EZ-CAP Claimshop Interface

Sanjay Goel

Manager, Software Development

Daren DeBow

Account / Sales Support Manager

Welcome!

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What is Claimshop?Why use Claimshop?EZ-Steps on pricing and getting Edits via

Claimshop.EZ-CAP Claimshop Configurations.Processing information and results.Claimshop changes in Auto Adjudication

and Workflow.Q&A

What is Claimshop?

• Pricing Hospital and Professional Claims using MedAssets managed care insurance pricing.• Get Contract and Copay values for the successfully priced claims.

• Show DRG grouper details for Hospital Inpatient Claims.

• Show APC details for each detail line for Hospital Outpatient Claims.

• Send various processing information.

• CCI Edits Hospital (Outpatient) and Professional Claims using MedAssets CCI Edits.• NCD, LCD, Policy, Age Gender, Modifier and many more.

• Show Trigger Code, Excluded Code and Description for each detail line for Hospital Outpatient and Professional Claims.

• DRG Claims (Hospital Inpatient Claims) not applicable for CCI Edits as they are included as part of pricing.

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Why Claimshop?

• More accurate Pricing/Edits based on Medicare.

• Beats manual pricing and Edits.

• Seamless integration from EZ-CAP saves time.

• Interface already included with EZ-CAP 651 onwards. Only activation is needed.

• No server installation and updates.

• Web service is hosted by MedAssets on their server with the latest changes always included.

• 99.9% up time.

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Pricing Supported by Claimshop

1. IPPS (MS-DRG) – all aspects and variations including CAH, SCH, EACH, MDH, RRP,VBP, low volume, and the rest

2. OPPS – including APC, all four fee schedules, and reasonable cost (SI = F or L)3. Physician RBRVS – includes all localities4. LTCH – including SSO and VSSO5. SNF6. ASC7. Ambulance8. Inpatient psych9. Inpatient rehab10. ESRD11. Hospice – both inpatient and outpatient12. RHC13. DME – everything except “portable oxygen”, which requires a series of “if-then”

decisions14. POS – “Prosthetics, Orthotics and Surgical Supplies”15. PEN – “Parenteral and Enteral Nutrition”16. ORF – “Outpatient Rehabilitation Facility”17. CORF – “Comprehensive Outpatient Rehabilitation Facility”18. CMHC – “Community Mental Health Center”19. HH- Home Health

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Claims Pricing/Edits Processing

• Two ways to price/Edit claims -1. Batch claims based on filter criteria for

multiple claims processing and scheduling.

2. On-Demand for individual claims.

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EZ Steps for Processing Claims

1. Assign an NPI or Medicare 1C to provider identification.

2. Create a claim with all mandatory fields.

3. Configuration (Global/Company/Reimbursement) if required. (For

CCI Edits these are not required).

• Global level.

• Company level at Health Plan, Option.

• Copay/Coinsurance, Allowed Amounts calculations.

• Reimbursement Value calculations.

4. Process the claim.

• Batch.

• On – Demand.

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Step 1 for Processing Claims

Add Provider NPI

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Step 1 for Processing Claims

Or Medicare ID as 1C Identification Type

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Step 1 for Processing Claims

Zip Code for Professional Claims

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Step 2 for Processing Claims

Create a claim with all mandatory fields entered

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Step 3 for Processing Claims

Create Configuration (Global/Company/Reimbursement) if required

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Processing Claims - Batch

Company ID, Batch Description and Batch Information.

Add a criteria to the Filter.

Pick Price, CCI Edit or both.

Preview the claim result with the criteria.

Create the Batch.

Process Batch with Claimshop or schedule the Batch to run later.

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Processing Claims - Batch

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Processing Claims – On Demand

Right-click Menu > Utilities > Price Via Claim Shop or CCI Edits or Price and CCE Edits

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Processing Claims –

Results

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Processing Claims –

Results

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Processing Claims –

Results

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Processing Claims –

Reports

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Processing Claims –

Reports

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Claimshop Configuration

Claim Adjustment handling

Copay/Coinsurance Calculation (Inpatient/Outpatient)

Allowed Amount determination (Hospital/Professional)

Global – Applies to all Claimshop processed claims

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Claimshop Configuration

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Company Healthplan Healthplan Option

Claimshop Configuration

Reimbursement

Apply Percent to Priced Amount coming from Claim Shop. Default is 100%.

Setup just like Fee Set Assignments.

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Edits Supported by Claimshop

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Included Edits in DRG and APC Groupers (UB)IOCE (Outpatient Facility) Includes, but not limited to the following:

Inpatient procedure conflict with TOB

Age/Gender

Invalid Procedure

Inpatient Procedure

Procedure and Gender Conflict

MCE – Medicare Code Edits (Inpatient Facility) Includes, but not limited to the following:

Inpatient specific validation

Invalid diagnosis or procedure code

Age/Gender

Non-covered procedures

NCCI – National Correct Code Initiatives

Other Edits (UB and 1500)• NCD –National Coverage Determination

• LCD – Local Coverage Determination

• NCCI – National Correct Code Initiatives

• Diagnosis code Validation

• Age Edits

• Gender Edits

• Modifier Edits

• Advance Beneficiary Notice of Non-coverage (ABN) edits

• History Edits/Global Pricing

• ICD9 Manifestation Edits

• ICD9 Unacceptable Principal Diagnosis

• ICD9 Validation Edits (for DOS)

• MUE – Medically Unlikely Edits

• CPT Validation Edits (for DOS)

• CPT Place of Service Edits

• CPT EM Surgical Edits with proper Modifiers

• RVU functionality/Edits

• Diagnosis Validation

• History Edits/Global Billing

Claim Shop Bill Types

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Auto Adjudication & Workflow

Elements added for Claim Shop with new pend codes for Auto Adjudication

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Auto Adjudication & Workflow

And Workflow

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Auto Adjudication & Workflow

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AUTO ADJUDICATION CRITERIA Value Description

CLAIM SHOP PRICE STATUS 0 TO 6 Various status returned by Claim Shop

IS CLAIM PRICED BY CLAIM SHOP? YES/ NO

IS CLAIM EDITED BY CLAIM SHOP? YES/ NO

PEND CODE MASTERS

P25 PSU PRICE SUSPENDED

P25 PNR PRICE NEEDS REVIEW

P26 EDF EDIT FAILED

PEND CODE DETAIL

DP23 CEF CLAIMSHOP EDIT FAIL

WORK FLOW RULESCLAIM SHOP PRICE STATUS 0 TO 6 Various status returned by Claim

ShopIS CLAIM PRICED BY CLAIM SHOP? YES/ NO

IS CLAIM EDITED BY CLAIM SHOP? YES/ NO

PEND CODE MASTERS

P25 PSU PRICE SUSPENDED

P25 PNR PRICE NEEDS REVIEW

P26 EDF EDIT FAILED

PEND CODE DETAIL

DP23 CEF CLAIMSHOP EDIT FAIL

Pricing, Edits and Benefits

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After the claim is priced via Claim Shop, the claim will still hit the EZ-CAP Benefits, Auto Adjudication and Workflow.

Copay and Coinsurance can be calculated based on benefit setup. Non-covered services will not be paid and an Adjustment Code will be applied.

Summary

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Claims can be Priced, sent for Edits or Priced and Edited together.

Batched or per claim.No installation is required.NPI is required for Hospital Claims and Zip Code is

required for Professional Claims. Both Auto Adjudication and Workflow include

Claimshop elements.All required information for pricing and edits are

stored in the claim.Activation key is required to process claims which

can be received from MedAssets and OrangeMZI.

EZ-CAP Claimshop Interface

Questions?

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