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TES - Ingenix Claims Manager & Medi-Cal TAR Edits

TES - Ingenix Claims Manager & Medi-Cal TAR Edits. UCSF. Agenda. 11:00 AM – 11:10 AM Overview 11:10 AM – 11:30 AM MCA - TAR Auths and TES TAR Edits 11:30 AM – 11:50 AM Ingenix Claims Manager Edits 11:50 AM-12:00 PM Q&A. Background. Business Problem Coding

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TES - Ingenix Claims Manager & Medi-Cal TAR Edits

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  1. TES- Ingenix Claims Manager& Medi-Cal TAR Edits UCSF

  2. Agenda • 11:00 AM – 11:10 AM • Overview • 11:10 AM – 11:30 AM • MCA - TAR Auths and TES TAR Edits • 11:30 AM – 11:50 AM • Ingenix Claims Manager Edits • 11:50 AM-12:00 PM • Q&A

  3. Background • Business Problem • Coding • Established Vs New Patient codes • LCDs • CCI • Procedure/Modifier/Diagnosis combinations • Etc… • Authorizations • Missing • Not in System • Modified at time of service

  4. Background • Business Solution • Coding • Ingenix Claims Manager • TES edits • Authorizations • MCA Authorizations • TES Edits

  5. MCA TAR Authorizations

  6. TAR Auths (Status)

  7. F7P-Page Function TAR Auth Details - 1

  8. TAR Auth Details - 2

  9. Linking TAR Auth to Visit • Action Code C

  10. Blank Ref Auth# Field Blank Referral Field TES Edits for missing or incomplete TAR • ?T look up

  11. Ingenix Claims Manger (ICM) • TES Encounters sent to Ingenix Claims Manager (ICM) Nightly • ICM utilize standard and custom edits across claims • ICM Edits returned that night to TES work files

  12. CONSTRAINTS AND ASSUMPTIONS • ICM edits will be rolled out in phases • Three Pilots • Dept. of Medicine • Dept. of Radiology • Dept. of Surgery • Medicare, and Commercial then Medi-Cal • TES redesign limited to Work File definitions and Edits • PFS will determine if new edit will hold SMS bound charges too

  13. Current Status • Hardware Implementation • Interface Set Up • Establish Edit Design Team

  14. Executive Wrap Up Q & A

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