.
The report will then be placed back into the reports viewer. Upon closing the „Archive Manager‟, the
report will then appear in the report list.
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5.0 REVENUE MANAGEMENT ELIGIBILITY
5.1 SET UP
The following steps should be followed to set up eligibility with Revenue Management in Medisoft. Click Process and then click Change Practice.
Click Configure.
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The Connection Wizard screen displays. Click Next.
Users will be required to login. Input your Medisoft username and password.
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„Connection‟ screen
Users will be required to choose the connection they wish to configure.
Multiple connections may be in the list, however they must be configured one at a time using the configuration wizard
Select the eligibility connection and click Next. The availability of any given connection is determined by your serial number.
Existing Receivers This screen displays receivers already configured in the practice management system If user has an existing RelayHealth eligibility receiver, select receiver on this screen and click
Next.
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New Receivers If user selected an existing RelayHealth receiver on the previous screen, do not select
RelayHealth on the „New Receivers‟ screen. If user did not select an existing RelayHealth receiver, select RelayHealth on the „New Receivers‟
screen Click Next to continue
Additional Receiver Information Group Practice: Not used
Primary Contact: Enter information
Type: Select Telephone.
Number: Enter phone number
Secondary Contact: Leave blank
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For RelayHealth Eligibility, „Identification Details‟ values are as follows:
ISA/GS Submitter ID: Enter the user‟s Integrated ID
1000A Submitter ID: ISA/GS Submitter ID: Enter the user‟s Integrated ID
User ID: ISA/GS Submitter ID: Enter the user‟s Integrated ID
Password: Enter “Webpass1” (without the quotes)
Taxonomy: Leave this field blank
Test Mode: Leave this field blank
Configuring Receivers
Double click Next
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Edit Receivers
If you need to edit the EDI Receivers, this is where you will need to complete the edits
Click Next
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Click Finish
Revenue Management Practice List
You will be required to choose a practice of which you want to verify eligibility
Highlight the practice, click Select.
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Enter login credentials and click OK.
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The Revenue Management Main Screen is displayed.
Associating Eligibility Receiver with Payer Code
Users will need to associate the RelayHealth eligibility receiver to the payor code.
Click Configure, Insurance, then Eligibility Receivers
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Click the drop down under the „Eligibility Receiver‟ column, select the RelayHealth eligibility receiver
Click Save
Associating Eligibility Payer ID in Insurance List
Click Configure, Insurance, then Insurance List.
Note: Highlighting one payer code , then holding down the „Ctrl‟ key on your keyboard
and pressing the letter „A‟ will select all rows. Release the „Ctrl‟ key and select the
eligibility receiver under the „Eligibility Receiver‟ column. This method will select that
receiver for all payers.
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Insurance List
Locate the „Primary Eli Payer ID‟ column and input the eligibility payor id for all carriers.
Example: Aetna Insurance carrier has Aetna as the Eligibility Payer ID
3.2 SENDING ELIGIBILITY REQUESTS
Eligibility through Office Hours
Bring up Office Hours
Right click on a patient
Click on “Eligibility Verification”
Note: RelayHealth users may obtain the RelayHealth eligibility payer ID‟s from the
Collaboration Compass website.
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Eligibility Verification Results Window appears
Click “Verify”
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Real-Time Eligibility Verification window appears
Click “Verify”
Revenue Management will build the eligibility request file.
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Upon successfully verifying, select the report format for the eligibility response and click OK.
The system will display the eligibility response report (271).
You may print, save, or export the file
Click the red „X‟ when you are done with the report
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Once you close out of the report, you will be asked if you are finished with this report.
Click Yes. This will move the report to the archive list.
If you are not finished with this report, you will be asked if you want to assign the report to another
practice. This will leave the report in your report list.
If you click Yes, you will be asked to choose the practice of which to assign the report to.
If the practice is displayed in the list, click the practice name and click OK.
If the practice is not displayed in the list, click the blue link to „choose a practice/receiver not
shown in the list‟.
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If the „Click here to choose a Practice/Receiver not shown in the list‟ link is clicked, choose the practice
from the drop down and click OK.
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The practice will then be displayed in the window. Click the practice name and click OK.
You may then be asked to choose the insurance company. Select the carrier from the drop down menu
and click OK.
You will then be asked to choose the receiver. Select the receiver from the drop down menu and click
OK.
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You will then receive a popup that the eligibility is now assigned and can be opened in the assigned
practice.
Eligibility Verification Results Window
Click “Details” Tab
This gives the user the Eligibility Verification Details
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Eligibility through Patient Cases
Bring up Medisoft
Go to List
Click on “Patients/Guarantors/Cases
Patient List window appears
Highlight the patient you wish to check eligibility for
Right click on a case, click “Eligibility Verification”
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Eligibility Verification Results Window appears
Click “Verify”
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Real-Time Eligibility Verification window appears
Click “Verify”
Revenue Management will build the eligibility request file.
Upon successfully verifying, select the report format for the eligibility response and click OK.
The system will display the eligibility response report (271).
You may print, save, or export the file
Click the red „X‟ when you are done with the report
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Once you close out of the report, you will be asked if you are finished with this report.
Click Yes. This will move the report to the archive list.
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6.0 REVENUE MANAGEMENT REMIT SET UP
The following steps should be followed to set up electronic remittance advice (ERA) files with Revenue
Management in Medisoft.
Requirements
Customers must be enrolled with their payor/clearinghouse to receive electronic remittance advice (ERA)
files (ANSI 835 X12 format).
6.1 REMITTANCE SETUP
To check RM preferences and assign posting codes:
In Revenue Management, click Configure and Preferences.
Once the Preferences window opens:
Click the Revenue Management tab
At the bottom of the window, click the Remit Posting Options tab
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A. Use Insurance Posting Codes Only – This check box determines whether Revenue Management uses the default insurance codes from Medisoft or uses the assigned remit posting codes from Revenue Management. McKesson recommends not checking this box. If this check box is checked, Revenue Management will:
i. Use the insurance default Adjustment codes selected when opening the electronic remittance advice.
ii. Automatically write off Contractual Obligations and Other Adjustments as long as the claim was not denied.
iii. Automatically mark the insurance as paid and change responsibility to the patient for all Patient Responsibility amounts.
B. Allow Remittance Edits – This checkbox determines if the users are allowed to edit the remittance
before posting it to Medisoft. McKesson recommends checking this box. C. Change Negative Payments to: – - This checkbox makes Revenue Management change any
Takeback on an electronic remittance advice to use the code selected. McKesson recommends checking this box and assign an Insurance Adjustment type code.
D. Post Secondary Adjustments – This check box makes Revenue Management automatically mark
secondary adjustments to post, if the remittance code is configured in the Assign Posting Codes Tab. If this check box is checked, the Allow Remittance Edits must be checked. McKesson recommends to check this box.
E. Never Write Off Patient Responsible (PR) – This checkbox makes Revenue Management never
write off any adjustment amount if the group code in the remittance is PR – Patient Responsible. McKesson recommends checking this box.
F. Always Match Last Name – This checkbox determines if Revenue Management will always match
the last name of the patient in Medisoft with the last name of the patient in the electronic remittance advice (835). McKesson recommends checking this box.
G. Match by Full Name and ID – This setting determines if Revenue Management uses the patient‟s
full name and insurance ID in the electronic remittance advice to find the correct service and claim from Medisoft. If this checkbox is checked, Revenue Management will try to match exactly the patient full name and insurance ID from the electronic remittance advice to the patient full name and insurance ID from Medisoft. McKesson recommends checking this box.
H. Set Primary Denied Claims to: McKesson recommends checking this box and selecting “Rejected”
from the drop-down list to change all primary denials to rejected status in Medisoft. I. Set Secondary Denied Claims to: McKesson recommends checking this box and selecting
“Rejected” from the drop-down list to change all secondary denials to rejected status in Medisoft. J. Post ICN [CLP07] to Claim Comment – This check box makes Revenue Management post the ICN
number (Segment CLP07) from the electronic remittance advice to the claim comment field in Medisoft. McKesson recommends checking this box.
Note: McKesson recommends that the Remit Posting Options be configured to reflect
the image below.
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Remittance Codes tab
This tab is for informational purposes. No configuration is done on this tab.
Adjustment Codes – Displays a list of all codes and the description of why a claim or service line was
paid differently than it was billed.
Remark Codes – Displays a list of all codes used to convey information about remittance processing or
to provide a supplemental explanation for an adjustment already described by a claim adjustment reason
code.
The next step is to assign the recommended posting codes.
Click the Assign Posting Codes tab.
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Setup the following ERA codes to these values for all receivers:
1 – (DE) Default Deductible
2 – COINS Coinsurance Amount
3 – DUECOPAY Copayment Amount
42 – (WO) Default Write-Off
45 – (WO) Default Write-Off
A2 – (WO) Default Write-Off Your grid should look similar to the images below
To create these codes follow these steps: 1. Open Medisoft
2. Click “List” then click “Procedure/Payment/Adjustment Codes.” After you open the Procedure/Payment/Adjustment code lists, click “New” at the bottom of the screen.
Note: If you browse the list and the codes, COINS, and DUECOPAY are not present, they
may need to be created in Medisoft. Once the codes have been created in Medisoft, the
preferences menu must be closed and reopened to refresh the list.
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A new record will open. Perform the following actions: 1. Type in the code 1: “COINS” without the quotation marks.
2. Type in the Description “COINSURANCE AMOUNT” without the quotation marks.
3. Change the Code Type to be “Comment.”
4. Click “Save”
Next, do the exact same steps for DUECOPAY and perform these actions: 1. Type in the code 1 “DUECOPAY” without the quotation marks.
2. Type in the description “DUE COPAYMENT AMOUNT” without the quotation marks.
3. Change the Code Type to be “Comment.”
4. Click “Save”
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6.2 POSTING REMITTANCE ADVICE
Now that the remit posting options and assigned posting codes are setup to McKesson‟s recommended
settings, please open one of the remits for the first time and assign the aliases:
Click Process and click Reports to open the Reports Processor.
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If this is the first time the remit opens, the alias window will appear asking to select a practice for the
remit.
If the practice is not in the list to select from, or if the list is blank:
Click “Click here to choose a Practice/Receiver not shown in the list”.
The “Choose a Practice for this Remittance” screen comes up
Click the drop down arrow, select the practice and click OK.
Note: The remits that have already downloaded will show up under the list of reports
(Remits are labeled as 835 with a description indicating „Payment‟). Double-click the
remit to open it.
Note: If unsure, the alias window in the background displays which payer the remit is
from and the practice the remit is made out to.
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After the practice is selected, it will show up in the list.
You must also choose an Insurance Carrier
Scroll down the list and choose a carrier that corresponds with the payor on the remit and click
OK.
Note: Revenue Management displays who the payor is in the background
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Once the remittance is opened, you have the option to print, post, or view. Please see descriptions of each option below: Print: This option allows you to print the remittance on paper. You may also use this button to save a
copy of the remit to your computer.
Post: This option allows you to begin the process of posting the remittance.
View: Acts like a filter allowing you to sort by viewing all unassigned remits, denials or takebacks.
Note: This is a one-time only step. The next time a remit is received from that same
carrier and made payable to that practice, Revenue Management will immediately
open the remit. Once the remit is opened, Revenue Management will match the
information in the remit to the corresponding information in the user‟s Medisoft.
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The process remittance window is broken up into three sections.
Check Summary Remit Totals Remit Details
Check Summary - The top left portion of the remit displaying basic remit information: Insurance carrier, check number, check date, amount of check and the practice the remit is payable to.
Note: If there are any denials on the remit, a red „X‟ will appear below „Pay to the order
of‟. A red „!‟ indicates takebacks or reversals. If either is displayed, the remit must be
reviewed accordingly.
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Remit Totals - The top right portion displaying the total remit amounts and the amounts set to be posted.
Recalculate Totals button – recalculates totals when changes has been made to the grid (Ex. Unchecking an item so that it wouldn‟t post). Total Remit Amount – Displays the dollar amounts contained in the remit file, or amounts the payor sent back for claim payments. Total To Post – Displays the amounts that are marked to post.
Remit Details – Contains a breakdown of all claim information, payments, and adjustments contained in
the remittance grouped by the service lines.
The top row displays claim and service line information from the remit file including the account number, service date, procedure code, modifier 1 and modifier 2.
The second row displays the information pertaining to the appropriate match Revenue Management found in Medisoft. This includes the chart number, service date, procedure code, modifier 1, modifier 2, billed amount, patient payment amount, insurance 1 payment amount, insurance 2 payment amount, insurance 3 payment amount, adjustment amount and claim balance.
Note: If the totals to post do not match the total remit amount, the numbers in the
totals to post column will turn red. This means that certain grid items, such as
patients or service lines, will need to be matched up manually. Assigning patients and
service lines are discussed within the next few pages of this document.
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The following lines represent payments or adjustments sent on the remit for services billed. The insurance payment will always be on the top line and all other group codes will fall below.
The „Totals After Posting‟ section displays the total amounts after the remittance has been posted with the remainder located on the far right.
Note: The two lines will reflect each other if Revenue Management was able to match the information in the remit to the information in Medisoft. If Revenue Management is unable to find a match between what was sent on the remit and Medisoft, the words „Not Found!‟ will display. In this instance, you will need to manually assign the patient and the service line.
Note: If the item is set to post and it would happen to over-adjust the amount in your
Medisoft, the entire bar here would become highlighted in yellow. This means
changes would need to be made to prevent over-applying a claim.
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The „Processed as Primary‟ section details claim information after clicking the remit header. This information allows you to observe how the claim was processed, the claim number, patient name, and insurance ID. In addition, much like the totals box on the top, the „Remit Amounts‟ for this claim are displayed in the left column and the amounts ready to be posted are displayed in the right column. Any other miscellaneous information, including remark codes, is displayed in tabs below the totals.
Assigning Patients and Service Lines
Assign Patient: To assign the patient, first make note of the patient information in the „Processed as Primary‟ section of the remit. Click the Assign Patient button. A list will display of all patients found in Medisoft. Click the patient that the claim corresponds to and click „OK‟. Next, the service line must be assigned.
Note: If the claim is denied, a red „X‟ will appear next to the claim number. Likewise, if
there is a takeback, a red exclamation point (!) will appear next to the claim number.
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Assign Service Line: To assign the service line, make note of the claim service line details (chart number, service date, and procedure code) and click the Assign Service Line button. The program will display a list of the patient‟s unpaid services. You must choose the service line that matches the details you observed earlier. Once selected, click OK. Revenue Management now knows where to post the information.
On the „Process Remittance‟ screen, click Post to begin the posting process.
The „Post Remittance‟ screen will appear allowing the opportunity to specify additional options. Check Summary – Reiterates the check details: Payer, payee, check number, date and amount Payment Posting Options – This section allows the user to specify a payment code or to use the payment codes shown in the remit grid. In addition, the posting date may also be specified. Click OK to begin posting the remit.
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Upon posting completion, Revenue Management will ask you to select a report format. Simply click the
OK button. The “835 ERA Posting Summary” report will be displayed showing items that the software
posted and those that didn‟t post. When finished with the report, simply close it. The posting is now
complete and the report is now archived.
6.3 EXPORTING REMITTANCES RECEIVED IN RM FOR VIEWING IN MEDICARE
REMITTANCE EASY PRINT (MREP)
1. Log into Revenue Management.
2. Click Configure then Preferences.
Note: Depending on the size of the remit, it could take anywhere from a minute to several
minutes to post. DURING THE POSTING PROCESS, DO NOT CLOSE OR END THE POSTING
PROCESS TASK. It is also important that when auto-posting remits, ensure no billers have the
Patient List or Charges and Payments screens open. If these screens are open while Revenue
Management is auto-posting, a record lock may occur resulting in an error message.
Note: McKesson highly recommends that you review the posting report as it will
display any issues occurred during the posting process.
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3. Below the Report Settings tab, locate the field entitled „Remit Export Folder‟. Click the ellipses to
specify where you want RM to automatically export your remittances.
4. Browse for the folder of where you want the remittances exported if a folder has already been created.
If you want to make a new folder, browse to the location where you want this folder and click Make New
Folder. You will then be required to name this folder. When done, click OK.
NOTE: DO NOT EXPORT THE REMITTANCES INTO THE REPORT OR DOWNLOAD
FOLDERS UNDER RMDATA.
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6. The path specified will automatically populate in the „Remit Export Folder‟ field. Verify that the path is
correct and click Save. The Preferences window will close.
NOTE: When an ERA is received and viewed in Revenue Management , a copy of the file
will be stored in the folder specified in the „Remit Export Folder‟ field.
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7. Open Medicare Remit EasyPrint.
8. Click Tools then Path Name Editor.
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9. Locate the „Exported reports‟ field and click Browse to specify the path indicated earlier in Revenue
Managements „Remit Export Folder‟.
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10. Browse to the folder that was specified in Revenue Management‟s „Remit Export Folder‟ field and
click OK.
11. The „Exported reports‟ field is now specified with the same path indicated in Revenue Management‟s
„Remit Export Folder‟ field. „Imported files‟, „Archive files‟, „X835 native files‟, and „Resource files‟ can be
specified as needed. Click Save.
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12. You are now directed back to the Medicare Remit EasyPrint main screen to import your remittances.
For instructions on importing remittances using Medicare Remit EasyPrint, please reference article
130942.
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7.0 SMART SCREENS
7.1 IMPORTING SMART SCREENS
Importing Smart Screens 1. Log into the practice management software and open the Revenue Management application.
2. On the Revenue Management practice list screen, select the practice of which to install the smart screen.
3. Using the PMS login credentials, log into Revenue Management.
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4. On the Revenue Management main screen, click Help and then select Services.
7.2 VERIFYING THE SMART SCREEN CONNECTION
1. Click the Connections tab and verify if the smart screen connection is active.
Note: The smart screen connection is considered active if there is a check mark in the
“Enabled?” column on the same line as the smart screen description. If the smart screen is
not enabled, then the connection will need to be purchased.
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7.3 PURCHASING A SMART SCREEN
1. On the Connections tab, place a check mark in the box below the “Enabled?” column next to the needed connection and click the Submit button.
2. You will be directed to the Billing Info tab and required to enter your billing information (i.e., credit card information). After completing the billing information fields, click on the Place My Order button.
Note: To purchase a smart screen, place a check mark in the box below the “Enabled?”
column next to the needed connection and click the Submit button. You will be directed to
the Billing Info tab and required to enter credit card information.
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7.4 IMPORTING A SMART SCREEN
1. Click Configure and then select Smart Screens.
Note: Before proceeding with importing a smart screen:
Note: The connections ARE NOT activated immediately. Once the order is processed, the
smart screen license will be attached to your serial on our servers and you will then be able
to proceed with importing.
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2. Click the Import button.
3. You will be required to browse your program folder to locate the smart screens.
The smart screens can be located by navigating on the local drive (of which the PMS is installed) to the program files folder, opening the practice management software folder, and then opening the RCM folder. Example: (Local Disk)\Program Files\Medisoft 16\Bin\RCM *** Smart screens are automatically installed with the Revenue Management installation. If your folder does not contain the smart screens, you will need to proceed to help/check for updates in your RM application.
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4. Select the purchased smart screen and click Open. The smart screen file names will begin with MS 15 for Medisoft v15 and MS 16 for Medisoft v16. In addition, each smart screen file name will end with (.SmartScreen).
5. Once the screen has been imported, the screen description will appear in the list and the importing is complete.
Note: During the import process, the screen may momentarily appear frozen. Do not end the
task as the importing may take a few moments.
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7.5 CONFIGURING THE EDI RECEIVER
1. Click Process then select Change Practice.
2. Highlight the practice of which to set up the EDI receiver and click Configure.
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3. On the Connection Wizard screen, click Next.
4. Login using your Medisoft username and password.
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5. On the Connection Wizard - Connection screen, place a check mark in the box to select the smart screen connection and click Next.
6. On the Existing Receivers screen, place a check mark in the box to select the receiver and click Next.
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7. On the New Receivers screen, select any additional receivers to configure with this connection. If there is none, click Next.
Enter all necessary information.
Note: This screen is optional.
Note: For assistance with setting up this screen, please refer to the “Revenue Management
Technical Support Guide for Medisoft” (KB article 134025)
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8. The wizard is now ready to create and configure the receivers. Click Next.
9. The Edit Receivers screen will display. Scroll to the right to the end of the screen. For the receiver being configured, click in the field under the “Transaction Sets” column. The transaction set box will appear. Roll your mouse over the I Guide name to ensure the correct IG related to your smart screen is attached. In this example, the MS UB04 IG is attached. Click Next.
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10. Click the Finish button to complete the wizard.
11. You will then be routed to the Revenue Management Practice List to select the practice.
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7.6 UTILIZING THE SMART SCREEN
1. Open the practice management software and navigate to the patient‟s case.
Once the case is opened, right click in the blank area next to the tabs at the top of the screen and
click on the newly imported smart screen. This will add the smart screen tab into the patient‟s case.
Click on the smart screen tab to view the screen fields.
Note: Once the smart screen has been imported successfully, receiver is configured and
attached to the insurance carrier and the information is entered onto the smart screen,
claims can then be sent as normal.
Right-click
here
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8.0 REVENUE MANAGEMENT EDITS
8.1 CONFIGURING THE CLAIM EDITS
Configuration of the claim edits was covered in the 2.4 Configuring “Preferences” section of this
guide. If you would like to review your Claims Editor to ensure it is setup correct, see page #32. The
Claims Editor configuration wizard can be accessed anytime by logging into Revenue Management
and clicking “Configure” -> “Preferences” -> “Claims Editor” tab.
8.2 PURCHASING THE EDITS
Revenue Management provides two different types of editing on your claims before they are sent to the payor or clearinghouse. These are known as the basic and the advanced edits. Basic edits include common billing rules and customized user defined edits that are free of charge and always available with Revenue Management. Advanced edits include medical policy edits, CCI edits, CPT and ICD9 code validation, and global periods that are available for an additional cost. The cost of subscribing to these advanced edits is $300 per year per practice. If you are interested in purchasing the advanced edits to work with your Revenue Management, contact East/West Orders at McKesson and have your company or practice information handy as well as your Revenue Management serial number.
8.3 ENABLING THE EDITS FOR THE INSURANCE CARRIERS
Once the advanced edits have been purchased, you can configure which carriers you want to apply the edits for and which ones you don‟t. This is done through the “Assign Edits” window in Revenue Management. Open Revenue Management and log into the practice. Click Configure -> Insurance -> Assign Edits.
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The Assign Edits window will appear showing a full list of every insurance company you currently have inside your Medisoft practice. If the advanced edits are not purchased then the majority of the checkboxes in this screen will be empty. If the advanced are purchased and activated, then all of the checkboxes will be enabled. Scroll through the list and find the insurance company you want to enable or disable certain edits for and check or uncheck the checkbox with the corresponding edit set.
Medicare Edits – Checks the insurance company‟s claims against Medicare‟s medical policy standards.
Check Dx – Validates the diagnosis codes on a claim.
Check CPT – Validates the procedure codes on a claim.
Global Periods – Checks the procedures for dates of service on a claim against global surgical rules to determine if a follow-up date is in conflict.
CCI Edits – Check mutually exclusive procedure codes and comprehensive component, or “bundled” codes that cannot normally be billed together.
Common Edits – Standard billing rules that are enabled in Revenue Management by default. These edits are free and always available in Revenue Management.
User Edits – Edits free of charge and always available with Revenue Management that can be customized and tweaked to validate billing specific to your practice‟s billing habits.
NOTE: If user edits are desired, the checkbox for User Edits must be enabled AND a rule set must be selected from the drop-down list to the right of the checkbox. Not having a rule set selected will result in no user-defined edits running against the claims.
8.4 CUSTOMIZING THE EDITS
To create your own edits or tweak existing ones, use the Claim Edits Rules window. Access this screen by opening Revenue Management and logging into your practice.
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Click Configure -> Claim Edit Rules
The Claim Edit Rules window will appear. Initially this list will show you all of the common rules that made available to all Revenue Management users. This window is broken down into three different panels:
Rules
Mapping and Messages
Data Tables & Fields
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The left panel displays your claim rules. In the above example, all the common billing rules are presented. If you want to edit an existing rule, scroll through the rules list until you locate it and click on it. If you want to add a new rule to the list or delete an existing one, use both the “Add” and “Delete Rule” buttons near the top of the panel. The center panel is the mapping and message section. This is where you can create or edit your criteria of what you would like Revenue Management to monitor or catch on your claims and make it display either a red flag for an error, a yellow flag for a warning, or a blue flag for an informational message and you own customizable edit message near the bottom. The right panel displays the data tables and fields pulled from Medisoft. This list acts as an aid when trying to assemble your mapping to tell Revenue Management what to monitor when checking claims for potential errors.
8.5 CREATING A NEW RULE SET
Here is a full example from start to finish on how to create a new customized rule for your own copy of
Revenue Management and your practice. In this example, we are going to tell Revenue Management
any time a claim is billed with a 99213 procedure code; it must have a modifier 1 along with it as well. If
this is not the case, Revenue Management will display an error.
Click Add Rule Set.
Give your new rule set a name (Ex: MyNewRuleSet)
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Click Add Rule.
Give your new rule a name (Ex: Procedure99213RequiresModifier1)
Now that you‟ve created a new rule set and added a new rule and given them both names, it‟s time to configure your mapping to tell Revenue Management what to watch for to catch any potential problems on your claims. In this example, we‟re going to focus on procedure code 99213 and modifier 1 since they are two key pieces to our error message. Click the Data Tables & Fields header on the right panel. This action will alphabetize the listing.
To start the process of devising your mapping, click the Add Condition button.
Now is the time to ask yourself what exactly you are trying to catch inside Medisoft. “What combination of information for my insurance carrier must be present on my claims?” “What fields need to be filled out or remain empty?” “Which checkboxes must be checked or unchecked?” “What typographical errors or data entry mistakes do I see often that causes my claims to reject?” For this example, we have two items we are verifying: procedure code 99213 and a modifier 1. “99213” is classified as a procedure code and procedure codes are entered on the service line. Same rule applies for any modifiers, so we need to find the “Charges” option in the Data Tables & Fields panel as it contains all service line items. Expand Charges, expand Charge, and locate CPTCode. We‟ve now browsed the list of items under Charges, or service lines, and narrowed down our selection to the procedure code, or CPTCode. Click on and drag this CPTCode from the Data Tables & Fields panel and into the blue shaded mapping field.
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The condition is already set to “equals” so all that is left to do is type in your procedure code in the grey shaded area on the right, in our case, 99213. Your mapping reads “If CPT code equals 99213…”
Our last condition is the modifier 1. We are trying to tell Revenue Management that if there is a 99213 procedure code on the claim, modifier 1 cannot be empty. Click Add Condition again to add your second condition, find Modifier 1 in the Charges list, click on and drag Modifier 1 into the blue shaded mapping field. Change “Equals” to be “is empty.” Your mapping reads “If modifier 1 is empty…” Now is a good time to read your mapping statement out loud to ensure everything makes sense. In our example, it reads “If CPT code equals 99213 and modifier 1 is empty, then…”
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We have essentially told Revenue Management that on all of our claims, if there is a 99213 procedure code and no modifier 1 along with it, then it is going to display an error. The severity of the error and the message it displays can be customized however you wish. Choose one of the following flags for choice of error severity.
Blue Flag: Informational Message
Yellow Flag: Warning
Red Flag: Error
Once the flag type is selected, the final step is to create your error message you want Revenue Management to display. Be creative and devise a message you and your billers will understand. The error message can always be edited later on if you need to add to it. For our example, these are some error messages that many would find acceptable: “Procedure Code 99213 must have a modifier 1 along with it!” “Cannot bill procedure 99213 without a modifier!” “A modifier is required whenever billing procedure code 99213!”
Revenue Management allows for many different scenarios to catch billing mistakes and data entry errors so use different combinations of the data tables & fields, options from the drop down lists to say if fields are empty, have information in them, are greater than, less than, equal to, longer than, shorter than, etc. Once you are finished creating your edit rule, you can continue to add rules and create more or click Save to save all your changes. Note: McKesson does not support creating and customizing common and user-defined edits.
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8.6 ASSIGNING YOUR NEW EDITS ON AN INSURANCE CARRIER
Once you created and customized your own rule sets, they need to be assigned to the insurance carriers
inside Revenue Management to take effect. This is done from the Assign Edits window.
Click Configure -> Insurance -> Assign Edits.
Locate the insurance carrier(s) in the grid that you want to assign your new edit rule set to. Scroll to
the User Edits column on the far right and put a checkmark in the checkbox. This will enable user
edits for this particular insurance carrier.
Find the Rule Set column and click in the cell to get a drop-down list with all of the rule sets currently
available in Revenue Management including the one you just created.
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Select the new rule set you just created and it will now become assigned to the insurance carrier. Click
Save to save your changes.
The next time you go to check claims in Revenue Management for errors, your claims for these
insurance carriers will also be checked against your customized edits. This is a good way to catch billing
mistakes or data entry problems specific to your company or practice that cause unnecessary rejections
or denials and to reduce the amount of time it takes to receive payment.