Information needed from clearing houses or carriers to resolve claim issues

 

-First determine where the claim is in the process which caused the error to occur

 

-Major steps in a claim's life, based on one patient and case

1. Transaction Manager- Transactions are created for a case and patient

2. Claims Manager- Transactions are tied together to create a claim

3. Transmission:
1. Electronic - Print Image
1. Print/Send Button- Pulls the data for the claims from Medisoft and creates a plain text document saved to the local computer; layout is the same as a paper HCFA or UB claim (depending on the Program File field in the EDI Receiver)
2. Use an upload client to transmit the file such as a Web browser, FTP client or another proprietary client;
1. Claim sent to Clearing House- Processes the claim file by mapping the appropriate fields and then performs their own edit checks against the data provided
2. Claim sent from Clearing House to Carrier and depending on the clearing house and/or carrier; the claim is then sent in ANSI 4/5010 or on paper to the carrier via the clearing house's proprietary methods
2. Electronic - ANSI
1. Revenue Manager
1. Pulls Selected Claims into the RM-Claims Process (issues that can be fixed here that cannot be fixed in Medisoft are:
1. Claim created without or incorrect facility
2. Claim created without or incorrect provider
2. Check Claims- validates required claim data against a set of pre-defined rules (as well as custom additional rules); Recognizable by the 'green Passed flag' or the 'red Error flag', expanding the plus symbol beside the claim and checking the 'Edits' tab will provide a "plain english" error explanation, correct the requested data in Medisoft and repeat to resolve the claim issue
3. Send Claims- Runs RM's edit checks which validates the information required for the claim with rules and logic defined by the Iguide being used which will also pull the required data for the claim from Medisoft; error claims are defined with Red Circles containing an X, correct claims will have a solid green circle; errors at this point are slightly cryptic but normally the information request is fairly easy to decipher
1. Removing a claim - will remove the claim from the current file but leave the claim's status at 'Ready to Send'
2. Removing all error claims - will remove all the error claims at once and it will change the claim's status from 'Ready to Send' to 'Alert'; this will also add the error displayed in RM to the claim's comment tab in Medisoft's Claim Manager
1. Correct the requested error data in Medisoft
2. Set the claim 'Ready to Send', if needed and 'Send Claims' again
3. Send Button
1. creates the file to be sent
2. Opens the Receiver's defined Communications Session
1. Internet Web Page
2. Dial-Up Connection
3. FTP Protocol
3. File is sent/uploaded to the:
1. Claim is sent to Clearing House- Processes the claim file and then performs their own edit checks against the data provided
2. Claim is sent from Clearing House to Carrier- Depending on the clearing house and/or carrier; the claim is then sent in ANSI 4/5010 or on paper to the carrier via the clearing house's proprietary methods
2. Carrier- Accepts the file and sends an acceptance file back to the clearing-house
3. Carrier Checks - performs their own edits against the file
4. Carrier processes the claims
5. Carrier returns response as either a payment or denial reason
3. Paper
1. Print/Send Button - allows the selection of the Custom Report claim form to print
2. Claim is previewed to screen (works in all situations, print directly to printer depends on the printer's specific drivers)
3. Print claim's data with forms onto plain paper or onto pre-printed forms
4. Send printed claims to the Carrier
5. Carrier processes the claim
6. Carrier returns a payment or denial reason

-We will want more information from the carrier or clearing house if you have made it past:

1. 3-a-i
2. 3-b-i-3-c-iii
3. 3-c-iv

If you have not made it to any of these points in the claim's life; give us a call to find out more about possible solutions within Medisoft or Revenue Manager.

 

Contacting the Clearing House and/or Carrier for more details-

Information to have on hand which helps to resolve issues quicker

1. Clearing House Assigned Number/Submitter ID

2. Error and description of error details

3. Information about the claim or an example claim or two:
1. Patient Full Name
2. Date Of Birth
3. Insurance Carrier
4. Dates of Service on the claim
5. Procedures on the claim
6. Diagnosis on claim and pointers per transaction line
7. Total amount of claim
8. Any other special circumstances surrounding the claim, case or patient
1. Times you have sent the claim previously, if ever
2. Special circumstances for
1. a particular program contained/billed on the claim
2. the patient or case the claim involves

-If the issue/problem is coming from the Clearing House directly

-Contacting the Clearing House directly and trying to determine if they can give you more specific details about the denial/rejection reason

(normally this will be errors:

1. Where an entire batch is rejected
2. Claims for a specific carrier(s) are not making it to the carrier(s) for processing
3. Edits that are proprietary to the clearing house (normally report titles will contain the clearing house name and not the carrier's))

1. Electronic Print Image or Paper - What information in/on the claim is causing the error
2. ANSI/Revenue Manager - What information is causing the problem with the specific loop(s) and segment(s) that is/are causing the problem (ex. Loop-2010AA-Billing Provider-Segment-NM1-Element-09-NPI or this can be shortened to Loop2010AA-NM109)

-If the issue/problem is reported from the Carrier

-Contacting the Carrier and trying to determine if they can give you more specific details about the denial /rejection reason

1. Electronic Print Image or Paper - What information in/on the claim is causing the error

2. ANSI/Revenue Manager - What information is causing the problem with specific loop and segment that is causing the problem (ex. Loop-2010AA-Billing Provider-Segment-NM1-Element-09-NPI or this can be shortened to Loop2010AA-NM109)