Practice InsightInstructional Webinar

SeriesAdvanced Claim

ManagerPresented by:

Shaun McAnulty – Product Training Specialist

Topics to Cover

• Transfer Files• Claim Status Use• Selection Criteria• Right Click Functionality• Editing a Claim

Transfer Files

Upload Files

• View complete file in the format is was sent to PI in.

• See who uploaded claim file.• See claim files original uploaded

file name.• View error messages if Claim File

fails to load.• File break down showing claim

basic stats.• Download file if you need.

Response Files

• Repost to SFTP using Right Click if File is missing on PM. (Integrated users)

• Download file to repost to PM (Manual)

• Full EOB View• Mark ERA responses as

Received once they are pulled into PM (Best tracking)

File ID: used in selection criteria to locate this group

of claimsFile Name: the original file name for the upload.

File Type: what file was uploaded and what format.

Staff Name: who uploaded the file.

If the claims have any issue loading there will be

a message displayed

Multi Select Responses Mark ERA responses Received

(organizational)

See when a response was viewed & who by, when mark received & who by.

Filter List Responses

• Locate responses by File Type, File Name, Date ranges, Description, Status, File ID (File responses came in on), Retrieved ID (What file responses came in on) and Perform a Check Search using the Check Number.

Green= Commonly expected Statuses Red= Error or Workable Statuses

Yellow= Additional Statuses

Claim Status Definition Source

VALID Claim Valid (Must be set to READY to SEND to Payer)

TESTER /SCRUBBER

READY Claim Ready to be Batched and Sent to Payer

Auto Processed /Manual Status Override

ACK Claim Acknowledged Response

ACCEPTED

Claim Accepted by the Payer

Payer Response

PAID-ERA Claim Paid by Payer Payer Response (ERA 835)

PAID Claim Paid according to a User

Manual Status Override/ Received paper EOB

Statuses

Common Working Statuses

Green= Commonly expected Statuses Red= Error or Workable Statuses

Yellow= Additional Statuses

Claim Status

Definition Source

INVALID Claim Invalid by Tester or Scrubber

TESTER /SCRUBBER

REJECTED Claim Rejected by Payer

Payer Response

DENIED Claim Denied by a Payer

Payer Response / Real Time Claim Status (276)

INVALID•Fix in Claim Manager & set to READY.•Fix in PM & Rebill, Mark it Delete.

REJECTED

• Fix it Claim Manager set to Ready.

• Rebill From PM.• Mark

Complete. (EX.

PT Responsibility)

DENIED•Mark Complete.•Appeal & send Appeal Letter.

Common Working Statuses

Claim Status

Definition Source

APPEALED Claim Appealed by End User

Manual Status Override

COMPLETE Claim considered Complete by User

Manual Status Override

DELETE Claim Marked Deleted by a User

Manual Status Override, will not show on reports.

PAID-PYR Claim Payment Acknowledged by Payer

Real Time Claim Status (276)

PEND-USR Claim Pended by User Manual Status Override

PENDED Claim Pended by Payer Payer Response / Real Time Claim Status (276)

Additional Statuses

Green= Commonly expected Statuses Red= Error or Workable Statuses

Yellow= Additional Statuses

PAID-PYR

•Manual Real Time Check Status was run.•Payers decision was to Pay.•ERA not delivered yet to change the status to Paid-ERA.

PENDED•Claim has been manually marked to wait.•Status for when claims need to be easily grouped together that are waiting to be worked.

APPEALED

•When the Appeal Letter is marked as Printed the claims status will change to APPEALED.•Marked so when a determination is given on the claim it can be easily found.

Additional Statuses

DELETE•Claim will be fixed on the PM & resubmitted.•Claims marked Delete will not show on Analytics, or in general searches.•History will remain

COMPLETE

•Claim that will not be fixed.•Completed claims will show on Analytics.•History on claim will remain intact.

Organizational Statuses

TESTER rejections • 1st level of testing • Rule-based edits are used to stop claims with missing or invalid data or to flag

claims that meet a particular criteria. • Double click on rejection to take you to field in error for easy correction• Once the claim is corrected in Practice Insight it will retest as VALID then Ready

the claim.

How we get Invalid Claims

EDIFECS rejections• 2nd level of testing• Runs after claim has batched but before it’s sent to the payer, further tests claims to

assure they are ANSI compliant.• Correcting the claim WILL NOT make it VALID, Correct then Ready Claim!

• The same rejection message does not always have the same reason. • Look for clues in the rejection message to determine the cause:

o Example: Rejection message A7:562:85 is an enrollment rejection. The 85 points to the billing provider. In the ANSI file the billing provider name has a qualifier of 85. See below example of an ANSI file billing provider loop:

o EDI ID# 131415021 in Demo Database• Loop 2010AA Billing Provider Name • NM1*85*2*GROUP MEDICAL*****XX*1234567890

How we get Rejected Claims.

Payer/Trading Partner Rejections

• View the ANSI file to see which qualifier the rejection message is referring to: Using the Right Click to View Batch File!

• Example of common qualifiers referenced in rejection messages:o NM1*85 = billing provider o NM1*82 = rendering provider o NM1*IL = subscribero NM1*77 = service facility o NM1*DN = referring provider

How we get Rejected Claims.

Payer/Trading Partner Rejections

Selection CriteriaVendor/ CBO Level only:

specify customer.

Give age buckets, or calendar dates. Then select what date should be used

for the selection.

Specify an uploaded claim file from Transfer Files.

Can narrow selections to specific Providers as well.

Narrow claim selections by staff member assigned to. (Hotkey: A on claim)

Name or range search, also can

use Wildcard Searches.

(EX: %%ith)

Unique Id for specific claim

in EDIIf Clinical

Scrubbing (Extra Service) Edit Id

can be entered to locate all claims

with error.

Returns all claims based on Responsible Payer.

Selects claims using PI Payer ID.

The Outbound ID # for a Payer

If Payer or CH sends back their

ID number for the claim it is

also searchable.

Narrow by Type of Payer.

Can group claims with the same Response ID

Select claims that contain the same Retrieved ID.

RIGHT CLICK OPTIONSClaim Selection

View

Status Message View

Standard Functions

Claim Related

Functions

Views of Claim

Reports

Functions for All Claims

Claim Related Functions

Editing Claim

• Have the capability to pass change log back to PM.• Eliminating dual work

• Easy, logical layout to work claims.• Change transaction sequence easily moving their

order.• Hover text displays ANSI coordinates.

• Assisting you in locating the potential problem the payer or tester may be flagging.

Views of Claim Reports

View Inbound File•View EXACTLY what PM sent.•To research & fix invalid claims.•Views Entire file.

View Outbound File (Batch)

•View EXACTLY what was sent to PAYER.•To research & fix Rejected or Denied claims.•Views individual claim.

Get Inbound File

•Downloads full Inbound claim file.•Same as Downloading file in Transfer Files.

Inbound or Outbound Files?

Functions for ALL SELECTED Claims

Status Message View Options

Additional Functionality

• Ctrl+C: With a line item (Claim list view, or Status message view) highlighted, the user can copy and paste values. When CTRL+C is used a clipboard of the data will appear, to copy data simply double click on value desired.

• Ctrl+B: Displays what the claim would look like on a potential batch. Allowing you to view the potential Ansi data you would send to the payer.

• Delete Key: If user has permissions, using the delete key can delete highlighted selection (i.e. Claim, Uploaded File).

• Space Bar: Clears radio selections when no radio selection is needed.

• F4: (for use in Selection Criteria fields) Displays search tool or multi select dialogue box for fields.

Question and Answer