LIFE OF A CLAIM PRESENTED BY: JANE PLANT, NANCY FEE & PATTY LAVIGNE

LIFE OF A CLAIM

PRESENTED BY: JANE PLANT, NANCY FEE & PATTY LAVIGNE

P R E S E N TAT I O N OV E RV I E W

• HCFA and UB changes released in 4.11.00

including ICD9/ICD10

• Upcoming Out of Pocket and Deductible changes

4.11.00 and 4.11.01

• Claim flow and Adjudication Control Rules

• Episode Records what else can they be used

for?

HCFA/UB CHANGES

H C FA : C H A N G E S

page 4 • Confidential

F I E L D 1 9 - A D D I T I O N I N F O R M AT I O N - LO C AT I O N

Located on Page 1 of the HCFA form

• Also gives advice on how to work certain exceptions

page 5 • Confidential

F I E LD 1 9 - P U R P O S E

• HCFA field 19 was previously a reserved field but is available now for Additional Claim information that can be required by payers. NUCC has defined a list of qualifiers that are used in the 5010A1 format.

• The information is written into the RPC_ADDCLINFO field the qualifier code and the identifier are joined into one entry.

• The information populated in this field will be populated within the 837 5010 outbound transaction.

TA B L E S A N D C O DE S

• THE NEW 302 TABLE WITHIN THE TABLE OF CONTENTS

CONTAINS THE AVAILABLE QUALIFIERS.

page 7 • Confidential

F I E L D - 2 1 – D I A G V E R S I O N A N D A D D I T I O N A L I C D C O D E S - LO C AT I O N

F I E LD - 2 1 - P U R P O S E

• HCFA field 21 is for diagnosis code entry and

previously allowed for four diagnosis codes to be

entered. This has now been expanded to allow for up

to twelve diagnosis code entries. A new field was

added to handle the ICD version indicator.

F I E LD 2 1

• Logic added to the form equals if ICD Version

indicator is populated the code is assumed to be that

version, if ICD Version is blank the version will be

determined by the code.

• ICD9 and ICD10 mixing on a claim is not allowed.

• ICD Version indicator can be found in the RPC_67A

and in 4.11.01 it will be added to the claim record in

a new field CLM_ICDV.

F I E L D - 2 2 R E S U B M I SS I O N C O D E A N D O R I G I N A L R E F E R E N C E N U M B E R - LO C AT I O N

F I E LD 2 2 - P U R P O S E

• Resubmission Code will be an optional field and will allow for a one byte numeric code of either “7” or “8”

• The value entered will be written to the RPC_ADJAC field.

• If the value is equal to 7 the HI ADJ exception

will be triggered.

• If the value is equal to 8 the HI VOD exception

will be triggered.

F I E LD 2 2 - P U R P O S E

• Original REF No. will be an optional field and will allow for up to 18 alpha numeric codes.

• A new RPC field was created to store this information – RPC_REFNR.

F I E L D - 2 3 E - D I AG N O S I S P O I N T E R

• Page 2 of the HCFA form is now for service line.

• Location has not changed however -

• Diagnosis pointers have been changed from numeric values to alpha values A-L.

• If numeric is entered the system will switch to Alpha.

F I E L D - 2 4 G - DAY S / U N I T

• Location has not changed however -

• The existing Days/Units field has been expanded to accept up to 7 bytes as required by the NUCC.

S E RV I C E L I N E S C R E E N

UB -CHANGES

• Only the UB04 form has been changed!

• Field 66 – ICD Version Indicator

• Follows the same logic as the HCFA Form.

• Field 46 – Units

• Has been expanded to now accept up to 7 bytes

4.11.01OUT OF POCKET AND DEDUCTIBLE CHANGES

P LA N B U I LD I N G - S C H E DU L E S -P LA N DE TA I L S - C H A N G E S

• New Combine Out of Pocket With field modeled off the current Combine Deductible with field.

P L A N B U I L D I N G – B A S I C P L A N – O U T O F P O C K E T C A L C U L AT I O N - C H A N G E

• Upon entering this area you will be presented with a new selection.

• You will have the ability to set one calculation method or many.

• You will be required to build at least the default.

• Once built you will be able to see all the calculation methods used for each schedule on one screen.

C H A N G E F O R F U L L A M O U N T O F D E D U C T I B L E F R O M T H E A C C U M U L AT O R S A C R O SS P R O D U C T S .

• When the Deductible amount for the service line is

calculated if the combined deductible flag is set for

multiple products the deductible accumulators will

be read for all products indicated.

• The amount read from the accumulators will be

written into the new field on the claim record

“Accumulator DED”.

• Clients can request changes to EOB’s to use this new

field to show combined deductibles.

N E W C O PAY M E N T S – C H A N G E F O R O U T O F P O C K E T

• Changes to New Copayment Only.

• Both the Standard and Exception Copayment area a new field will be added – Suppress Copayment from Out of Pocket.

• Options will be Y or N

H O W D O E S I T W O R K ?

• If Suppress Copayment from OOP flag is set to Y and

Out of Pocket Calculation Method indicates

Copayment as part of the Out of Pocket.

• Copayment will not be added to the Out of

Pocket

• If Suppress Copayment from OOP flag is set to Y and

Out of Pocket Calculation Method indicates

Copayment is not part of the Out of Pocket.

• Copayment will not be added to the Out of

Pocket

• If Suppress Copayment from OOP flag is set to N and

Out of Pocket Calculation Method indicates

Copayment as part of the Out of Pocket.

• Copayment will be added to the Out of

Pocket

• If Suppress Copayment from OOP flag is set to N and

Out of Pocket Calculation Method indicates

Copayment is not part of the Out of Pocket.

• Copayment will not be added to the Out of

Pocket

N E W C O PAY M E N T S – C H A N G E F O R DE DU C T I B L E

• Changes to New Copayment Only.

• The Standard Copayment area has two new fields:

• Apply to Deductible

• Continue Taking Copayment After Deductible Met

• Options will be Y or N

S C R E E N C H A N G E

H O W DO E S I T W O R K ?

• Apply to Deductible• If equal to Y the amount the copayment will show

on the claim as deductible and the amount will be

written to the appropriate Deductible based on

plan setup.

• If equal to N the copayment will show as a

copayment and does not write to the deductible

bucket.

• Continue Taking Copayment after Deductible Met• If equal to Y the copayment when taken will show

on the claim as a copayment and the amount will

not be written to the deductible bucket.

• If equal to N the copayment will not be taken on

the claim.

CLAIM FLOW

ADJUDICATION CONTROL RULES

• Adjudication Logic – The Adjudication Logic which is stored

on the Adjudication Control Rules is actually read at the

time the logic is applied..

• Patient Not Eligible – Compares claim earliest date of

service to the patient eligibility. If patient is terminated or

not active at the earliest date of service rule applies.

• Question in Exceptions – Questions are only allowed at the

Benefit Exception and the application will always pend to

allow a user response.

• Unable to Find Occurrence - Occurrence benefits can be on

either a DGN or Benefit Exception and again the system

will always pend for user intervention.

• Pend if COB Flag Set – If the COB flag on the patients

eligibility record is set to Y the rule will apply.

• Group Not Paid Up to Date - If the COB flag on the patients

eligibility record is set to Y this rule will apply.

• When Claim/Accum Locked - If for example two examiners

are attempting to update the same accumulator at the

same time the claim will pend. Once the claim is unpended

all benefit limits will recalculate and the accumulators will

be updated.

• Hold When Payment Exceeds – Designed to control the

ability to review claims that exceed a specific gross

payment amount. Claim is compared to dollar limit on the

user and dollar limit in the control rules and the lessor

amount wins.

• Other Insurance Plan – If set on the HCFA template it will

be read but it is not set at 837.

• Condition of Employment – Reads the flag Employment on

the HCFA template.

• Related to Auto Accident – Reads the flag Auto Accident o

the HCFA template.

• Related to Other Accident – Reads the flag Other Accident

on the HCFA template.

• Set by 837 – Loop 2300>Segment CLM>Position 11-1,11-2, or 11-3> AA

equal Auto Accident, OA equal Other Accident and EM equals

Employment. The state for the Auto Accident is 11-4.

• Enable Capitation – If set allows the plan to apply Managed

Care Capitation.

• Add Encountered to Accums – If set the encountered value

from the claim will write to the accumulators.

• Change in Elig Since –Compares patient's eligibility to each

service line of the claim. Applies when there are spanned

dates of service on the claim and a change in eligibility

status.

• Pre-Authorization –Pertains to only Dental Pre-D claims so

it is only read on Dental Template Claims. * Upcoming

change Pre-D claims will apply eligibility denials before

determining benefits*

• Pend EDI Attachment – Will allow claims to pend when the

837 PWK segment indicates an attachment.

• Allow Zero Charge Claim –If yes the system accepts zero as

a valid charge on claims. If no the system will create a BD

ZRO exception when a claim has zero charge if keyed or

edi.

• Adjustment Claim –All adjusted claims pend during claims

processing.

• Enable Provider Withholds –If Yes, applies the provider

withhold , a contractual amount withheld from provider's

payment that should not be billed to the patient . If No,

does not apply a withhold from the claim, even if the

provider is set to apply a withhold.

•

• Deductible Carryover - Only active if the plan has a carry

over deductible provision. If three conditions are met, the

claim applies the selected action, though pend is

recommended.

• Claim is for the prior plan year

• Charges would have applied to the carry over deductible

• Deductible for the next year has already been satisfied

• Example -The plan year is the calendar year, set for three month

carry over on the benefit schedule. The individual deductible of

$100 has been satisfied for 2013. A claim for November 2012

which would have applied to the 2012 deductible and would have

carried over and applied 2013 deductible. ECI recommends

pending this claim for review.

• EXT Pricing on COB Claim -If COB flag in

employee/dependent coverage is set to Yes, and this

option is No, the claim is placed in exception status with

the code PTCOB before adjudication. This is done by

checking for COB in the eligibility record during pricing.

You can create a workflow rule to route claims with PTCOB

to a user defined queue.

• If COB flag is set to No in patient's eligibility, and this

option is also No, the system functions as usual.

• If this option is set to Yes, the system functions as usual

D E N I A L S T H AT D O N ’ T S H O W D I S C O U N T• Age edits

• Patient not Eligible

• Other Ins Plan

• Condition of Employment

• Related to Auto Accident

• Related to Other Accident

• Dup Checking Denial

• PreCert Denial

EPISODE RECORDS

LO G I C A N D E P I S O D E R E C O R D S - P R E - C E RT

• In adjudication logic when you are looking for Pre-Cert any episode that has CM, UR, PC, PA or WC in the Case Type Field will be read.

LO G I C A N D E P I S O D E R E C O R D S - R E F E R R A L

• In adjudication logic when you are looking for Referral the Case Type Field must have RF.

U S I N G E P I S O D E S F O R N E G O T I AT E D P R I C I N G

• Patient needs a wheelchair and there are no In Network DME providers available in his area. I was able to negotiate a price on the wheel chair he needs.

Once Complete select Pricing

Set the Action as Exceed Except

I F T H E P R O V I D E R B I L L S F U L L C H A R G E S

• Claim applies the exceed except rule because the full

charge was billed.

S E RV I C E L I N E

• Shows the difference in U&C due to claim being Penalty

M O D I F I C AT I O N M AY B E R E Q U I R E D F O R S E R V I C E L I N E

• You may be required to correct the placement of the disallowed if you want this to show as not patient responsibility.

• If the provider bills the negotiated amount this will not be an issue.

TA K I N G A P E R C E N T D I S C O U N T U S I N G E P I S O D E R E C O R D

• Patient needs an out of network MRI that I was able to get the provider to agree to a Discount if it is paid as In Network.

Set to

Force

Network that will be

used

Negotiated Price

Pricing set to pay by

Episode

U S I N G E P I S O D E S

• Episodes can be used to control unit limitations within your benefit plan requirements.

U S I N G E P I S O D E S T O C O N T R O L U N I T L I M I T S

Any Questions?