Selecting a FSC/Plan Overview Intrductin This lessn intrduces yu t assigning a FSC/Plan. Failure t crrectly assign the FSC/Plan can significantly impact revenues and can result in unnecessary prblems fr the patient. Crrectly identifying the crrect FSC/Plan is ne f the mst imprtant aspects f cllecting infrmatin frm the patient. Objectives Upn cmpletin f this lessn, yu shuld: Understand the keys t assigning a FSC/Plan Knw hw t use ur tls t select a FSC/Plan Learn hw t assign a plan Prerequisites: Prir t cmpleting this lessn, yu shuld have: Met the prerequisites specified fr the current mdule 1
Remember Keys t Success Number 7 7. Crrectly selecting a FSC/Plan and cmpleting the fllw-up questins Once the demgraphic infrmatin and billing/insurance infrmatin is available, a Financial Status Classificatin (FSC)/Plan is assigned. A FSC/Plan is a name, mnemnic r numeric cde assigned t billing/insurance infrmatin Crrectly identifying the patient s FSC/Plan is ne f the mst imprtant aspects f registratin Failure t crrectly assign the FSC/Plan can significantly impact revenues and can result in unnecessary prblems fr the patient Assigning a FSC/Plan is a challenge. There are a multitude f health insurance cmpanies wh Have a variety f health insurance plans that Usually have cmplex billing requirements that are ften changing Why is assigning a FSC/Plan such a challenge? Gvernment prgrams such as Medicare and Medicaid have their wn unique set f rules that must be fllwed when assigning a FSC/Plan. Example: With Medicaid it is imprtant t knw The state that prvides benefit If cverage is fr a fee-fr-service Medicaid r an HMO prduct 2
Remember Key t Success number 4: 4. Determining if Washingtn University Schl f Medicine (WUSM) is cntracted with a plan The reasns why assigning a FSC/Plan are such a challenge is cmpunded when the FSC/Plan assignr must determine if Washingtn University Schl f Medicine (WUSM) has a cntract with a given health insurance cmpany. Cmpanies which have cntracts with WUSM are called cntracted Cmpanies withut a cntract are called nn-cntracted What des this mean fr the Schl f Medicine? Established patients in IDX must have their insurance infrmatin reviewed frequently. There are ften changes resulting in the need t assign a new FSC/Plan. Whenever a new FSC/Plan is assigned, it is imprtant t verify eligibility with the payr using the Washingtn University Schl f Medicine schl-wide eligibility verificatin prcedures. It is als critical t cllect and enter a terminatin date n the ld FSC/Plan. Entering a term date will insure the ld plan will nt default t any new visit created after the terminatin date. 3
Review f the Basics f a FSC/Plan Key t assigning a FSC/Plan The keys t assigning a FSC/Plan are asking the crrect questins when: Pre-registering the patient during the scheduling call r pre-arrival. Lking at an insurance card btained at pint f service. Insurance Card Review The insurance card is the key surce dcument fr insurance infrmatin. It is essential that the patient/caller is asked if the insurance card is current. It is nt unusual fr sme patients t have multiple insurance cards r multiple plans. Yu must verify the health insurance card is current. The patient may have received a new insurance card fr new health insurance cverage, but may nt have the current card with them at the time f the appintment. 1. The first critical questin t ask when assigning a FSC/Plan is: Wh is the payr and what is the plan type? 2. The secnd critical questin is: Des the Schl f Medicine have a cntract with the plan? 3. The third critical questin is: If we are nt cntracted, des the patient s plan allw fr ut-fnetwrk benefits? T assist in answering these questins, refer t the P-FSC/Plan assignment jb aids: PFS Payr Database Determining FSC Assignment-Decisin Grid #1 4
Hw ften shuld insurance be verified? Medicare re-verificatins shuld be cmpleted every 30 days. Medicaid re-verificatins shuld be cmpleted n the mrning f the appintment befre the start f ffice/clinic hurs. All ther re-verificatins shuld be cmpleted at least every 120 days, r as frequently as the department plicy guidelines recmmend. 5
Selecting a FSC/Plan There are many critical questins t ask when assigning a FSC/Plan: Wh is the payr What is the plan type Des the card indicate a payr ID r destinatin cde Des the Schl f Medicine have a cntract with the payr Des the patient have ut-f-netwrk benefits What is the claims address What is the telephne number fr the payr Wh is the subscriber t the insurance If the subscriber is different than the patient: What is the subscribers name What is the subscribers date f birth What is the gender f the subscriber Wh is the emplyer f the subscriber What is the relatinship f the subscriber t the patient What is the effective date f the plan 6
Hw t Assign a FSC at the Registratin Level A patient presents with his Aetna HMO Insurance card. Steps used t assign a FSC frm the Manage Insurance Infrmatin Screen 1. Select t assign a new Registratin FSC. Example: Select Actin Cde A Add 7
2. At enter a FSC name, mnemnic, r number. Press r click. Example: FSC Dictinary Lk-up Screen (Name) Example: FSC Dictinary Lk-up Screen (Number) Example: FSC Dictinary Lk-up Screen (Mnemnic) 8
Entering the FSC by name will display a pp-up bx. Make the apprpriate selectin. Yu will chse the crrect FSC by verifying: A. name f the insurance cmpany B. type f plan (ex. HMO, PPO, etc) C. Payr ID cde/destinatin Cde (if available n the patient s card) Click Example: FSC Dictinary Lk-up 3. The system will branch t the FSC fllw-up questins. When cmpleting the FSC fllw-up questins, yu need t ask the patient the questins as they appear n the FSC fllw-up questins screen. The Subscriber is a persn wh receives health insurance benefits n behalf f themselves r their dependents. 9
If the subscriber is the patient, enter Self at the field. Example: HMO FSC Fllw-up Questins Example: Family Relatinships Dictinary 10
If the subscriber is different than the patient enter: Patient s Relatinship t Subscriber Name n Card (subscribers name) Subscriber s Emplyer Subscriber s Sex Subscriber s Birthdate Example: HMO FSC Fllw-up Questins Example: Family Relatinships Dictinary 11
What questins are nt asked f the patient? All eligibility verificatin questins, such as: Verificatin date Status Surce These fields are results f eligibility verificatin Pre-Arrival/Pint f Service/AR staff nly enter if manually verified Example: HMO FSC Fllw-up Questins (nt asked f patient) 12
1. Click t file and save the infrmatin. 4. The FSC is nw assigned t the patient s registratin n the Manage Insurance Infrmatin Screen. Example: Manage Insurance Infrmatin Screen Click t file and save the infrmatin. Actin Cde 1-Clear/Invke Plans shuld be used when the changes made at the Registratin level need t be reflected n the affected visit(s). 13
Hw t Assign a Plan at the Visit Level A patient presents with their Aetna HMO Insurance card. Steps used t assign a plan frm the Visit Insurance Plan Screen 2. Select t assign a new visit insurance plan. The system will branch t a secndary set f actin cdes. Example: Select Actin Cde A Add Plans 14
3. Select t add a new Visit Insurance Plan by FSC name, mnemnic, r number. Example: Select Actin Cde 1 Add By FSC 15
4. After selecting the system will branch t the FSC Dictinary Lk-up Screen. Example: FSC Dictinary Lk-up Screen 16
5. At the Name prmpt, enter the Plan/FSC by name, number, r mnemnic. Press r click. Example: FSC Dictinary Lk-up Screen (Name) Example: FSC Dictinary Lk-up Screen (Number) Example: FSC Dictinary Lk-up Screen (Mnemnic) 17
Entering the Plan/FSC by name will display a pp-up bx. Make the apprpriate selectin. Yu will chse the crrect plan by verifying: D. name f the insurance cmpany E. type f plan (ex. HMO, PPO, etc) F. Payr ID cde/destinatin Cde (if available n the patient s card) Click Example: FSC Dictinary Lk-up 18
The plan displays by name, number and mnemnic. Click Example: FSC Dictinary Lk-up 6. The system will branch t the plan fllw-up questins. When cmpleting the FSC/Plan fllw-up questins, yu need t ask the patient the questins as they appear n the FSC/Plan fllw-up questins screen(s). 19
If the subscriber is the patient, enter Self at the field. The Subscriber is a persn wh receives health insurance benefits n behalf f themselves r their dependents. Fill ut the field if the name n the card is different than what is entered in registratin. If the name is the same, but the card lists the middle initial rather than the full middle name, leave this field blank. IDX will nly pull the middle initial nt the patient s claim frm. Example: HMO FSC/Plan Fllw-up Questins Example: Family Relatinships Dictinary 20
If the subscriber is different than the patient enter: Patient s Relatinship t Subscriber Name n Card (subscribers name) Subscriber s Emplyer Subscriber s Sex Subscriber s Birthdate Example: PPO FSC/Plan Fllw-up Questins Example: Family Relatinships Dictinary 21
What questins are nt asked f the patient? All eligibility verificatin questins, such as: Verificatin date Status Surce These fields are results f eligibility verificatin the scheduler des nt ppulate these fields Pre-Arrival/Pint f Service nly enters if manually verified Example: PPO FSC/Plan Fllw-up Questins (nt asked f patient) Click t file and save the infrmatin. 7. The plan is nw assigned t the visit n the Visit Insurance Screen. Example: Visit Insurance Screen Click t file and save the infrmatin. 22
TPA/ASO/CMR Third Party Administratrs (TPA) A Third Party Administratr plan (TPA) will prcess and pay claims after the insurance cmpany apprves hw much will be paid fr the charges submitted. Example: A Third Party Administratr (TPA) is a claims payr wh assumes respnsibility fr administering health benefit plans withut assuming any financial risk. HealthLink is an insurance cmpany the Schl f Medicine has a cntract. HealthLink determines hw much the Schl f Medicine will be paid based upn cntractual agreements. HealthLink then frwards the claim t third party administratrs fr prcessing and payment. The Third Party Administratr (TPA) infrmatin is added t the visit in the fllw-up questins. Example: Third Party Administratr (TPA) Fields The Third Party Administratr (TPA) infrmatin aids the Accunts Receivable staff in the appeals and fllw-up prcess by prviding a means t cntact the TPA/ASO. 23
Example: The patient presents the insurance card shwn belw: HealthLink is the carrier The Third Party Administratr is The EPOCH Grup, L.C. Nte: Third Party Administratrs (TPA) are subject t change per cntractual agreements. When yu enter HeathLink the fllwing list appears: 24
Example: HealthLink The Payr Cde (destinatin cde) allws the claim t be sent electrnically. Example: Payr Cde 90001 Example: TPA/ASO/CMR Fllw-up Questins 25
What are ASO prducts? ASO refers t Administratin Services Only and refers t GHP line f prducts. GHP ffers different plan ptins t meet custmer needs. The custmer (emplyer grup) designs the insurance plan ptins that best fit their business. Examples f ASO prducts IBEW LOCAL NO 1, IBEW LOCAL 309 H&W FUND SP ST CHARLES COUNTY GOVT SP AMEREN GHP SP BRICKLAYERS LOCAL NO 1 OF MO BELLEVILLE SHOE MFG CO, ST LOUIS UNIVERSITY SP HENKEL OF AMERICA SP What abut CMR Prducts? CMR stands fr Care Management Resurces. CMR is part f the TPA/ASO categry f plans. The CMR name and phne number are added in these same fields. Examples: Beech Street/Capp Care BES/841 Cx Health Netwrk PPO/Primrse PRR/849 Decatur Memrial Hspital DMH/844 GHP Cventry/U Of Missuri GUM/184 26
Lessn Summary In this lessn yu learned: Steps t selecting a FSC/Plan Hw t use ur tls t select a FSC/Plan Steps used t assign a plan 27