P-Plan Workbook 1 16 15 - Home Realm Discovery Assignment Common Terms: FSC ... Mnemonic = NCP Commercial Non-Contracted PPO FSC/Plan = 348/P348 Mnemonic = NPP Non-Contracted Exchange/Marketplace

*Insurance plan contracts are subject to change. Refer to FSC Wizard for current FSC/plan information. 1

P-Plan Assignment

Common Terms:

FSC (Financial Status Classification) - Name, number, or mnemonic code assigned to billing/insurance information at the registration (account) level.

Plan - Name, number, or mnemonic code assigned to billing/insurance information at the visit level.

FSC Wizard http://fppfscwizard.wusm.wustl.edu/ - Online tool from Patient Financial Services that provides the following:

Tools to assist in the selection of appropriate FSCs and plans Contracted payor specific information

o Referrals o Pre-certifications o Laboratory information

References guides Claim filing deadlines Quick Links to helpful websites

Marketplace/Exchange Programs - The Health Insurance Marketplace or “Exchange” offers standardized health insurance plans to individuals, families, and small businesses. The Health Insurance Marketplace was established as part of the Patient Protection and Affordable Care Act.

Marketplace Assistant https://train2web.wustl.edu/marketplace - Online tool to be used in combination with the FSC Wizard to identify Marketplace/Exchange products

Managed Care Plans – Type of health insurance that have contracts with healthcare providers and medical facilities to provide care for members at reduced costs. These providers make up the plans network.

Third Party Administrator (TPA) – Organization that processes claims and performs other administrative services in accordance with an insurance plan.


Priority

Individual and Spouse Priority Guidelines

If the patient is covered through his/her own plan and is also covered by his/her spouse’s family plan

The patient’s insurance is primary. The spouse’s insurance is secondary.

Note: Excludes Medicare eligibility, based on age and employment.

Dependent Child Priority Guidelines

If a dependent child is covered by both parents’ insurance plans, the Birthday Rule is used to determine priority. The Birthday Rule is defined as the parent whose birthday comes first in a calendar year. If the father’s birthday is June 26 and the mother’s birthday December 3, the father’s insurance is primary. Note: Some insurance companies may use the Gender Rule if both parents have the same birth date (month and day only). The Gender Rule states that the father’s insurance would be billed primary.


Example:

Francois is insured with Healthlink PPO through his employer. He is also insured with his spouse’s Unicare PPO plan.

Priority 1 = _________________

Priority 2 = _________________

Example:

Little Johnnie is insured by both mom’s and dad’s insurance. Mom carries Humana Choice Care HMO through her employer and dad carries Coventry ASO through his employer.

Mom’s birthday is March 1. Dad’s birthday is January 8.

Priority 1 = _________________

Priority 2 = _________________


Assignment Tool Address

FPP Education http://fppeducation.wustl.edu

Marketplace Assistant https://train2web.wustl.edu/marketplace

FSC Wizard http://fppfscwizard.wusm.wustl.edu

Black Font = _______________________________________________________

Blue Font = __________________________________________________________________

Green Font = _________________________________________________________________


Let’s Assign Contracted Plans (1) ________ *

(2) ________ *


(3) ________ *

NOTES: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Example:

Marla is insured with Aetna PPO through her employer and also has Aetna PPO through her husband’s employer.

Priority 1 = _________________

Priority 2 = _________________

Example:

Bertha is insured with Cigna HMO through her employer and has coverage through her husband’s Cigna Open Access plan.

Priority 1 = _________________

Priority 2 = _________________


What is Commercial?

Commercial – Insurance plans with which we do not have contracts

Managed Care plans with which we are not contracted :

Commercial Non-Contracted HMO

FSC/Plan = 945/P945 Mnemonic = NCH

Commercial Non-Contracted POS

FSC/Plan = 545/P545 Mnemonic = NCP

Commercial Non-Contracted PPO

FSC/Plan = 348/P348 Mnemonic = NPP

Non-Contracted Exchange/Marketplace

FSC/Plan = 317/P317 Mnemonic = NCE

Insurance plans that do NOT sign contracts (Examples: indemnity plans and Medicare supplement plans):

Commercial Insurance

FSC/Plan = 48/P48 Mnemonic = COM


Additional Commercial Insurance FSC/Plans :

Commercial Second

FSC/Plan = 51/P51 Mnemonic = CS

If the patient has two non-contracted plans assign Commercial Second to identify the second commercial insurance plan.

Commercial Third

FSC/Plan = 52/P52 Mnemonic = CTA

If the patient has three non-contracted plans assign Commercial Third to identify the third commercial insurance plan. Commercial Fourth

FSC/Plan = 170/P170 Mnemonic = COF

If the patient has four non-contracted plans assign Commercial Fourth to identify the fourth commercial insurance plan.

Note: See examples (next page)


Let’s Assign Non-Contracted Plans (1) ________ *

(2) ________ *


(3) ________ *

NOTES: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Example:

Marcus is insured with UHC Choice Plus through his employer. He is also covered under supplemental policies: Reliable Life as secondary, Prudential as third (tertiary), and Physicians Mutual as his fourth plan.

Priority 1 = _________________

Priority 2 = _________________

Priority 3 = _________________

Priority 4 = _________________

Example:

Jayla is insured with New York Provider HMO as primary and Illinois’ Best PPO as secondary.

Priority 1 = _________________

Priority 2 = _________________


What are Complementary Networks (Wrap Around Plans)?

Complementary Networks – Complementary networks allow patients to see a provider who is not contracted with their insurance plan, if the provider is contracted with the complementary network. If we are NOT contracted with an a patient’s insurance plan, but the insurance card indicates a complementary network we are contracted with, we will assign the patient’s insurance using the complementary network.

Examples of Complementary Networks / Wrap Around Plan logos:

Complementary Network

Insurance Plan


Let’s Assign Plans that include complementary networks

(1) ________ *

(2) ________ *


Medicare

Medicare Part A

Hospital, Skilled Nurse Facility, Home Health, and Hospice Care In most cases, no monthy plan premium Patients are enrolled when age or disability requirements are met

Medicare Part B

Physician Charges, Durable Medical Equipment, and Ambulance Services Monthy plan premium Patients can purchase when age or disability requirements are met

Medicare Managed Care Plan

Monthy plan premium Plan offered by a private company that contracts with Medicare to provide Part A and Part B benefits

Medicare Supplement Plan (Medigap)

Monthy plan premium Plan offered by a private company that helps to pay some of the out-of-pocket expenses not covered by Medicare


Medicare Priority Over Age 65 Guidelines

If a Medicare patient is over the age of 65, is employed, and is covered by their employer’s health insurance: OR If a Medicare patient is over the age of 65 and is covered by their spouse’s employer’s health insurance: If the employer has fewer than 20 employees

o Medicare is primary o Employer group insurance is secondary

If the employer has 20 or more employees

o Employer group insurance is primary o Medicare is secondary

Disability Guidelines

If a patient has Medicare due to a disability, is employed, and covered under the employer’s health insurance: OR If a patient has Medicare due to a disability and is covered by their spouse’s employer’s health insurance:

If employer has less than 100 employees

o Medicare is primary o Employer group insurance is secondary

If the employer has 100 or more employees

o Employer insurance is primary o Medicare is secondary


Medicare Assignment

Medicare Part A Only

As primary payor:

FSC/Plan = 481/P481 Mnemonic = MPA

As secondary payor:

FSC/Plan = 176/P176 Mnemonic = PAS

Medicare Part A & B (or Part B Only)

As primary payor:

FSC/Plan = 81/P81 Mnemonic = MPB

As secondary payor:

FSC/Plan = 969/P969 Mnemonic = MSE


Let’s Assign Medicare Plans

(1) If Primary ________ If Secondary ________ *

(2) If Primary ________ *


(3) ________*

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


Example:

Doris is 65, retired, and has Medicare Part A (she does not have Part B). Doris’ husband is employed and carries family coverage through Welborn Health Plan POS. The employer has 22 employees.

Priority 1 = _________________

Priority 2 = _________________

Example:

Leroy is insured with Medicare Part A & B. He also purchased an AARP supplemental policy.

Priority 1 = _________________

Priority 2 = _________________


Medicaid

Medicaid is a health care program that helps pay medical costs for people with limited incomes and resources. Medicaid is jointly funded by federal and state governments and administered by state governments. Medicaid benefits cover a range of both inpatient and outpatient services. Patients can receive Medicaid benefits through the state Medicaid plan or through a Medicaid Managed Care (MC+) plan.

Missouri Medicaid – MO Healthnet

FSC/Plan = 101/P101 Mnemonic = MCD

Illinois Medicaid – Illinois Public Aid (IDPA)

FSC/Plan = 105/P105 Mnemonic = IPA

Medicaid Managed Care Plans (MC+ Plans)

Plan offered by a private company that contracts with Medicaid to provide Medicaid benefits Not all MC+ plans are contracted

Medicaid Priority Medicaid will always be billed last (lowest priority) if the patient is covered under any other insurance plan. Medicaid is the payor of last resort.


Let’s Assign Medicaid Plans

(1) ________ *

(2) ________ *


(3) ________ *


(4) ________ *


Example:

Sophia is 10 years old. She is covered under her dad’s HealthLink Open Access plan , her mom’s Cigna HMO plan, and she is also covered under Illinois Public Aid.

Mom’s birthday is June 12. Dad’s birthday is November 2.

Priority 1 = _________________ Priority 2 = _________________

Priority 3 = _________________

Example:

Max is insured with Medicare Part A & B. He is also insured with MO Healthnet (Missouri Medicaid).

Priority 1 = _________________

Priority 2 = _________________


Registration Form

Legal Name: (Your Last Name)____ Sylvester___________ Cat

Last Name First Name Middle Name Other names you prefer to go by:

Social Security Number: Prefer not to give out

Date of Birth: 07/15/47 Gender: (Circle) Male / Female

Address: 1909 Locust Ave St Louis, MO 63144 Primary Phone: (314) 555-1245 Landline Alt Phone: (314) 555-8265 Cell Street City/State Zip code (Area Code) Number (Area Code) Number

E-mail: [email protected]

Guarantor (Responsible Party): __ Self

Guarantor Address (if different from patient): Phone: Street City/State Zip code

Primary Care Physician: James Avery Physician Phone: (314) 555-4466

(Area Code) Number

Do you have any special needs when you arrive for your appointment? Yes / No If so, specify: __N/A__________________________________

Employment Status (circle):

Active Military / Employed Full Time / Employed Part Time / Self Employed / Student / Retired / Not Employed

Employer: ABC Company Employer Address: 123 Maple Ave Brentwood, MO 63144 Street City/State Zip code

Employer Phone: (314) 555-1245 Ext: none (Area Code) Number

Marital Status: (circle): Single Married Widowed Separated Divorced


Sylvester’s Appointment Information

Appointment Reason: Headaches

Provider: Train MD,Charles

Sylvester is a NEW patient.

(This is not Special Billing)

Comments: Patient has had headaches for 1 week Referring Physician: James Avery, MD Caller: Sylvester (Your Last Name) Caller Phone: 314-555-8265


Sylvester’s Insurance Cards


Dictionary 120 Lock-Down

Claims can be submitted as: Electronic Claims Paper Claims

When FSC/Plans are assigned, the GE system often knows the electronic and paper claims submission address. For other FSC/plans, there are multiple addresses to which a claim might be sent. If there is more than one claims address for a FSC/plan, the follow-up questions will include a Dictionary 120 selection field that offers options appropriate for that FSC/plan. If you receive the Dictionary 120 field, you must click the magnifying glass and make a selection from the Dictionary 120 lock-down. If you do not, the claims for the patient will be stopped. After making this selection, the paper mailing address may need to be entered manually, may appear by default, or you may be provided with the Payor Address Dictionary field.


Payor Address Dictionary

If you receive the Payor Address Dictionary field, click the magnifying glass and select the appropriate claims mailing address P.O. Box.

The P.O. Box, City, State, and zipcode will be added based on your selection.


Insurances with a 120 Lock-Down



Removing

Terminated Plans


Patient with Terminated Insurance Plan

When a patient reports an insurance plan is no longer active, terminate and delete the inactive plan and add the new plan.

Steps to terminate a visit plan

1. Edit Plan Follow up questions 2. Enter plan termination date 3. Delete plan 4. Add new plan


Changing Incorrectly Assigned

Plans


Changing an Incorrectly Assigned Insurance Plan

If the wrong insurance plan has been assigned to a visit, you follow these steps to permantly remove the plan from the account.


1. Edit Plan Follow up questions 2. Enter T for effective date 3. Enter T for termination date 4. Delete plan 5. Add correct plan


Changing Plan Priority

(Moving Plans)


Moving Insurance Plans To change the priority order of plans on a visit use Action Code M - Move Plan.


1. Select M- Move Plan 2. Enter priority number of plan 3. Enter priority plan should be moved to 4. Click OK to view new priority


Copy Plan Follow-ups from G-Plan to P-Plan


Copying Plan Follow-ups from G-Plan to P-Plan Copying Plan Follow-ups – G-Plans need to be changed to P-Plans prior to the patient’s appointment. Using enables you to retain the follow-up question information and copy it to the P-Plan.

Steps used to change a G-Plan to a P-Plan:

1. Highlight the G-Plan to be changed. 2. Select A-Add Plans

3. Select 2-Copy Plan Follow-ups

4. Enter the appropriate P-Plan

5. Click Yes to delete G-Plan and copy to P-Plan

6. Verify all P-Plan follow-ups are completed



Understanding

Self Pay


Self Pay vs Patient Responsible vs Auto-Assigned Self Pay

Auto-Assigned Self Pay (Z99)

Patient Self Pay (PSP/976) Patient Responsible for Payment (PRP/139) Self Pay After Insurance (SPI)


Example:

William does not have insurance coverage.

Priority 1 = _________________

Example:

Lucille is insured with Medicare Part A. She does not have Part B or any other insurance coverage.

Priority 1 = _________________

Priority 2 = _________________

Example:

Roxanne has insurance coverage, but has asked that we do not bill this visit to her insurance plan.

Priority 1 = _________________

NOTES: _____________________________________________________________________________________________________________________________________________________________________________________________


Special Billing


Special Billing

Special Billing – Marking a visit as special billing indicates a situation in which the charges will be sent to a payor other than the payor listed in the patient’s account.

Special Billing situations include:

Worker’s Compensation Automobile Accidents Carve-out plans (Mental Health and Vision Claims) Patient Responsible for Payment

Special Billing can be assigned at the time of scheduling.


If special billing needs to be corrected, use the following steps:

1. At enter XV to access the visit.

2. Click to continue. The Edit Visit screen displays.

Example: Edit Visit Screen


3. At , select Work Comp.

4. At , enter the date of injury (if applicable).

5. At , select Work.

Example: Edit Visit Screen


6. Click

The Manage Transfers Screen displays.

Example: Manage Transfers Screen

7. Click and select to correct the Visit Type.


Example: Transfer Visit Type -- Fix -- Screen

8. Correct the Visit Type. Enter OSB (Outpatient Special Billing) at the field.

9. Click to return to the Manage Transfers Screen.


10. Click to go to the Visit Insurance Plan Screen.

Example: Visit Insurance Plan Screen

The Visit Insurance Plan screen displays with the incorrect visit plan(s). The plan(s) needs to be removed and the correct plan(s) added.

11. Click on to delete all existing plans and re-invoke Plan Simplification to update the visit.


The Special Billing Plan Follow-up questions display.

Example: Visit Level Insurance – Insurance Fields and Values Screen

12. Complete the plan follow-up questions.

13. Click to continue.


The Visit Insurance Plan Screen displays with the new Special Billing plan assigned (Workers’ Compensation). Example: Visit Insurance Plan Screen

14. Click to file.

*Insurance plan contracts are subject to change. Refer to FSC Wizard for current FSC/plan information.

P-Plan Assignment - Check Your Knowledge

1. What are three Special Billing situations?

a)

b)

c)

2. What is the web address to the FSC Wizard?

3. What is the web address to the Marketplace Assistant?

4. Walter is employed at ABC Company. He is insured with the employer’s group coverage

through United Healthcare Choice Plus and also has coverage through Medicare Part B. In order to correctly assign insurance priority, what critical piece of information do you need?

____________________________________________________________________

____________________________________________________________________


5. A patient presents the insurance card displayed below:

a) Who is the Third Party Administrator (TPA) for this plan? What is the TPA phone number?

6. While completing the insurance plan follow up questions, you see the following fields:

a) What should you do at the Ins. Co Dictionary Entry: prompt?

____________________________________________________________________

b) Why is this important?

____________________________________________________________________

____________________________________________________________________


7. You are scheduling an appointment for Suzie, who is a dependent child. She has insurance coverage through both parents. Mom carries Aetna HMO and dad carries CIGNA PPO. In order to correctly assign insurance priority, what critical piece of information do you need?

8. If you add a visit insurance plan in error, what steps must be taken to correct?

9. If you delete a visit insurance plan without an appropriate termination date, what happens to the deleted plan?


10. Define the following:

a) Patient Self Pay (PSP/P976)

b) Patient Responsible for Payment (PRP/P139)

c) Z99 Auto Assigned Self Pay


11. You are completing the Insurance Plan follow-up questions for a patient’s commercial plan, ZEPAR MUTUAL. After making the 120 selection, Commercial Ins defaulted into the Insurance Co. Name Override field.

What should you do? ___________________________________________________

12. A patient has Medicare Part A Only and no other insurance. Which of the following statements is correct?

a) Assign Medicare Part A Only (481/MPA) primary & Patient Self Pay (976/PSP) as secondary.

b) Assign Patient Self Pay (976/PSP)

c) Assign Patient Self Pay (976/PSP) primary & Medicare Part A Only (481/MPA) as secondary.

d) None of the above.


13. What does each color font mean on the FSC Wizard?

a) Black

_______________________________________________________________________

_______________________________________________________________________

b) Green

_______________________________________________________________________

_______________________________________________________________________

c) Blue

_______________________________________________________________________

_______________________________________________________________________


14. Identify the appropriate Plan Number or Mnemonic.

I. _______________

II. _______________

III. _______________


IV. _______________

V. _______________

VI. _______________


Identify the appropriate Plan Number or Mnemonic.

15. Ruth is insured with Medicare Part A & B. She is also covered under AARP Medicare Supplemental coverage.


16. Herbert is insured with Medicare Part A Only. He is also covered under Healthlink PPO as secondary.


17. Cheryl is insured with Health Smart - NPPN as primary and Humana HMO Premier as secondary.

Priority 1 = _________________

Priority 2 = _________________

18. Emma is a dependent child who is covered under both mom and dad’s insurance. Mom has Aetna PPO and dad has Cigna HMO. In addition, Emma is covered under MO Healthnet.

Mom’s birthday is June 14

Dad’s birthday is April 22

Priority 1 = _________________

Priority 2 = _________________

Priority 3 = _________________

Documents

P-Plan Workbook 1 16 15 - Home Realm Discovery Assignment Common Terms: FSC ... Mnemonic = NCP Commercial Non-Contracted PPO FSC/Plan = 348/P348 Mnemonic = NPP Non-Contracted Exchange/Marketplace