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Anatomy of a ClaimDiagnosing and Treating
The Curable Disease of Non - Payment
Understanding the Basics of EDI
Annela Petrisca
Agenda
• Welcome• Rejections, Rejections, Rejections• Visit Anatomy 101• Show Me the Money!• Cleaning Up• Question and Answer• Stump the Presenter
Rejections - Symptoms
• Rejected claims are usually a result of setup, enrollment or patient eligibility– Setup is the number one Symptoms in claims not
batching correctly or being sent out correctly. Ultimately not being paid at all or correctly!
– Enrollment at company or provider level is a big player in claims not being paid
– Eligibility is the next contributor to claims not being paid
• Rejections can be reduced, time can be saved and money can be made!
Rejections - Manifestation
• Common Batching Rejections– Output Revenue Code is missing– CLIA number is missing– NDC Unit of Measure is missing– Patient Relationship ANSI code is missing– Other payer ID is missing– Procedure Code Qualifier is missing
• Common Clearinghouse Rejections– Entity is not enrolled: billing or subscriber– Claim is out of balance– Payer Paid Amount missing/invalid
Anatomy 101
• Where are the components of my visit coming from?
• How do I make the right changes?• What is my visit supposed to look like?• Can I leverage other departments to
help reduce rejections?
Anatomy 101
Visit Info Tab
• Company• Rendering Provider• Facility• Insurance Carrier• Allocation Set• Financial Class• Benefit Assignment• Filing Method
Anatomy 101
Visit Info
• Company• Rendering Provider• Facility• Insurance Carrier• Allocation Set• Financial Class• Benefit Assignment• Filing Method
Errors
• Missing/Invalid NPI• Missing/Invalid Billing
Taxonomy Code• Results
– NPI – claim will batch and reject at clearinghouse
– Taxonomy Code – claim will batch and reject at the payer or clearinghouse
Anatomy 101
• Company - Treatment– Review Company Information and
Identification Tab to correct/enter NPI
Anatomy 101
• Company Taxonomy - Treatment– Review Company Identification Tab to
correct/enter Taxonomy
• Missing Provider Row• Invalid Taxonomy• Invalid Provider NPI• Results
– Provider ID: Unable to Batch Claim
– Invalid IDs/Taxonomy: Clearinghouse/Payer Rejection
Anatomy 101
Visit Info
• Company• Rendering Provider• Facility• Insurance Carrier• Allocation Set• Financial Class• Benefit Assignment• Filing Method
Errors
Anatomy 101
• Rendering Provider - Manifestation– Missing/Invalid Provider ID Row/Enrollment Rejections– Invalid Provider Taxonomy
Anatomy 101• Rendering Provider - Symptoms
– Review Provider Information and Identification to correct/enter NPI• CPS 12: Administration – Providers and Resources• CPS 11: Administration – Edit Responsible Providers
– Review Provider Information for correct Specialty• Correct Specialty: Administration – List Editor/System/User and Resource/Users
Anatomy 101
• Rendering Provider - Treatment– Review Provider Information and Identification to correct/enter
NPI– Review Provider Information for correct Specialty
• Missing Place of Service
• Missing/Invalid CLIA Number– Company Level– Single CLIA Number for
whole organization Missing Type of Bill
• Result – Unable to Batch Claims
Anatomy 101
Visit Info
• Company• Rendering Provider• Facility• Insurance Carrier• Allocation Set• Financial Class• Benefit Assignment• Filing Method
Errors
Anatomy 101
• Facility - Manifestation– Missing/Invalid Place of Service– Missing Type of Bill– Missing Facility Type ID
Anatomy 101
• Facility - Symptoms– Review Facility Information and Identification
to correct/enter NPI
• Missing Payer ID• Missing Other Payer ID• Missing Carrier Type• Result – Unable to
Batch Claims
Anatomy 101
Visit Info
• Company• Rendering Provider• Facility• Insurance Carrier• Allocation Set• Financial Class• Benefit Assignment• Filing Method
Errors
Anatomy 101
• Insurance Carrier - Manifestation– Payer ID is Missing– Other Payer Primary ID is Missing– Carrier Type is Missing
Anatomy 101
• Insurance Carrier - Symptoms– Insurance Carrier EDI Tab– Insurance Carrier Identification Tab– Insurance Carrier Information Tab
Anatomy 101
• Insurance Carrier - Treatment– Correct Insurance Carrier EDI Tab– Correct Insurance Carrier Identification Tab– Correct Insurance Carrier Information Tab
• Missing Allocation Set• Result - Unable to
Batch
Anatomy 101
Visit Info
• Company• Rendering Provider• Facility• Insurance Carrier• Allocation Set• Financial Class• Benefit Assignment• Filing Method
Errors
Anatomy 101
• Allocation Set- Symptoms– Missing Allocation Set Patient Profile– Missing Allocation Set Insurance Carrier– Missing Allocation Set Visit Info Tab
Anatomy 101
• Allocation Set- Treatment– Review and Correct Visit Info Tab– Review Patient Information Insurance Tab– Review Insurance Carrier
• Missing Financial Class
• Result – Unable to Batch
Anatomy 101
Visit Info
• Company• Rendering Provider• Facility• Insurance Carrier• Allocation Set• Financial Class• Benefit Assignment• Filing Method
Errors
Anatomy 101
• Financial Class - Symptoms– Review Visit Info Tab– Review Insurance Carrier Information– Review Patient Information
Anatomy 101
• Financial Class - Treatment– Review and Correct Visit Info Tab– Review and Correct Insurance Carrier– Review and Correct Patient Information
• Missing Benefit Assignment
• Result – Unable to Batch
Anatomy 101
Visit Info
• Company• Rendering Provider• Facility• Insurance Carrier• Allocation Set• Financial Class• Benefit Assignment• Filing Method
Errors
Anatomy 101
• Benefit Assignment - Treatment– Review and Correct Visit Info Tab– Review and Correct Insurance Information– Review and Correct Patient Information
• Review Internal Policy for Benefit Assignment
• Missing Filing Method• Result
– Cannot Approve – Adjustment will not happen
– Cannot Batch Claims
Anatomy 101
Visit Info
• Company• Rendering Provider• Facility• Insurance Carrier• Allocation Set• Financial Class• Benefit Assignment• Filing Method
Errors
Anatomy 101
• Filing Method - Manifestation– Either No Plugin or Clearinghouse is Inactive for this this
ticket– Cannot Allocate Money to Insurance Carrier
Anatomy 101
• Filing Method - Treatment– Review and Correct Visit Info Tab
• Click Drop Down• Click Set Carrier
– Review and Correct Insurance Carrier
• Fee Schedule• Cases• Charges• Missing Diagnosis Pointer• Results
– Fee Schedule: Charges are incorrect, missing encounter type
– Cases: Incorrect Carrier, Incorrect Fee Schedule
– Charges: Incorrect Fees, missing revenue codes
– Diagnosis: Claim will not approve
Anatomy 101
Charges
• Fee Schedule• Cases• Charges• Diagnosis
Errors
• Incorrect Charges• Incorrect/Missing
Encounter Codes• Missing Revenue
Codes
Anatomy 101
Charges
• Fee Schedule• Cases• Diagnosis• Charges
Anatomy 101
• Fee Schedule - Manifestation– Missing encounter code– Incorrect Fees– Missing adjustments– Missing/Incorrect Revenue Codes
• Incorrect Carrier for Visit Type
• Incorrect Fee Schedule• Incorrect Charges• Missing Authorization
Numbers
Anatomy 101
Charges
• Fee Schedule• Cases• Diagnosis• Charges
Errors
Anatomy 101
• Cases - Manifestation– Incorrect Carrier on visit– Incorrect Fee Schedule on visit– Possible Missing Authorizations
Anatomy 101
• Cases - Symptoms– Case not setup
• Patient Registration
– Case not attached to the visit
• Approve Failed Claim• Result: Cannot
Approve Claim
Anatomy 101
Charges
• Fee Schedule• Cases• Diagnosis• Charges
Errors
• Incorrect Charges for Facility
• Incorrect Charge Setup• File Rejected Claims• Results:
– Do I really know what my visit should look like?
Anatomy 101
Charges
• Fee Schedule• Cases• Diagnosis• Charges
Errors
Anatomy 101
• Charges - Symptoms– Incorrect Provider setup– Incorrect Fee schedule / Incorrect Provider setup– Incorrect Fee Schedule setup
Anatomy 101
• One saying, one mantra, one thing to live by:“If Patient Registration isn’t Right; Billing isn’t Right!”
• Correct Administration Setup is just as important!
• It is the day to day entries from supporting departments that is key!
• Missing Check Date• Missing Line
Information• Missing 0.00 Payment• Missing COB
Anatomy 101
Transactions
• Payments• Filing Secondary
Errors
Anatomy 101
• Payment Posting - Treatment– Electronic Payment Posting– Reconciliation– Add Line Info, COB, 0.00 Payments
Anatomy 101• Filing Secondary- Manifestation
– File Rejected Claim from Clearinghouse• Claim is out of balance• Missing COB information• UPLOADED: TOTAL CLAIM CHARGE AMOUNT (60) DOES NOT EQUAL THE SUM (0) OF
OTHER PAYER PAID AMOUNT (0) + ADJUSTMENT AMOUNTS (0) - PRIMARY PAYER
Clean Up!
• EDI Response Management• Miscellaneous files• What can you archive?• May I delete files?
Clean Up!EDI Response Managment
• Miscellaneous files• What can you
archive?• May I delete files?
File Names:
MSGU/MSGD - CEDI
BST/UGSA – ClaimRemedi
RSP – Practice Insight
Remit_.txt
EOB
Type: For Review Only
Clean Up!EDI Response Managment
• Miscellaneous files• What can you
archive?• May I delete files?
Archive Anything!
MSGU/MSGD - CEDI
BST/UGSA – ClaimRemedi
RSP – Practice Insight
Remit_.txt
EOB
For Review Only
Clean Up!EDI Response Managment
• Miscellaneous files• What can you
archive?• May I delete files?
Not in your Best Interest to Delete Anything!
Please Don’t Delete Anything!
It is Not advisable to Delete Anything!