TheraManager Help Note

Transcription

1 Subject: EDI Claim Troubleshooting Guide TheraManager Help Note This Help Note consists of a list of selected elements within an EDI claim (ANSI 837, version 5010) and the TheraManager screen where the associated data are entered. You can use this list to troubleshoot a rejected EDI claim or inquiry. This troubleshooting guide should greatly reduce the need to contact TheraManager customer support and more importantly to resolve issues impeding timely remittance to your practice. To troubleshoot a claim: 1. Within the rejection report from the clearinghouse or other EDI Target, note the missing or incorrect data within the claim (e.g., missing NPI number, incorrect POS code etc.) 2. Within TheraManager, identify the claim by statement number, which you can do by either of two ways: On the Batch screen, section. See Printing or Reprinting a Claim - Single Patient.pdf as needed for guidance on navigating. On the Accounts Printed screen. See Viewing a Patients Printed Statements.pdf as needed. 2. On the computer from which the batch was generated, go to Computer (My PC in Windows 8). 3. Within This PC (Windows 8/10) or Computer (Windows 7), navigate to the.\theramanager\electronic Claims folder. 4. Within the Electronic Claims folder, navigate to the desired batch file. Double-click to open the file in Notepad. A typical EDI claim for a single DOS might look like this: ISA*00* *00* *ZZ*HMSAEDI *30* *111007*1619*^*00501* *1*P*:~GS*HC*ACC*CLM* *161903*1*X*005010X222A1~ST*837* * X222A1~BHT*0019*00* * *161903*CH~NM1*41*2*WKNAME*****46*HMSAEDI~PER*IC* Randy the P*FX* *TE* *EM*WEBELAWEBELU@GMAIL.COM~NM1*40*2*HAWAII MEDICAL SERVICE ASSOCIATION*****46* ~HL*1**20*1~NM1*85*2*WKNAME*****XX*BILLNPI~N3*47 MOTHER GOOSE LANE~N4*MAKEBELIEVELAND*OH*~REF*EI* ~REF*1G*BILLINGID1~HL*2*1*22*1~SBR*P**INS1FECANUMBER* *****CI~NM1*IL*1*INS1LASTNAME*INS1FIRSTNAME****MI*INS1IDNUMBER~REF*SY* ~NM1*PR*2*INSGN1* ****PI*NHPI1~N3*INSAUTHNADDRESS1~N4*INSAUTHNTOWN1*ST* ~REF*2U*MEDICARENUMBER~HL*3*2*23 *0~PAT*G8~NM1*QC*1*PATLASTNAME*PATFIRSTNAME~N3*PATADDRESS~N4*PATTOWN*ST*12345~DMG*D8* *M~REF*SY* ~CLM*6294*145.50***13:B:1*Y*A*Y*Y~DTP*454*D8* ~DTP*304*D8* ~DTP*431 *D8* ~DTP*297*D8* ~DTP*296*D8* ~DTP*435*D8* ~DTP*096*D8* ~HI*BK:24 4*BF:29643*BF:3180~NM1*DN*1*PPLASTNAME*PPFIRSTNAME****XX*ppnpi~REF*1G* ~NM1*82*1*THLASTNAME *THFIRSTNAME****XX*NPI24~PRV*PE*ZZ*103TC0700X~NM1*77*2*HUNDRED ACRE WOOD*****XX*POSNPI~N3*789 PEACHTREELANE~N4*SANDERS*VT*05245~REF*1G*POSID1~NM1*DQ*1*PESQUIN*GEGES****XX* ~SB R*S*01*Ins2FECANumber******CI~OI***Y***I~NM1*IL*1*Ins2LastName*Ins2FirstName****MI*Ins2IDNumber~N3*Insured2Add ress~n4*insured2town*st* ~ref*sy* ~nm1*pr*2*insgn2*****pi*nhpi2~n3*insauthnaddres S2~N4*INSAUTHNTOWN2*ST* ~SBR*T*01*Ins3FECANumber******CI~OI***Y***I~NM1*IL*1*Ins3LastName*Ins3Fi rstname****mi*ins3idnumber~n3*insured3address~n4*insured3town*st* ~ref*sy* ~nm1*pr*2*ins GN3*****PI*NHPI3~N3*INSAUTHNADDRESS3~N4*INSAUTHNTOWN3*ST* ~LX*1~SV1*HC:90806:21*145.5*U N*1***1:2:3~DTP*472*D8* ~NTE*ADD*SUPPLEMENTARY~SE*67* ~GE*1*1~IEA*1* ~ Last updated: October 1, 2018 TheraManager Docutrac Page 1 of 12

2 5. Within Notepad, use the Edit Find (Ctrl+F) function to find the desired item from the leftmost column of table in the following pages. Since the desired item might appear more than once within the claim (e.g., ~NM1*IL*1*), click the Find Next button as needed. If the EDI target should reject one or more of your claims, the rejection notice may include one of the segments referenced in the leftmost column. These are listed below in the order that they appear in the claim. The datum (e.g., a patient s DOB, a provider s NPI number) should appear immediately thereafter within the claim. As troubleshooter, your job is to find the item. If the item does not appear in the claim or if it was entered incorrectly go to the applicable TheraManager screen and resolve the issue. Strictly for reference, the following table also lists the equivalent box within the paper CMS- form where the data would appear. [Data elements are included in brackets.] The careful reader will note that some data within the EDI claim does not appear within the CMS- form; conversely, some data in the CMS- form does not appear in the EDI claim. ISA: Elements specific to the EDI target (Note 1) ~GS*HC* EDI-target-specific, followed by date and time statement was printed ~ST*837* Statement number (within TheraManager) ~BHT*0019*00* Statement number of claim Statement Batch number of batch Date and time of claim generation Upon printing/reprinting Accounts CPT Records 31 (date only) Loop 1000A Submitter Information ~NM1*41*2* Submitter name Administrator 33 ****46* [NM109] Submitter ID Electronic Setup ~PER*IC* User real name (i.e., the user who generated the claim) Administrator User/s Rights *FX* Submitter fax number Administrator *TE* Submitter telephone number Electronic Setup *EM* Submitter address Administrator Corporation/s Loop 1000B Receiver Information ~NM1*40*2* [NM103] Receiver name (i.e., the EDI target) Administrator Electronic Setup Loop 2000A Billing/Pay-to Provider Information HL*1**20*1 Orgns/Plans PRV*BI*PXC* Billing entity non-npi ID (Note 2) 33b Last updated: October 1, 2018 TheraManager Docutrac Page 2 of 12

3 Loop 2000B Subscriber Hierarchical Level (not included in TheraManager-generated claims) Loop 2000C Patient Hierarchical Level (not included in TheraManager-generated claims) Loop 2010AA Billing Provider Information (Note 3) ~NM1*85*2* Corporation name Administrator 33 (Note 4) Electronic Setup *****XX* [NM108, NM109] Billing entity code 33a qualifier and NPI number ~N3* Corporation address 33 ~N4* Corporation town * Corporation state * Corporation ZIP+4 [REF01, REF02] Administrator Corporation/s ~REF*EI* Employer identification number ~REF*SY Social Security number ~PRV*PE*PXC Billing entity non-npi ID (Note 5) Orgns/Plans Loop 2010BA, 2320 and 2330A Subscriber Information ~SBR*P* [NM109]~SBR*P* only: (~SBR*S*) ((~SBR*T*)) IF the subscriber is the patient 18* IF the subscriber is not the patient [null] followed by Insurance Primary (Secondary) ((Tertiary)) 33b 11 [SBR03] Primary (secondary) ((tertiary)) insured group policy or FECA number Last updated: October 1, 2018 TheraManager Docutrac Page 3 of 12

4 ****** Plan type (Claim Filing Indicator code): IF BL Blue Cross Blue Shield IF CH TriCare/Champus IF CI Commercial insurer (non- HMO) IF FI Federal Employee Program (FEP) IF MB Medicare Part B IF MC Medicaid IF OF FECA IF VA Champus/VA Orgns/Plans Plans (Note 6) 1 ~AMT*D ~NM1*IL*1* ****MI* ~N3* ~N4* IF 16 Commercial insurer (HMO) (Secondary) ((tertiary)) Amount paid by (primary) ((secondary)) insurer [NM103, NM104, NM105, NM107] Primary (secondary) ((tertiary)) insured LFMName [NM108, NM102] Primary (secondary) ((tertiary)) insured ID number [N301, N302] Primary (secondary) ((tertiary)) insured address [N401] Primary (secondary) ((tertiary)) insured town * [N402] Primary (secondary) ((tertiary)) insured state * [N403] Primary (secondary) ((tertiary)) insured ZIP Accounts CPT Records (Note 7) Insurance Primary (Secondary) ((Tertiary)) ~DMG*D8* [DMG01, DMG02] Insured DOB 11a M or F [DMG03] Gender a 7 Last updated: October 1, 2018 TheraManager Docutrac Page 4 of 12

5 Loop 2010BB Payer Information ~NM1*PR*2* [NM103] Primary (secondary) ((tertiary)) insurance organization official name *****PI* [NM108, NM109] Primary (secondary) ((tertiary)) insurance payer ID ~N3* Primary (secondary) ((tertiary)) insurance organization address (Note 8) ~N4* Primary (secondary) ((tertiary)) insurance organization town * Primary (secondary) ((tertiary)) insurance state * Primary (secondary) ((tertiary)) insurance ZIP+4 ~REF* [REF01] Primary (secondary) ((tertiary)) insurance secondary information for payer (Note 9) Loop 2010CA Patient Information (Note 10) ~PAT* Primary (secondary) ((tertiary)) insured relation to patient: IF 01 Spouse IF 19 Child Orgns/Plans Insurance Primary (Secondary) ((Tertiary)) Top center Top center 6 IF G8 Other ~NM1*QC*1* Patient LFMName Patients Patient 2 ~N3* Patient address Data 5 ~N4* Patient town * Patient state * Patient ZIP (ZIP+4 not required for patients) ~DMG*D8* Patient DOB 3 * Patient sex: IF M Male ~REF*SY* IF F Female Patient SSN Last updated: October 1, 2018 TheraManager Docutrac Page 5 of 12

6 Loop 2300 Claim Information ~CLM* Patnumber Patients Patient * Primary: Amount billed ( field on Accounts CPT Records) Secondary: Tertiary: Data Customization Codes etc Orgns/Plans Box 26 (Note 11) 24F, 29 Loop 2310C Facility Information *** [CLM05-1] Facility Code Value (i.e., POS code) :B [CLM05-2] Facility Code Qualifier (Note 12) Loop 2300 Claim Information 1 7 [CLM05-3: Claim Frequency Code] 1: Original claim Customization Places of Service 7: Replacement claim *Y*A*Y* [OI05] Accepts (declines) assignment Post Appointment (*Y*C*N) form Y (I) [CLM10] Signed record release on file Insurance (not on file) Primary (Secondary) ((Tertiary)) ~DTP*454*D8* [DTP01, DTP03] First date of same or Insurance similar illness Miscellaneous ~DTP*304*D8* DOS Book Appointment form ~DTP*431*D8* [DTP01, DTP03] Date of current Insurance illness/trauma Miscellaneous ~DTP*297*D8* Dates unable to work in current occupation (start) ~DTP*296*D8* Dates unable to work in current occupation (end) 24B 22 (Note 13) A Last updated: October 1, 2018 TheraManager Docutrac Page 6 of 12

7 ~DTP*435*D8* Hospitalization dates related to current Insurance services (start) Miscellaneous ~DTP*096*D8* Hospitalization dates related to current services (end) Note 14 ~HI*ABK: [HI101-1, HI-101-2] Diagnosis code 1 Dx/Problems *ABF: [HI102-1, HI-102-2] Diagnosis code 2 *ABF: [HI103-1, HI-103-2] Diagnosis code 3 *ABF: [HI104-1, HI-104-2] Diagnosis code 4 *ABF: [HI105-1, HI-105-2] Diagnosis code 5 *ABF: [HI106-1, HI-106-2] Diagnosis code 6 Loop 2310A Referring Provider Information Post Appointment form ~NM1*DN*1* [NM103, NM104, NM105, NM107] Contacts 17 Referring physician LFMName ****XX* [NM109, NM108] Referring physician NPI 17b number ~REF* Referring physician non-npi ID (Note 2) 17a Loop 2310B Rendering Provider Information ~NM1*82*1* Provider LFMName Orgns/Plans (paper) 31 ****XX* [NM109, NM108] Rendering provider NPI number (Notes 15 and 16) Administrator Clinician/s (electronic) Customization Clinician Information ~PRV*PE*PXC* Taxonomy code (Note 17) Orgns/Plans ~REF*0B Provider state license number Customization Clinician Information J (bottom) 24J (top) 31 Last updated: October 1, 2018 TheraManager Docutrac Page 7 of 12

8 Loop 2310C Facility Information ~NM1*77*2* Facility name Customization 32 ****XX* [NM108, NM109] Facility NPI number Places of Service 32a ~N3* [NM301] Facility address 32 ~N4* Facility town * Facility state * Facility ZIP+4 ~REF* Facility non-npi ID Orgns/Plans 32b Loop 2310D Supervising Provider Information (Notes 18 and 19) ~NM1*DQ*2* [NM101, NM102] Supervising provider Customization Clinician Information ~REF* [NM109, NM108] Supervising provider non-npi ID (Note 2) Orgns/Plans 24J (top) Loop 2400 Service Line ~SV1*HC: CPT code Customization 24D : Modifier (MOD) code Codes etc * Amount billed Customization Codes etc 24F Orgns/Plans *UN* Number of units Post Appointment 24G form *** Pointers ( field on Accounts Dx/Problems 21 CPT Records) each pointer in the claim separated by a colon ~DTP*472*D8* DOS Book Appointment 24A form ~PRV*PE*ZZ* Taxonomy code (Note 17) Customization Codes etc ~SVD* National Plan ID Orgns/Plans Plans * Amount paid by primary (secondary) Accounts CPT 29 insurer (Note 20) Records (Note 7) HC: [SV101-1] CPT code Customization 24D : [SV101-3, SV101-4, SV101-5, SV101-6] Codes etc Modifier (MOD) code Last updated: October 1, 2018 TheraManager Docutrac Page 8 of 12

9 Loop 2430 Line Adjudication Information ~CAS*CO*45 (Secondary) Contractual adjustment Accounts CPT (Note 21) Records (Note 7) ~CAS*PR* (Secondary) ((tertiary)) Patient s responsibility (Note 22) 2* Claim adjustment reason code (Note 23) ~DTP*573*D8* [DTP02, DTP01] Date of primary Accounts CPT (secondary) insurer payment Records ~REF*G1* Authorization code (from primary insurer Authorization only) Authorizations ~CAS*OA*23 Other adjustments (Note 24) Accounts CPT Records (Note 7) ~NTE*ADD* Supplementary code Post Appointment form ~SE* Statement number Upon printing/reprinting (top half) See EDI Setup and Verification Checklist.pdf for a pro-active means to minimizing these tedious, time-consuming troubleshooting exercises. Notes 1. See Comparison of EDI Target Headers.pdf as needed. 2. Element PRV*BI*PXC appears in the claim if: Version 5010 is selected for the selected EDI target (cf. Setting Up Electronic Billing,pdf as needed) AND For the selected insurance organization, a taxonomy code is entered in, and prefix from 3. The billing provider information is excluded from the claim IF: On the Customization Clinician Information screen, is blank (default) for the selected clinician AND Last updated: October 1, 2018 TheraManager Docutrac Page 9 of 12

10 On the Orgns/Plans screen, is selected for the selected clinician and organization Solution: Either select a supervisor select for each organization 4. Element ~NM1*85*2* denotes the billing entity as a group. To change the billing entity to the individual provider (i.e., ~NM1*85*1) : Go to the Administrator Corporation/s screen Under : o Uncheck o Clear the radio button it should look like or Log back into TheraManager and regenerate the claim(s): o The segment will be ~NM1*85*1*, followed by the clinician s LFMIname o The clearinghouse will remove the NPI number within this loop 5. When indicated by the payer, the two-character secondary qualifier must be included with the non-npi ID:. This equates to Box 24I on the CMS- form. 6. The plan codes are generated based on plan type set on the Orgns/Plans Plans screen: MB CH CI 16 MC VA OF CI BL 7. Payment amounts are entered on the Payments Insurance screen. See the applicable Entering an Insurance Payment Help Note as needed. 8. Only the content of the upper field is included in the claim: Last updated: October 1, 2018 TheraManager Docutrac Page 10 of 12

11 9. See Secondary Payer ID.pdf for details. 10. Loop 2010CA is omitted if the patient and the insured ( subscriber ) are the same. 11. In contrast, Box 26 contains the patient s account number. 12. The Facility Code Qualifier appears in EDI version 5010 only appears in original claims. 7 appears in regenerated claims. With the latter, see Reprinting One or More Claims.pdf for details. 14. For ICD-9 codes, the A preceding the BK (for primary) and BF (for secondary) diagnoses is omitted: DSM-4/ICD-9 BK: xxxxx*bf:yyyyy DSM-5/ICD-10 ABK: xxxxx*abf:yyyyy 15. The provider LFMName will not appear in electronic claims if the NPI number is missing. 16. The billing entity NPI number will appear instead of the rendering provider NPI number if is selected in the Orgns/Plans screen. See Entering NPIs.pdf as needed. 17. Appears in this loop (actually, loop 2420A) only if: A taxonomy code is entered in the Customization Codes etc screen and Orgns/Plans screen, The taxonomy codes differ between screens AND If no taxonomy code is entered in The taxonomy code entered in Customization Codes etc appears in loop 2310B. If the receiver cannot process differing codes You should enter the same taxonomy code for all CPT codes for the selected clinician. 18. Loop 2310D is omitted for POS=12 (Home). Last updated: October 1, 2018 TheraManager Docutrac Page 11 of 12

12 19. Loop 2310E is omitted unless a supervisor is designated on the Customization Clinician Information screen ( ) AND on the Orgns/Plans screen ( ). See Designating a Supervising Clinician.pdf as needed. 20. The amount paid by the insurer within the claim should be consistent with the value in on the Accounts CPT Records screen. 21. Appears in the secondary or tertiary claim. Derived from the difference between the billed amount and the amount paid by insurance, i.e., With value becomes. Secondary:. checked on the Administrator Electronic Setup screen, this 22. Appears in the secondary claim only if is checked on the Administrator Electronic Setup screen. With checked, this value consists of the difference between the allowed fee and the amount paid by the primary insurer, i.e.,. 23. Refer to for the list of claim adjustment reason codes (CARCs). Within TheraManager, the default CARC is 2 (Coinsurance Amount). For any other CARC, the claim must be edited in Notepad. 24. Appears in the tertiary claim only if is checked on the Administrator Electronic Setup screen. With checked, this value consists of the difference between the regular charge and the patient responsibility, i.e., CAS*PR + +. Last updated: October 1, 2018 TheraManager Docutrac Page 12 of 12