Claims Management and Insurance Follow-Up Reports

Transcription

1 Claims Management and Insurance Follow-Up Reports

2 Insurance Collection Reporting A. Insurance Control Summary 1. Description: 2. Purpose: a) Report used to view all claims generated for a given run. b) Key report to balance to audit trails to determine that all claims were received by carrier (NEIC and Medicare, BC or Medicaid audit trails) c) Any claims with errors can be worked from this report or could have been worked from Online Claims Management report. a) To list and total, by insurance carrier, all claims generated in a given insurance run, noting any errors on the claims. 3. Frequency : a) Prints with each insurance run b) Generally at least weekly 4. Parameters: a) Can be sorted by insurance carrier, dept info (1) Client file option TRN-W-513 Published 03/26/07 2

3 (a) Blank, 0, or 1 dept/insurance company/doc/assignment/pat # sequence (b) 2 ins company/patient name/dept/doc/assignment sequence (c) 3 dept/doc/ins/assignment/patient number sequence b) Can be presented with only electronic claims or all claims 5. Key Features: (1) Client file option (2) Blank or N = N; Y = yes, only electronic claims a) Original claims first, refiled claims next and finally serial claims. b) For each different type of claim, the report will show a separate section for each insurance carrier. c) Errors and comments appear in right hand column (1) ELEC = Electronic filing (2) AUTO = Automatically refiled (3) Error codes = See listing of codes (4) If errors are less than 400; claims allowed to go electronically even with error 352 = Date admitted and/or date discharged is missing TRN-W-513 Published 03/26/07 3

4 d) Error code legend appears at end of each section and a summary of all errors appears at end of report e) Column headings (1) RF Refiled column 0=No, an original claim; 1=yes, refile (2) AS Assignment at filing (1, 2, 3, 4) (3) CL Claim number if claims were split (1 or 2) (4) AA Claims filed from Account Analysis Y=yes; N=No (5) FR form number used for filing; based upon carrier support file setup f) The last page is Summary Recap (1) Totals all claims for all carriers in the run by electronic and other claims Total Electronic Column used for balancing (2) Electronic separates the NEIC Electronic Totals from all others (MC, BC, Medicaid) (3) Subtract NEIC from Complete Run Total to get the other total for balancing MC, BC, & Medicaid audit trails submitted next transmission (4) These totals are used for audit trail balancing. (5) For NEIC balancing use the NEIC totals on Insurance Ctrl summary and balance to the next transmission from NEIC Provider Daily Statistics (R022) report Claims Input Value or Provider Daily Summary (R023) report Provider Totals Claims DLY Input Value TRN-W-513 Published 03/26/07 4

5 g) How to Work Report (1) Gather weekly reports, audit trails, and claims (2) Balance to previous audit trails and NEIC report (3) Determine errors research AA & patient setup (a) If using Online Claims Management, the errored claims would have been worked through the COE Correctable Edits category and do not need to be reworked here. (4) Rectify errors and refile claims (5) Obtain all serial claims error 552, 551 and submit with EOB (6) Check audit trails and NEIC for rejections (7) Make corrections and resubmit or release to patient as appropriate TRN-W-513 Published 03/26/07 5

6 B. NEIC Reports 1. Description: a) These are an assortment of reports transmitted by ENVOY Corp (NEIC). b) Important for balancing electronic transmissions and for working NEIC and carrier rejected claims c) The Run Date in the right hand corner (1) Guide to the date of Insurance Control Summary to use for balancing (2) The Insurance Control Summary date is usually 1 to 3 days before the Run Date (3) Varies depending upon frequency of insurance run for client. (4) A pattern can readily be established for each client TRN-W-513 Published 03/26/07 6

7 2. Purpose: d) For particular questions about the reports or errors, contact ENVOY reps. e) For questions about carrier-specific rejections contact the carrier. f) Monthly recap from NEIC with carrier specific breakdown of numbers of claims and dollar amounts to each carrier comes with the beginning of each month a) Provides a record of totals and dollar values of all claims set by DST to NEIC on client s behalf (1) Important to balance to previous Insurance Control Summary to be sure all electronic claims submitted were received by NEIC b) Provides a detail record of all claims received by NEIC (1) These can be verified against Insurance Control Summary as well c) Provides various levels of claims rejections (1) Claim Level rejection by NEIC (R022 & R023) (2) Unprocessed Claims Report from NEIC to carrier (R059) (3) Request for Additional Information (R060) TRN-W-513 Published 03/26/07 7

8 d) Documentation for verification of filing 3. Frequency a) The reports are transmitted electronically along with claims run reports generally weekly 4. Parameters a) The type and number of reports received vary depending upon the type of claims run b) Basically three reports most common for each run c) R022 Provider Daily Statistics d) R023 Provider Daily Summary e) R026 Daily Acceptance Report by Provider 5. Key Features (refer to handouts from NEIC) a) Provider Daily Statistics (R022) (1) Statistics, by batch, for each provider (2) Summary only of all claims submitted (Claims Input) with Claims Accepted and Claims Rejected (3) The Claims Input Total is to be used to balance to the previous Insurance Control Summary NEIC Electronic Totals on the Summary Recap (4) Reason for claim level rejection is given, if any TRN-W-513 Published 03/26/07 8

9 (5) These rejections are to be corrected and claim(s) refiled. (6) Questions about the rejection codes should be made to ENVOY b) Provider Daily Summary (R023) (1) A summary of the number of accepted claims per batch (2) Also has a totals section which display all input, accepted and rejected daily, month-to-day and year-to-day statistics (3) The Daily Input Total can be used for balancing to the previous Insurance Control Summary NEIC Electronic Totals on Summary Recap (4) Also divides the claims into Commercial, Medicare, and Commercial & Medicare c) Daily Acceptance Report by Provider (R026) (1) Detail report of claims accepted by Envoy (2) Represent claims that were sent to the insurance carriers (3) Can be verified with names on the Insurance Control Summary (4) Provided with Patient Number, Patient name, and Type of Claim (5) In numeric order d) Unprocessed Claims Report (R059) (1) Detail of claims that the carrier was unable to process (Carrier specific rejections) TRN-W-513 Published 03/26/07 9

10 (2) Basically, this is an ENVOY audit trail from different carriers and should be worked completely (3) Specifies the corrective action to be taken (4) Provides specifics about the filed claim (5) Generally provides a phone number for contacting payer e) Request for Additional Information (R060) (1) Detail report from carrier (2) Claims that require additional information for processing (3) Claim detail information submitted with the specific request from carrier defined (4) Work all these items and submit info as directed f) Zero Payment Report (R061) (1) Summary of claims that will not be paid by the carrier (2) Not available from all carriers (3) Example of non-payment would be duplicate claim (4) Do not post rejection from this report; post from remittance g) Claim Settlement Report (R062) (1) Provides data regarding adjudicated (processed) claims TRN-W-513 Published 03/26/07 10

11 (2) An explanation report of payments (3) Not available from all carriers (4) Note: Do not see the actual payment (always says Amount of zero) (5) Does show zero payment claims as well (6) Post payments from remittance; not this report TRN-W-513 Published 03/26/07 11

12 C. Claims Management Recap 1. Description: a) Weekly report supplies a complete breakdown of outstanding insurance receivables. b) Recap created following each insurance run c) By using the internal claim tracking mechanisms and the information we receive from electronic transmissions, we provide aged tracking on outstanding charges to a significant level of detail. d) The most up-to-date insurance receivables report that places the claim one of the 10 categories e) The detail for this reporting is available online on the Follow-up screens or can print a Claims Management Detail report f) Shows claim number as sequence number and can use this number to go the that item in account analysis g) Includes a Claims Management Insurance Carrier Recap (1) Provides a summary of all carriers and their aging groups for the Claims Management Report (2) Summarizes the Claims Management Recap with a one-line total dollar amount of claims for each individual carrier. (3) The total dollar amount reflects the sum total of the aging categories within the Insurance Carrier Recap TRN-W-513 Published 03/26/07 12

13 h) Categories Defined: (1) A Not Filed - all charges that have been entered for patients with the specified insurance coverage that have never been filed to that carrier but are in suspense to the carrier (2) B Correctable DST Edits - all charges that were filed with the specified carrier, but whose claims were edited and erred by DST insurance programs. Only claims that were deemed correctable will be included in this column. By this, we mean that the errors could be corrected in the computer system and the claim resubmitted to file electronically to most carriers. (3) C Original Claim Paper - all charges that have been filed on paper to the specified insurance carrier. (4) D Original Claim Electronic - all charges that have been filed electronically to the specified insurance carrier. (5) E Refiled Claim, Paper - all charges that have been refiled to the specified insurance carrier on paper. (6) F Refiled Claim, Electronic - All charges that have been refiled to the specified insurance carrier electronically. (7) G Claim Bumped - all charges that have been bumped or forwarded from Medicare to a secondary carrier. This will include claims that Medicare forwarded to BCBS of AL, AL Medicaid and all Medigap Carriers. (8) H Audit Trail Rejected - all charges that have been rejected on an electronic audit trail. (Alabama only) (9) I Audit Trail Accepted - all charges that have been accepted on an electronic audit trail (Alabama only). (10) J EOB Rejected - all charges that have been rejected by the payor under specified circumstances. The rejections that are reported in this column are: Any rejection that was posted but retained ins suspense at time of posting TRN-W-513 Published 03/26/07 13

14 Any Alabama Medicare or BCBS rejection that falls into a category that we deem either correctable or needed research i) Aging Rows Defined Category Days TRN-W-513 Published 03/26/07 14

15 2. Purpose: a) To provide the aged, outstanding amounts to each insurance carrier, with detailed breakdowns of the last recorded activity for each charge 3. Frequency: a) Weekly or following each insurance run b) Can be produced on Requestor - page Parameters: a) Can be produced at clinic, department, or doctor levels b) It is available for suspended insurance receivables only, for all outstanding receivables (?) c) Detail is available on online claims management (follow-up screens). d) Reporting can be done from data query reporting as well e) Aging categories are based upon the age of the claim in that specific category and NOT based upon the age from DOS f) 5. Key features: a) Can track an outstanding charge to the point of telling you that the last recorded action taken on the charge, whether the action was taken by your office or the carrier. TRN-W-513 Published 03/26/07 15

16 b) Each outstanding charge is reported only once, in the section on the last recorded action on the charge. 6. Data Query a) There are four reports that can provide additional claims management review generated through Data Query access only (1) Client must be set up as an Associate Data Query user (2) Logon and password specific for each client (3) Reports can be viewed online, printed at client office, or printed at DST b) Allow user to change sort parameters and limit view of reports by claims management categories, departments, doctors, carriers and aging rows. c) The four reports are as follows: (1) Claims Management Report Clinic Level (a) Displays claims management for entire clinic (2) Claims Management Report Dept/Doc level (a) Displays claims management for specific departments and doctor combinations (3) Claims Management Report Dept Level (a) Displays claims management for all doctors in specific department TRN-W-513 Published 03/26/07 16

17 D. Insurance Suspense File 1. Description: 2. Purpose: (4) Claims Management Report Doctor Level (a) Displays claims management for specific doctor in all departments a) Lists all insurance fling history for charge items. b) A record of charges in suspense c) Contains separate listings for each insurance carrier a) Useful for finding claims which have not been paid within a reasonable time by suspense insurance carriers. 3. Frequency: a) weekly 4. Parameters: a) Standard sort is by contract/policy number b) Other sorts are: (1) Date filed TRN-W-513 Published 03/26/07 17

18 (2) DOS (3) Alphabetic (4) Department/Doctor number TRN-W-513 Published 03/26/07 18

19 5. Key features: a) The report is totaled by insurance carrier, with a grand total line at the end of the report b) The recap that follows provides a breakdown of electronic, paper, other, and combined claims for the aging periods. c) The recap shows total dollar amounts for the charges in suspense and the count of the number of charges in suspense. E. Insurance History Report 1. Description: 2. Purpose: a) Lists all insurance filing history for charge items. a) In limited format, this can be useful to catch charges that have never been filed. b) To list all charges in the system with a notation for every insurance filing. c) Can tell at a glance exactly how a charge was entered, with which insurance companies it has been filed, and corresponding filing dates. d) Accurate refiles are most easily obtained through reference to this report. 3. Frequency: a) Monthly TRN-W-513 Published 03/26/07 19

20 b) Usually it is requested at infrequent intervals (twice a year). 4. Parameters: a) Can be limited to only active patients, only patients with unfiled charges, only a particular patient, and no files with insurance. b) Provides quickest most accurate check of the insurance filing for any given charge. 5. Key features: a) Accurate refiles are most easily obtained through reference to this report b) The report is totaled by insurance carrier, with a grand total line at the end of the report F. Outstanding Claims Report 1. Description: a) Provides a listing of all unpaid claims for specified carriers. b) Shows the detail of the charges on the claims as well as other transactions applied to the charges (i.e., payments and adjustments from other carriers.) c) Consists of 4 sections: (1) Claim detail (2) Carrier analysis TRN-W-513 Published 03/26/07 20

21 (3) Aging recap (4) Carrier recap 2. Purpose: a) To provide a detail listing of all unpaid claims for specified carriers 3. Frequency: a) On request b) Available on requestor 4. Parameters: a) Suspended charges only or for all charges b) Options to limit the report by carrier, age of the claim, ranking, type accounts, department/doctors, or by outstanding balance. c) Can be sorted by patient number, patient name, or date filed, or outstanding amount, or type. d) Can request detail or just recaps only e) Options can be set for defaults (1) Count zero amount payments as responses TRN-W-513 Published 03/26/07 21

22 5. Key features: (2) Count rejections as responses (3) Count manual releases as responses a) 4 sections (1) Detail -provides detail of claim filing plus any transactions applied to the charges (payments and adjustments from other carriers, for example) (2) Carrier Analysis - provides an analysis for each carrier by aging groups (a) Provides a breakdown of the aging for primary, non-primary claims, electronic, paper, other and all claims. (b) Shows the dollar amounts, percentages, and number of claims for each of the above categories. (3) Aging Recap - provides a summary of all carriers and their aging groups (a) Shows outstanding amounts and percentages for all carriers that have outstanding claims. (b) May be sorted by carrier, or by outstanding balance or sorted both ways. (4) Carrier Recap - provides a summary of primary and secondary claims for each carrier with outstanding claims. (a) May be sorted by carrier or by outstanding balance or both ways. TRN-W-513 Published 03/26/07 22

23 II. Insurance Analysis Reports A. Service Code Summary by Insurance Carrier By Doctor 1. Description: 2. Purpose: a) Shows transaction activity for any specified time frame, by service code, distributed to the patient's primary insurance coverage. b) The precedence of the insurance coverage is determined by the order in which the carriers are listed on the report. a) To recap service code activity for a given time frame, breaking information out by specified carriers. b) Provides service activity by percentage for each carrier. 3. Frequency: a) Requested report. b) Based upon closeout. c) Not standard 4. Parameters: a) Standard carriers are the default but any 4 carriers can be selected TRN-W-513 Published 03/26/07 23

24 b) Can be limited to one or more specified service codes c) Can be produced at doctor, department or clinic level. 5. Key features: a) If run for a family member clinic, only charge codes will appear on this report. b) Cash pay column for items with no claims generated. c) ** for percentage means 100% B. Patient Mix by Insurance Carrier 1. Description: 2. Purpose: a) Provides a count of patients covered by particular types of insurance or living in particular zip codes b) The patient will be recorded under whichever insurance is primary. c) For zip code reporting patients are selected by the address in the patient address file. a) To provide a count of patients by particular insurance carriers or living in particular zip codes b) Can be useful in determining whether a satellite office would be worthwhile in a given area. TRN-W-513 Published 03/26/07 24

25 3. Frequency: a) Upon request. b) Available in Requestor. 4. Parameters: a) Can be generated for all insurance carriers or up to 20 specified insurance carriers with all others patients showing as "Private Pay." b) Can specify a date and the report will only include patients who have had account charge activity since that date. 5. Key features: a) Keys off primary insurance only. b) Patient address determines zip code c) Only accounts with activity are counted. d) Can be all carriers or up to 20. C. Insurance Reimbursement By Charge 1. Description: a) Tracks reimbursement by all insurance carriers for specified procedures and time frames. TRN-W-513 Published 03/26/07 25

26 2. Purpose: b) Only payment/nonallowed records which were entered through the insurance or HMO payment screen can be tracked. c) The report will show for each service code, count of charges, charge amounts, payment amounts, nonallowed amounts, and associated percentages for all carriers who have made payment. d) Zero payments will be tracked separately. a) Useful for comparing reimbursement between carriers b) Finding information on a particular carrier's payment c) Evaluate payment patterns for particular procedures d) Identify problem areas 3. Frequency: a) Requested upon demand. b) Available in requestor 4. Parameters: a) The service code to be reported must be specified. b) Up to 60 codes may be specified for each report. TRN-W-513 Published 03/26/07 26

27 c) The report can be run for a particular closing period or for any specified time frame. d) Different levels can be produced (1) department (2) doctor (3) clinic TRN-W-513 Published 03/26/07 27

28 e) Can be produced for a range of departments or doctors by using * for wildcards. 5. Key features: a) Must chose either closing period or date of service b) Displays each service code with a summary of payment and nonallowed statistics for the charge (>0) c) Presents numbers of zero payments for each charge and each carrier (=0) d) Followed by the specific carriers in numeric order and the statistics for the respective carrier. e) Displays number D. Insurance Non-allowed 1. Description: 2. Purpose: a) Tracks insurance payment history by carrier based on procedure code. b) It contains the detail for each charge item paid by a carrier, including the elapsed time from filing to payment. c) Breaks out all charges paid by a specified suspense carrier over a given period, listing the original charge, nonallowed, coinsurance, deductible, amount paid, and dates filed and paid. TRN-W-513 Published 03/26/07 28

29 a) To list by procedure code, the amounts which have been non-allowed and paid by specified suspense carriers over a given period. b) May be used to establish the common payment amount on a given code c) To spot differences in payment amounts for identical charges d) To calculate a carrier's average payment period. e) To evaluate days from DOS and from payment. 3. Frequency: a) Upon request b) Usually only periodically (year end) and not routinely 4. Parameters: a) Dept, doctor clinic levels available b) Can be sorted by department primary and carrier secondary c) Different versions (1) Recap only (2) Details only (3) Both TRN-W-513 Published 03/26/07 29

30 d) Recap level can be selected (1) Clinic (2) Department (3) both TRN-W-513 Published 03/26/07 30

31 5. Key features: a) In order for a charge to appear in this report, the charge must have had a payment posted to it through the insurance payment or HMO payment screens. b) A separate listing is generated for each suspense carrier, with totals given for each carrier. c) Number of days since original filing of charge from DOS and number of days since payment posted E. Inpatient/Outpatient Service Code Summary 1. Description: 2. Purpose: a) Provides production information by procedure code, contrasting inpatient (place of service 2) versus outpatient hospital (place of service 3) and clinic (all other places of services. b) Gives the number of occurrences, average charge, and total dollars charged for each code, with each of these categories further divided into inpatient hospital, outpatient hospital, and clinic sections. a) To recap service codes used during the given time frame, dividing information into inpatient versus outpatient portions. 3. Frequency: a) On request TRN-W-513 Published 03/26/07 31

32 b) Not often used c) Limited use 4. Parameters: a) Can be run for current month only or for any other specified time frame for which you have history. (1) A report for the current month will balance back to the SCD b) Two levels choices for report (1) Department which is default (2) Clinic c) Can specify a minimum number of occurrences for a code to have a detail line printed on this reports (1) All codes with fewer than the minimum number of occurrences will be grouped together in a line labeled "other items." d) It is possible to have the outpatient hospital section determined from location code. (1) To use this option it is necessary to have the location codes hard coded into the programming (2) Will necessitate additional programming codes TRN-W-513 Published 03/26/07 32

33 5. Key features: a) The place of service code is used for determining into which section a given code is to be placed (1) 2 - inpatient hospital (2) 3 - outpatient hospital (3) * - all others grouped under clinic TRN-W-513 Published 03/26/07 33

34 F. Transactions By Insurance Carrier 1. Description: 2. Purpose: a) Tracks charges by insurance responsibility for each month of the fiscal year. b) The charge will appear as due from the patient's primary insurance coverage. c) Can also track other types of transactions, such as payments, credits, or refunds, etc. a) To track charges, payments or adjustments by insurance responsibility for each month of the fiscal year. 3. Frequency: a) On request b) Usually annually 4. Parameters: a) Can be sorted by insurance carrier or by total yearly transaction amount b) Can be run by department or clinic level 5. Key features: a) Displays only whole dollar amounts TRN-W-513 Published 03/26/07 34

35 b) Gives a breakdown of transaction amounts by insurance carrier and by month of the year. c) Total lines for carriers and months are included d) The month is determined by the DOS of the charge e) Legend appears with the names of the carriers at bottom of report G. Capitation Services Comparison 1. Description: 2. Purpose: a) Provides a numerical list of every service code entered for a capitated carrier during the current month and year to date with the number of items the codes have been used and the fee for service dollar figures which would have been charged if the service were not capitated. b) During data entry, any services entered for a capitated carrier that were marked as noncovered will show as actual charge amounts but will not be added into the count, quantity, or amounts of the regular service code distribution. a) To compare capitated carriers by service code for current month and year to date within clinic, department, doctor, location, and /or department/doctor. 3. Frequency: a) Monthly b) As requested TRN-W-513 Published 03/26/07 35

36 4. Parameters: a) May be requested in detail, recap, or both formats 5. Key features: H. Capitation Report a) In the detail version of the report, payments linked to capitated charges will be listed. b) The FFSE - Fee for Service - the amount that would have been charged if it had not been capitated. c) The percentage of the total FFSE that this service code represents is calculated. d) The recap displays payments linked to the capitated carriers as well as categories for covered and non-covered charges. 1. Description: a) This recap of all capitated services is divided into 2 sections: (1) Section 1 - provides a numerical list of every service code entered for a capitated carrier during the current month and year-to-date along with the number of times they have been used and the fee for service dollar figures which would have been charged if the service were not capitated. (2) Section 2 - shows any services entered for a capitated carrier that were marked as non-covered during data entry. These services are not added into the count, quantity or amounts of the regular service code distribution. TRN-W-513 Published 03/26/07 36

37 2. Purpose: a) To recap all capitated service codes during the month and year-to-date. 3. Frequency: a) Monthly b) Upon request 4. Parameters: a) Available at clinic, department, doctor, consolidated doctor and location. 5. Key features: TRN-W-513 Published 03/26/07 37