Claim Management

1. 10 Claim Management

2. 10-2 Learning Outcomes When you finish this chapter, you will be able to: 10.1 Briefly compare the CMS-1500 paper claim and the 837 electronic claim. 10.2 Discuss the information contained in the Claim Management dialog box. 10.3 Explain the process of creating claims. 10.4 Describe how to locate a specific claim. 10.5 Discuss the purpose of reviewing and editing claims. 10.6 Analyze the methods used to submit electronic claims.

3. 10-3 Learning Outcomes (Continued) When you finish this chapter, you will be able to: 10.7 List the steps required to submit electronic claims. 10.8 Describe how to add attachments to electronic claims. 10.9 Explain the claim determination process used by health plans. 10.10 Discuss the use of the PM/EHR to monitor claims.

4. 10-4 Key Terms • adjudication • aging • claim status category codes • claim status codes • claim turnaround time • CMS-1500 (08/05) claim • companion guide • crossover claim • data elements • determination • development • filter • HIPAA X12 837 Health Care Claim • HIPAA X12 276/277 Health Care Claim Status Inquiry/Response • insurance aging report • medical necessity denial • National Uniform Claim Committee (NUCC) • navigator buttons

5. 10-5 Key Terms (Continued) • pending • prompt payment laws • suspended • timely filing

6. 10-6 10.1 Introduction to Health Care Claims • Timely filing—health plan’s rules specifying the number of days after the date of service that the practice has to file the claim • HIPAA X12 837 Health Care Claim—HIPAA standard format for electronic transmission of the claim to a health plan • CMS-1500 (08/05) claim—mandated paper insurance claim form • National Uniform Claim Committee (NUCC)—organization responsible for claim content

7. 10-7 10.1 Introduction to Health Care Claims (Continued) • Data element—smallest unit of information in a HIPAA transaction • Notable features of the HIPAA 837 transaction (as compared to the CMS-1500 paper form): • It has many more data elements, though many are conditional and apply to particular specialties only. • It uses some different terms, and a few additional information items must be relayed to the payer. • It requires a claim filing indicator code.

8. 10-8 10.2 Claim Management in Medisoft Network Professional • Insurance claims are created, edited, and submitted for payment within the Claim Management area of MNP. • Information contained in the Claim Management dialog box: • All claims that have already been created • Status of existing claims • Options for editing, creating, printing/sending, reprinting, and deleting claims • Navigator buttons—buttons that simplify the task of moving from one entry to another

9. 10-9 10.3 Creating Claims • Claims are created in the Create Claims dialog box of MNP; to create a claim: • Click the Create Claims button in the Claim Management dialog box; the Create Claims dialog box will open. • Apply the appropriate filters; any box that is not filled in will default to include all data. • Click the Create button to create the claims. • Filter—condition that data must meet to be selected

10. 10-10 10.4 Locating Claims To locate a claim in MNP: • Click the List Only… button in the Claim Management dialog box; the List Only Claims That Match dialog box will be displayed. • Apply the appropriate filters. • Click the Apply button. • The Claim Management dialog box is displayed, listing only the claims that match the criteria that were selected. • Claims can now be edited, printed, or transmitted from the Claim Management dialog box.

11. 10-11 10.5 Reviewing Claims • Claims should be checked before transmission. • Most PM/EHRs provide a way for billing specialists to review claims for accuracy. • In MNP, this task is accomplished by using the Edit button in the Claim Management dialog box to load the Claim dialog box. • The more problems that can be spotted and solved before claims are sent to carriers, the sooner the practice will receive payment.

12. 10-12 10.6 Methods of Claim Submission • Three most common methods of transmitting electronic claims: • Direct transmission to the payer—Claims created in the PM/EHR are sent to the payer’s computer directly via a connection. • Direct data entry—A member of the provider’s staff manually enters claims into an application on the payer’s website. • Transmission through a clearinghouse—Practices send their claims to clearinghouses to be edited and then sent to the payer; this is the method used by most providers.

13. 10-13 10.6 Methods of Claim Submission (Continued) • Companion guide—guide published by a payer that lists its own set of claim edits and formatting conventions • Crossover claim—claim billed to Medicare and then submitted to Medicaid

14. 10-14 10.7 Submitting Claims in MedisoftNetwork Professional To submit electronic claims in MNP: • Select Revenue Management > Revenue Management… on the Activities menu; the Revenue Management window opens. • Select Claims on the Process menu. • Select an EDI receiver. • To perform an edit check, click Check Claims; when complete, the Edit Status column displays the status of each claim. • To continue with ready-to-send claims, select Send, select Claims, and select the EDI receiver.

15. 10-15 10.7 Submitting Claims in MedisoftNetwork Professional (Continued) To submit electronic claims in MNP (continued): • A claim file is created and a preview report is displayed. • If any errors are identified, the claims must be edited before they can be transmitted. • Click the Send button to send the claim files.

16. 10-16 10.8 Sending Electronic ClaimAttachments • Attachments that accompany electronically transmitted claims must be referred to in the claim. • In MNP, the EDI Report Area within the Diagnosis tab of the Case dialog box is used to indicate that there is an attachment and how it will be transmitted. • An attachment control number is required if the transmission code is anything other than AA.

17. 10-17 10.9 Claim Adjudication • Adjudication—series of steps that determine whether a claim should be paid • Initial processing—Data elements are checked by the payer’s front-end claims processing systems. • Automated review—Payers’ computer systems apply edits that reflect their payment policies. • Manual review—Claims with problems are set aside for further review. • Determination—Payer makes a decision about how to handle a claim. • Payment—If due, payment is sent to the provider.

18. 10-18 10.9 Claim Adjudication (Continued) • Suspended—claim status when the payer is developing the claim • Development—process of gathering information to adjudicate a claim • Determination—payer’s decision about the benefits due for a claim • Medical necessity denial—refusal by a plan to pay for a procedure that does not meet its medical necessity criteria

19. 10-19 10.10 Monitoring Claim Status • Practices closely track their accounts receivable using their PM/EHR. • After claims have been accepted for processing by payers, their status is monitored using the PM/EHR. • Monitoring claims during adjudication requires two types of information: • The amount of time the payer is allowed to take to respond to the claim • How long the claim has been in process

20. 10-20 10.10 Monitoring Claim Status(Continued) • Prompt payment laws—state laws that mandate a time period within which clean claims must be paid • Claim turnaround time—time period in which a health plan must process a claim • Aging—classification of accounts receivable by length of time • Insurance aging report—report that lists how long a payer has taken to respond to insurance claims

21. 10-21 10.10 Monitoring Claim Status(Continued) • HIPAA X12 276/277 Health Care Claim Status Inquiry/Response—electronic format used to ask payers about claims • Claim status category codes—used to report the status group for a claim • Pending—claim status in which the payer is waiting for information before making a payment decision • Claim status codes—used to provide a detailed answer to a claim status inquiry