Over 25 years of experience in the medical field, including 10 years of medical billing using Centricity. Eleven years with Visualutions, assisting

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2 1. Agenda 2. Credentialing 3. Clearinghouse 4. Company 1. Information 2. Identification 5. Administration Tables 1. Zip Codes 2. Fee Schedules 6. Responsible Provider 1. Information 2. Identification 3. Fee Schedule 7. Facility 1. Information 2. Identification 8. Insurance Carrier 1. Information 2. EDI 3. Identification 9. Procedure Code 1. Information 2. Procedure Fee Schedule 10. Insurance Carrier 1. Information 2. EDI 3. Identification 11.EDI Submission Management 12.EDI Response Management 13. Recap

3 Over 25 years of experience in the medical field, including 10 years of medical billing using Centricity. Eleven years with Visualutions, assisting customers with their EDI, PM, and FQHC issues. My main role is serving as an EDI specialist: remittance, electronic claims (primary & secondary), real-time eligibility and PPS.

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5 Search for all active Clearinghouses Inactivate clearinghouses that are no longer used If you are unsure if a clearinghouse is being used You can do a search in EDI Submission and EDI Response Management

6 EDI Submission Management Depending on how large your database is you may need to minimize your criteria in your search Clearinghouse: Either drop down to each clearinghouse if your database is large or leave at all File Type: Leave ALL checked Date Transmitted: From At least 6 months back; To leave blank

7 EDI Submission Management If you selected ALL under Clearinghouse then you can sort your clearinghouse column

8 EDI Response Management Depending on how large your database is you may need to minimize your criteria in your search Clearinghouse: Either drop down to each clearinghouse if your database is large or leave at all Date Received: From At least 6 months back; To leave blank Processed Status: Leave ALL checked Include Archived: Check

9 EDI Response Management If you selected ALL under Clearinghouse then you can sort your clearinghouse column

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11 ZIP Code MUST have Zip+4 on Company, Facility and Provider Tables NPI If you have multiple Billing NPI s - populate an NPI here that is credentialed with ALL carriers. You MUST have an NPI populated. Tax ID Must be populated No spaces, no dashes Pay To Address If you have a different address that is used for payment remittance; you will populate that address here. Otherwise it will pull from the information tab. Make sure the address does not have any special characters i.e. Suite #25. You only need multiple companies if you have different Federal Tax ID s or if you have different billing requirements i.e. Dental Authorization.

12 There should only be 1 ALL ROW! This is the default row for ALL carriers that are not specifically credentialed for a facility NPI or the carrier doesn t require any specific filing This information populates the Billing Provider Information

13 Note the screenshot now Only has 1 All row Facility trumps Insurance Carrier Insurance Carrier trumps Insurance Group

14 You only need to break out by carrier if the information on the ALL row is not the same i.e. CLIA, Place of Service, NPI. Information populated in the Additional ID 1 and Additional ID 2 fields will be sent in the file even if you have the Do Not Send Legacy selected in the claim creator settings. Do not populate Legacy Numbers here i.e. Medicare/Medicaid numbers

15 If your facility is credentialed with their own NPI for billing for specific carriers then you will need to set up a row specific for that facility and carrier at the Company level. If your facility is credentialed with ALL carriers to bill with its own NPI then you will set up a row under the company with that facility and ALL insurance carriers. If your facility is credentialed to bill under the Billing NPI then you do not need separate rows under the company. The facility NPI would be sent in the facility loop and the billing NPI would be sent in the billing loop. If you have extra rows and are unsure if they are needed?? Review the rows do they have everything the same as the ALL row (NPI, POS, CLIA)? Then you can remove it.

16 Another way to review what rows are pulling in each visit: You can review the Claim ID Summary report from either the Billing or Visit component; this report will provide which row is being used. File>>Reports>>Claim ID Summary>>Preview

17 By previewing this report you can tell which identification row each visit is looking at to pull data. In this example, for the Company it is using identification row 132. You would look in the Administration tables under Company for that identification row.

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19 ZIP Code Review and clean up your zip code table regularly Remove anything in Country field Update any zip codes that do not have a city or state

20 Fee Schedule Inactivate old fee schedules; they are still applied to visits even if you inactivate them. Name new/copied fee schedules with the year at the beginning; This makes locating those fee schedules easier. If nothing has changed on the fee schedules there is no need to create new. Add descriptions to each fee schedule in the Notes section to help explain why the fee schedule was created. This will help other Admin users know which carriers to associate the fee schedule. Do not create fee schedules if there is nothing special about them. If you MUST have special filing that is carrier(s) specific, then you would create a different fee schedule.

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22 Sort your Responsible Providers by the Specialty column. The Specialty is what ties the provider to a specific Taxonomy Code. Make sure all of your responsible providers have the appropriate specialty associated to them.

23 Address make sure no PO Box ZIP +4 NPI Specialty Confirm Taxonomy set up Dentists need state license Your provider name MUST be setup exactly how it s listed on NPPES website. MD is not part of the last name so put in Suffix. Do NOT populate USA in country

24 Specialty Confirm Taxonomy Setup o System>User and Resource Management>Users>Specialties Confirm Taxonomy Code is populated AND correct.

25 If the provider will file under another provider or works 18 hours or less a week you will select Services may be billed using another provider s billing information. If the provider may be used as the billing provider for another provider you cannot select this option. Federal Tax ID MUST be populated An ALL row MUST be added at the very least Company trumps Facility Facility trumps Insurance Carrier Insurance Carrier trumps Insurance Group

26 This information if filing as a group will populate the NPI in the rendering/attending provider. NPI MUST be populated; if not, set to pull from Company. CANNOT leave blank. Filing as an individual means the check will be written to that individual provider.

27 You only need to add additional rows if you file differently. For example, bill under another provider, or as an individual.

28 An ALL row MUST be added at the very least to all providers Company trumps Facility Facility trumps Insurance Carrier Insurance Carrier trumps Insurance Group

29 Review each row. If you have any rows by Insurance Group confirm you don t have any rows by carrier that are part of that group. If you do and they use the same fee schedule then delete the insurance carrier row.

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31 Must Have: Address make sure no PO Box ZIP +4 Federal Tax ID NPI Default Company Default Place of Service Type of Bill

32 MUST HAVE: ALL row You only need additional rows if you file differently. For example, place of service is different for a specific carrier. Remember if you need to send the facility NPI at the billing level that set up is done at the company level.

33 This Facility row is set up to pull everything from the company identification table. The Place of Service will pull from the information tab of this facility. (This is the only field you can leave blank) Type is 77. FA was 4010.

34 IF the facility NPI is different and must be filed to the carrier it would be populated in the NPI field.

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36 Review Your Top 5 Carriers 1. Information Tab - Verify all the REQUIRED information is populated on the Information Tab. 2. EDI Tab Verify your rows for both claims and eligibility. 3. Identification Tab Make sure you have an ALL row.

37 Any Carrier Information Tab

38 Any Carrier Information Tab Name Enter the insurance carrier name to print on the standard claim form. (REQUIRED) List Name Enter the insurance carrier name as you would like it to appear in the Find Insurance Carrier window search results. Address, City, State, ZIP An invalid address may cause claim rejections for claims dropped to paper or marked to include carrier address on the electronic claim file creator settings. (REQUIRED for paper claims and some electronic) o Paper Claims (in-house or clearinghouse) Claim will be mailed to this address. o Electronic Carrier Settings Carrier will reject if ZIP code is invalid. Carrier Type Select the appropriate Carrier Type for each carrier (REQUIRED) Financial Class Select the default financial class for patients with this insurance. At patient registration, when selecting this carrier as primary, this financial class automatically appears as the patient s financial class.

39 Any Carrier Information Tab Allocation Set Depending on carrier, you have two options: o Select the default allocation method for patients with this insurance. At patient registration, when selecting this carrier as primary, this allocation set automatically appears as the patient s allocation set. o Leave this field blank if you do not want this allocation set to appear as a default for this insurance carrier. NOTE: If you are on the new Community Health Enhancements you MUST populate an allocation set on the sliding fee carrier. Insurance Group This field is used to combine carriers using the same: o Fee Schedules o Credentials o EOBs i.e. Medical and Dental

40 Any Carrier Information Tab Transaction Column Set Select the transaction column set to use when posting payments from this insurance carrier. This field is required in order to post payments received by this payer. (REQUIRED) Benefit Assignment Specify whether the provider accepts assignment from this payer. This will be the default value for patient visits associated with this payer. You can override this value at the time of the visit or in the patient information for patients who refuse to assign benefits to the provider. (REQUIRED) Policy Type Select the policy type to be used as the default for this carrier. (REQUIRED)

41 Medicare FQHC Information Tab

42 Medicare FQHC Information Tab The following fields are specific to Medicare FQHC. Carrier Type Select Medicare Part A. Alternate Payer Leave blank in order to not require the user to open the visit to split Part B. Transaction Column Set You may have a carrier specific adjustment or payment types for this carrier. Otherwise, use your standard insurance payments transaction column set. Policy Type Select Medicare Primary or Medicare Part A. Filing Method Select Electronic Institutional/UB-04. Remove Subscriber ID Mask as the Medicare numbers are changing.

43 1. Claim Creator row MUST have a filing method 2. If your group does eligibility the Eligibility row MUST have the claims payer ID in the claims payer field.

44 MUST be populated: o Filing Method o Claims Clearinghouse o Claims Payer ID o Claims Creator Plug-In o Approval Plug-In

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46 Do not send patient amount paid in Loop 2300 AMT Segment Always select this setting. This will suppress any monies collected from the patient which will prevent any potential rejections, specifically from Medicare. Send Pay-To Provider Information in Loop 2010AB This setting is required if a pay-to address is a PO Box or an address different than the billing address. See the Pay to Address section to complete the pay to address setup. Always select Do Not Send Legacy numbers when NPI is sent in NM109 Uncommonly, this may be left blank when required by the carrier to send legacy information such as provider IDs or facility IDs. Report Adjudication on Encounter for 2 nd claim This setting is required for secondary claim filing. Receiver ID Required when sending to a clearinghouse. Use the clearinghouse Payer ID. If filing direct, enter the carrier specific Receiver ID (this is a less common usage). Send CPT Code in Loop 2400 SV2 Segment Select for Medicare FQHC Claims.

47 Provider Based Hospital Billing/Institutional Claim Defaults Admission Type, Admission Source and Patient Status are required on all Institutional / UB04 claims. These values must be setup in the Institutional Tables prior to adding to Insurance Carriers. A default can be set up for each Insurance Carrier that files in an Institutional /UB04 format. Provider Based Hospital Billing Utilizing this section will default values in the 837I (institutional claim file). These values may be overridden at the visit level. All of the required settings options for Admission Type, Admission Source and Patient Status are found in the CPS EDI Administration Setup document located in our library.

48 Primary Tab The settings below are required prior to setting up the Medicare PPS tab. The entry of the single row with the 521 CPT Code is only utilized as the Federally Qualified Health Center check is required when Medicare is an FQHC/PPS carrier. The Use Fee Schedule setting is used and no rate will be entered. (The 521 must be set up as a procedure code prior to entering in this field.)

49 Other Settings The setting Auto Adjust Visits will adjust the procedure code to the specified allowed amount on the primary carrier s fee schedule. The setting Insured Always Same as Patient will automatically update the patient demographics making the Patient the Insured on specific carriers such as Medicare and Medicaid (where the patient is always the insured). The PBB Carrier Setting will allow you to determine the Alternate Payer for Medicare Part B claims with the appropriate contract type code without having to open up each visit.

50 Medicare A PPS Tab This tab is configured off of the Medicare PPS document. You will need to update this tab yearly if there have been any updates to the PPS rate. Please Note: You do not have to manually calculate your PPS rate there are settings behind the scenes that do this for you. Simply review Medicare s website for your GAF and update the PPS rate off of the document we release annually.

51 Create an additional EDI row specifically for Eligibility. Do not add Claims Clearinghouse, Claims Plug-In or the Approval Plug-In to the Eligibility row. The payer ID in the Claims Payer ID field is required to prevent claim batching errors. The Eligibility Payer ID is not typically the same as the Claims Payer ID.

52 EVERY carrier MUST have an ALL row on the identification tab. You must populate the same payer ID that is on the EDI tab Claims Payer ID. If there is not one, you will need to put the word UNKNOWN as the Payer ID.

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54 Procedure Information Tab: It is important to remember that the information tab is to be used as a default for ALL fee schedules. Data entered into the Fee Schedule tabs will override the data entered onto the Information tab.

55 Procedure Information Tab: Procedure Code Qualifier: Is a REQUIRED field. This information populates on the visit which populates on the claim. Revenue Code: Do not enter revenue codes used for billing i.e Revenue codes used in billing are keyed on the procedure fee schedule tab.

56 Procedure Information Tab: UPN/VPN/NDC: NDC Codes must be 11 numeric digits (no hyphens, spacing). It is recommended to populate the following fields. If these fields are not populated, the user must enter this on each procedure code at the visit level. Code Qualifier must be format. Drug Pricing Composite Unit is Unit.

57 Procedure Fee Schedules Tab: Fee: This is the value of service performed. All fee schedules must have a fee entered. If the fee is 0.00, you must enter 0.00, and not leave the fee field blank. Allowed: The total amount collected on the procedure code, and may represent an adjusted A/R. Enter 0.00 here when the fee schedule is associated with any carrier considered encounter based or capitated and no patient portion will be assigned based on the fee schedule. These carriers include the following: FQHC/RHC Medicaid, Medicare Part A FQHC PPS, and sliding fee. Enter 20% of the Standard Fee for Medicare RHC. Enter the contracted rate or the standard fee in the allowed for all other fee schedules including: Standard, Capitation carve-outs, or any Fee for Service fee schedule.

58 Procedure Fee Schedules Tab: CPT Code: All procedure fee schedules must have the CPT code appearing on the claim entered i.e The CPT code on the information tab will be overridden by the procedure fee schedule CPT code. Contract Type Codes: Contract Type Codes are utilized for the following lines of business: Medicare PPS, Medicare RHC, Medicaid FQHC/RHC, Critical Access and Provider Based Billing.

59 Procedure Fee Schedules Tab: Revenue Code: All procedures that can be filed on an institutional claim must have a valid revenue code on the Procedure Fee Schedules. Exclude any encounter codes that are not filed on a claim i.e If a code such as 01, 18, T1015, or G0466-G0470 can be filed on an institutional claim, therefore a valid four digit revenue code is required. Please see the document located at or contact Medicare Part A. All Fee Schedules must have the appropriate revenue code for the procedure; this includes the Standard fee schedule, any dental fee schedules and all Medicare and Medicaid fee schedules. The Sliding Fee fee schedule should not have any revenue codes entered.

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62 Once a week pull up all files for your Eligibility clearinghouse that have not been transmitted and DELETE these. These files do not need to be sent manually as they DO NOT update the patient insurance record.

63 Once a month pull up all Statement Files that have not been transmitted and review any old files. Anything that was batched and never transmitted that is a month or older could be out of date i.e. patient paid. I would delete those batches and start over.

64 If you have not transmitted Claim Files that were created awhile back but never transmitted for some reason you need to review these. Look to see if they were ever transmitted (Last Filed). If there is no Last Filed date I suggest you delete the batch and then batch those claims again and transmit. (Check the batch and select Delete)

65 If they have a Last Filed date after the date the batch that has not been transmitted I would do a Mock filing. **Note this will update the claims tab that the claim was filed but this is the only way to get it out of EDI Submission Management and not update the Visit Status. (Check the batch and select Export>Set status to transmitted>export Directory browse to your desktop so you can delete these files)

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67 Once a week archive all files for all clearinghouses unless they are remit files that need to be processed/posted. This will help you work through response files that truly need to be worked. Do not delete reports in EDI Response Management just archive them. This gets them out of your view and leaves them in your database for future review. Remove Delete access in Admin for EDI Response Management for EVERYONE!!

68 Referenced documentation can be located in our portal in the library. CPS EDI Administration Setup is a very handy tool that can help you with your setup and every day questions. (In the Training folder) Setting Up Medicare PPS Webinar and Medicare PPS Changes Webinar are webinars that show you how to set up and make changes to Medicare PPS. (In the Webinars Folder under Medicare FQHC in PPS Folder) F1 from any screen in your CPS application

69 1. A clean database is much more manageable then a cluttered database. 2. Confirm which identification rows you truly need under your Company, Facility, and Responsible Provider. Make sure you have an ALL row under each. 3. If you make any annual changes i.e. fee schedule increases, remember to clean up old ones at the same time (Charge Maintenance & Responsible Provider Fee Schedule). If you have no clue what is different on a fee schedule from another do not copy all of those fee schedules the following year. Just start using one of them. 4. Delete eligibility records in EDI Submission - Archive your response files in EDI Response Management get them out of Active view.

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