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Billing Cycle

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HOW WE RUN INSURANCE CLAIMS NOW:

Run Insurance Report

This report includes an error report to show if there is any demographic (ie: not dob/sex for pt/insured), and duplicate entries (office visits only).

If insurance has not been verified, verify at this time.

Review each charge and corresponding ICD-9 code to make sure both correlate to chart notes and are an acceptable reimbursable codes. At this time if any modifiers are needed that these are properly in place.

When reviewing lab charges, check to make sure that if Lab Corp. is billing labs for that insurance that the charges are then placed to zero and not included on the claim. Any CLIA waived tests performed in our office are billed on our claim.

If there are any electronic secondary claims, electronically attach the eob with proper codes to show what the contractual obligation and patient obligation is. Any insurance that doesn't accept 2ndary claims electronically will be printed and a copy of the primary ins. pmt attached to the claim. (The only insurances that accept electronic 2ndary claims are BCBS, Medicare and United Healthcare.)

On Medicaid claims white out the provider ID in box's 33B and box 24J the pink portion, leaving only the NPI# as the identifying number.

When all looks correct. then the claims are printed and electronically submitted. The printed claims are mailed.


HOW WE WOULD LIKE TO RUN INSURANCE CLAIMS:

Run claim report.

Send electronic claims. Print and mail paper claims.

MI-SQUARED Adds (will start the merge of this shortly) This flow is based on changes we have added to the Billing Process tool that don't exist in the wild yet, but will very soon now.


Electronic Claims Workflow

  1. Select date that is ‘from last run’ to ‘yesterday’, this is because we run in multi day batches and ‘today’ is not usually complete on the same day
  2. Select Unbilled, with Insurance, Electronic
  3. Review claims for obvious error (adding a filter rule here would be good)
    • Claim with no charges or with made up charge codes is the most usual
    • Claim with Secondary, but no Primary ins is another issue
  4. Select all the good claims
  5. Select GEN X12 button
  6. Download the resulting file
  7. View the resulting log
    • If log has errors go back to ‘Select’ and do it again, then remember to remove the bad batches.
    • Obviously this is backwards, gen x12 should create a temp file and only offer it for download if there are no errors
  8. Mark as Cleared


Paper Claims Workflow

  1. Select dates you used before.
  2. Select Unbilled, with Insurance, Paper
  3. Review claims for obvious error (adding a filter rule here would be good)
    • Claim with no charges or with made up charge codes is the most usual
    • Claim with Secondary, but no Primary ins is another issue
  4. Select all the good claims
  5. Select GEN HCFA button
  6. Download the resulting file
  7. View the resulting log
    • If log has errors go back to ‘Select’ and do it again, then remember to remove the bad batches.
    • Obviously this is backwards, gen HCFA should create a temp file and only offer it for download if there are no errors (and it should be CMS1500 now not HCFA)
  8. Load the forms and do an alignment test (none exists yet) I’ve been printing page one of the PDF. PDF viewer must have scaling turned off or really weird stuff happens.
  9. Print the forms, sort them, address envelopes and mail them


Error Processing (currently Availity Only)

  1. Select to show Errors (no dates)
  2. Look at whatever the errors and try and fix them using the links to “demographics and encounters”
  3. Select the claims to be re-opened as you fix them
  4. Select REOPEN
  5. Goto to the top and do the other two processes as needed


Demand Statement Processing (hypothetical)

  1. Select dates you used before.
  2. Select Unbilled, unselect all insurance related boxes
  3. Review the entries and select them
  4. Select ‘Gen Stmts’ button
    • allow for template format or CSV file
  5. View the resulting log
  6. Download the resulting file
  7. Print or send to accountant
  8. Mark as CLEARED


Electronic Transmission and Response Processing

  1. Send X12 files to Availity via sFTP into the ‘Send’ folder
  2. Download responses from the ‘Receive’ folder
  3. Parse responses for errors (and perhaps success as well)
  4. Update patient notes with Error Text and success text
  5. Update billing record to flag error conditions
  6. Write a Office Note indicated the summary action (or failure to connect with retry status)


Single Encounter processing

  1. Enter the PID and Encounter ID and process as above