This information summarizes PCG s and Programs role in accepting data, billing and moving claims towards full adjudication. 1
Workable Claims: Commercial Claims: For Dates of Service from July 1, 2017 to January 31, 2018 PCG will work the Commercial Claims results as needed. For Dates of Service February 1, 2018 and after Programs will work the claims as described on the Adjudication Matrix. Medicaid Claims: PCG is working with DSS on claims that have partially paid or not paid at all due to Medicaid edits that were in place, but have been removed. PCG works these claims by resubmitting them. Schedules: SPIDER is the system of record for child, visit, insurance, provider and IFSP information. PCG receives data on a regular schedule from Birth to Three. The following is a table of the data and dates received. This information provides assistance in determining when you correct something in SPIDER, when it will be received and applied to your claims. PCG bills daily for Commercial insurance and Medicaid. Data Type Visit Data Child Information (IFSP) Insurance Information Provider Information Family Fee Data Schedule Daily Every Sunday Every Sunday Weekly (Day to be determined) Monthly (Currently around the 20 th of each month) The Medicaid Cycle Calendar can be accessed here. 2
Adjudication Matrix Reason Codes: Claims decisions include CAR and RAR codes which have a description of the reason the claim was either rejected, approved or denied. These descriptions are those maintained by CMS, the National Uniform Claim Committee and committees that meet during the standard X12 meetings. Sometimes these reasons are clear and other times these reasons are vague and require research. There are many reason codes in each category. PCG reviews claim responses for codes which they must work. They also look for trends in claims denials, which may indicate a data issue or change in payer processing. PCG will address these situation with Birth to Three or the Payer; and follow up with information to the Programs. Resource: Click here for more information from Washington Publishing about CARC and RARC codes. Click here for more information about CT Medical Assistance Program s Non-Pharmacy EOB Crosswalk Needs Attention Queue: There are few opportunities to change data in EIBilling. In the Needs Attention queue there is the option to correct diagnosis, CPT and therapist. All other data that requires correction must be corrected in the source system, SPIDER. This information will then be received by EIBilling and the claim will have the appropriate action taken. The next action may be to rebill the same claim as a corrected claim, void the claim or bill it as a new claim. If the Payer request more information, you may provide this information directly to the payer. In most cases, the payer will take an action on the claim and the decision will be received on an 835 (ERA) which will then move the claim from the Needs Attention queue and on to the second payer if necessary. SOMETIMES, the claim will not move out the Needs Attention queue after a period of time and the provider must select the Resubmit Selected Claims button in the Needs Attention queue. Please see the training Claiming Tab 3
Adjudication Matrix Error Categories Payer Type (Medicaid or Commercial) Examples Non-Workable Workable By PCG Workable by Billing Programs Provider Enrollment Both Most of errors are due to billing provider/practitioner setup issues with Medicaid. Eligibility Both Workable errors include instances where a claim is billed to Medicaid and Medicaid has determined the child to have other 3rd party coverage. Workable errors include a secondary commercial insurance was billed as primary. Non-workable errors include accounts where the payer has the member on file but the subscriber s benefits have terminated. 4
Adjudication Matrix Error Categories Payer Type (Medicaid or Commercial) Examples Non-Workable By PCG Workable Workable by Billing Programs Benefits Commercial The payer has denied the claim and determined that the child coverage does not include Early Intervention benefits or that the child has reached the maximum benefit limit for the plan. Authorization Both This occurs when the Payer requires the provider to obtain an authorization for services. This is most common when the practitioner is a non-participating provider. * Billing Both These are errors due to timely filing limit, claim denials errors caused by incorrect billing of claims or errors due to duplicate claim submission. Most of these claims are Medicaid related and can be resubmitted by PCG. 5
Error Categories Payer Type (Medicaid or Commercial) Examples Non-Workable Workable By PCG Workable by Billing Programs CPT Code Both The payer has determined that the CPT code for the service billed is invalid. Diagnosis Code Both The diagnosis code billed is not accepted by the payer. Contractual Adjustment Commercial The allowed amount by the payer is less than the billed amount. The difference between the billed amount and the allowed amount is the contractual adjustment. Patient Responsibility Commercial The payer reimburses the Provider less than the billed amount since as it has applied a coinsurance, deductible or co-payment to the billed amount. Out of Network Commercial The Billing Provider is not in the payer s network or a non-participating practitioner and is not eligible to receive reimbursement for services rendered. 6
Error Categories Payer Type (Medicaid or Commercial) Examples Non-Workable Workable By PCG Workable by Billing Programs Miscellaneous Both These are errors that have low volume and do not easily fit into one of the other 12 main categories. Claims that fall into this category primarily include: Payments paid to the families, payer requires additional documentation to process claims, payer considers services are bundled charges more than allowed amounts and the payer deems the service to not be effective or not a medical necessity. All workable errors are the responsibility of the billing provider to correct 7
Commercial Insurance Provider credentialing with CI Insurance Verification Preauthorization Additional documentation requested by CI PCG If, as part of the claims process, PCG identifies a Payer who requires credentialing to pay claims, PCG will notify the billing program. Information and links to the credentialing process will be provided as available from Payers. PCG will use the 270/271 EDI transaction to verify insurance; PCG will return a file to B23 with errors determined in the insurance verification process. If a claims decision shows preauthorization is required, PCG will notify the program through the Needs Attention queue. The Program may also receive a notification from the Payer. If claims analysis shows a Payer/service often requires preauthorization PCG will notify programs. If claims analysis shows a change in a Payer/service authorization requirement, PCG will notify programs PCG will notify the programs if additional documentation is required by a payer through the Needs Attention queue in EIBilling. The Program may also receive a notification from the Payer Billing programs Programs are responsible for notifying practitioners if credentialing is required. Practitioners complete the payer requirements. Programs are responsible for collecting insurance information and entering it into SPIDER accurately. They are also responsible for obtaining the correct insurance information if invalid information is identified by PCGs process. Once correct insurance information is entered into SPIDER, it will be received by PCG the following Sunday and a claim will be submitted by PCG Programs will obtain the preauthorization from the Payer and enter the preauthorization number in SPIDER Programs will submit documentation required by the Payer directly to the payer. Some payers will complete processing the claims and send a final response on the 835 (ERA) which will remove the claims from the Needs Attention queue. At other times Programs will have to select the Resubmit Selected Claims button in the Needs Attention queue. 8
Commercial Insurance PCG Billing programs Submission of IFSP Mandated/Not mandated EOBs EI Billing New Users SPIDER data Claim Editing and Validation Process PCG will notify billing programs of the need to submit an IFSP (additional documentation) through the Needs Attention queue PCG will determine through 1) data received from SPIDER 2) the insurance verification process 3) claims response PCG will use the 835 ERA process to receive claims data. Programs have signed up with Change Healthcare. In some cases, a payer may not offer the 835s, in this case PCG will accept EOBs from the program PCG offers training on EIBilling Use through scheduled and on demand trainings posted to the EIBilling website. PCG will receive child, insurance, service, program and Family Cost Participation data from SPIDER and bring it into EIBilling. PCG will notify B23 of errors in this data which effect the claims or FCP payment process PCG will receive the Data from SPIDER to create the claims. PCG will apply edits to assure the data is complete and a claim can be created Program will submit the IFSP, if requested by the payer If a consent to bill is required, the program will complete this form with the family and enter the information in SPIDER Billing Programs will fax EOBs to 860-955-1480 or 860-955-3528. Fax EOBs only. Do not fax letters requesting documentation or copies of checks. The EOBs are used to adjudicate claims and move them to the next Payer. Do not write notes on the EOB. If there is information you need PCG to know please contact the Call Center at 844-293-0023. The representative will assist in directing your information appropriately. Programs should offer the EiBilling training videos and material to new employees who will be using EIBilling prior to their use of EIBilling. Programs may create log ins for new users. Click here for more information Programs will work to correct incorrect data in SPIDER Programs will work to correct missing or invalid data in SPIDER 9
Commercial Insurance PCG Billing programs Claim Submission Process Apply CPT Codes to claims Apply Diagnosis Codes to claims Adjudication Matrix PCG will submit the claims via the 837 EDI transaction to Payers. PCG will receive Service Type and Disciplines from SPIDER and map them to CPT codes to submit on claims. PCG will work claims denied for incorrect CPT code and resubmit the claim. PCG will work with Birth to Three to map combinations of Service Type and Disciplines which are not previously mapped. PCG can assist with diagnosis related items such as assuring all diagnosis received from SPIDER are on the claims, identifying Payer trends and communicating these results to Programs. PCG may not add a diagnosis to the claim that is not reflected by the Practitioner in SPIDER. PCG may also advise on the order of diagnosis codes related to the service billed. PCG will work to keep this matrix updated as changes are made in moving claims through EIBilling due to payer responses or B23 request. PCG will share this information with Programs Once a program has worked a claim in the Needs Attention queue, they will select the 'resubmit' button send the claim to the payer. However, the initial claims submission will be by PCG. Programs will enter service data into SPIDER which will be translated into a CPT codes and sent to PCG. Billing programs/practitioners enter the diagnosis in SPIDER. PCG will receive these codes and enter them on the claim. Programs will review claims denial or rejections related to diagnosis in the Needs Attention queue. Programs will work those they can, i.e. missing diagnosis. (PCG will offer more guidance on coding requirements of Payers in a separate document) Programs will be responsible for applying any applicable new changes to the adjudication matrix * At times, authorizations can be non-workable. The denial reason provided in the matrix will determine whether it is workable or non-workable 10
Roles Billing Providers Practitioner Payer Insurance Subrogation Letter Administrative Services Only (ASO) Glossary Programs or agencies billing for EI Services Individuals who are providing EI Services, sometimes called rendering provider by insurance companies Commercial Insurance, Medicaid or the State paying for EI services A document sent to a commercial payer by a billing provider to exercise their right of subrogation upon the practitioner's assignment as the early intervention service provider for the child. A group health self-insurance program for large employers wherein the employer assumes responsibility for all the risk, purchasing only administrative services from the insurer. Such administrative services include: preparation of an administration manual, communication with employees, determination and payment of benefits, preparation of government reports, preparation of summary plan descriptions, and accounting. Claims Decisions Approved Denied Rejected Pending Claims Processing Adjudication Partially Paid Paid in Full The commercial payer or Medicaid has reviewed the claim and determined it meets their coverage criteria. The decision by a commercial payer or Medicaid to refuse to honor a request for payment by a billing provider to pay for health care services obtained from a health care professional or early intervention practitioner. The commercial or Medicaid claim has failed automated edits preventing the claim for services to be reviewed against insurance or program coverage criteria. The claim has made it through the review of the demographics and eligibility for both provider and the insured. However, at the review of the service there is additional information required to make a final decision on the claim. This generally only applies to Medicaid. The process of making a decision about the claim The billing provider is reimbursed at less than the billed amount The billing provider is reimbursed at or above the billed amount and the claim is closed 11
Billing Errors Workable Non-workable Remittance Advice Explanation of Benefits (EOB) Electronic Transactions EDI - Electronic Data Interchange EDI 270 EDI 271 EDI 276 EDI 277 EDI 835 EDI 837 Errors determined by commercial payer or Medicaid that can be fixed. A claim that is not paid by a payer but the claim may be correct/appropriate. These claims move to the next payer. A letter returned by the commercial payer to the person filing the claim which describes the decision. The insurance company s written summary of a claim. The EOB shows what the provider billed, what the insurance company paid, and the remaining amount still owed. It also includes an explanation of any denial or reduction in benefits paid. the computer to computer exchange of business documents in a structured format Eligibility, Coverage or Benefit Inquiry Eligibility, Coverage or Benefit Information Health Care Claim Status Request Health Care Information Status Notification Health Care Claim Payment/Advice Health Care Claim Service Category Service Type Individual or Agent EIBilling Term Terminology Crosswalk SPIDER Term Service Type Discipline Practitioner or Billing Provider 12
Creating User Access for Your Agency Log in to EIBilling Select Maintenance from the menu Select Manage Users from the Maintenance Menu 13
Find the Add User button in the bottom left corner of the screen Enter the information for the user you would like to add. Select Save 14
Tips Upon receipts of the system generated user password, Users should create their own strong password which is easier to remember If an agency wishes to no longer allow EIBilling access to a User, they may disable their access by changing the email on their account and then resetting the password 15