Workflow and Optimization of Remit Processing Make the system work for you! Learn the nuances of remit processing and utilizing tools to help manage remit rejections and establish workflows to increase efficiency in your RCM department Ashley Smith Senior Application Specialist
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Workflow and Optimization of Remit Processing Make the system work for you! Learn the nuances of remit processing and utilizing tools to help manage remit.
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Workflow and Optimization of Remit Processing
Make the system work for you! Learn the nuances of remit processing and utilizing tools to help manage remit rejections and establish workflows to increase efficiency in your RCM
department
Ashley Smith
Senior Application Specialist
Topics
• General• Understanding your Electronic Remittance Advice
(ERA/835) File• Create Visit Owners to help workflow• Setup the Clearinghouse• Setting up your Transaction Column Sets (TCS)• Researching your reason codes• Setup the insurance carrier ERA settings• Processing an ERA file• Review• Questions????
General
Use this as your “Go-To” document for ERA setup If you have remit posting issues – refer back to this
document and review the steps against your setup
o Increases accuracy of data entry vs manual payment entry
o Time and cost savings for the practice o Automatically populates required information for
secondary filing o Quicker response from insurance companies
If you use Vis Processor you have additional settings:• Check Automatically Process
Remittance• Exclude 835 Remittance
This will process all response files automatically from the clearinghouse except your 835 files
Transaction Column Set (TCS) Setup
Transaction Column Set (TCS) SetupTypical ERA
Transaction Column Set (TCS) Setup
Column order changes in Payment Distribution CAN cause display issues. If you need to change the order, GE suggest to make the changes in Administration.
This will change for ALL USERS!!!
Transaction Column Set (TCS) Setup
Payment
The payment column must have a payment type populated. You can select Allow Payment Type Override to change the payment on a needed basis at the visit level.
Transaction Column Set (TCS) Setup
Payment
If the payment column does NOT have a payment type then ALL the payment amounts will go to unapplied. Everything else including adjustments will post.
Transaction Column Set (TCS) Setup
Actual Allowed
VERY IMPORTANT to create a column with type of Actual Allowed• AMT*B6 amounts post to this column
FEE = Actual Allowed + Contractual Adjustment
Transaction Column Set (TCS) Setup
Contractual Adjustment
• If ‘Contractual’ on the Adjustment column is checked off, then Centricity links the Actual Allowed column to the Contractual Adjustment
• Check off to ‘Allow Adjustment Type Override’ in order to see the Adjustment type in the TCS
• If you have multiple Adjustment columns – ONLY ONE needs the Contractual box selected
Contractual Adjustment = Fee – Actual Allowed
Transaction Column Set (TCS) Setup
If you do NOT have ‘Contractual’ checked off then:The Actual Allowed will postThe Contractual Adj will not post
Transaction Column Set (TCS) Setup
Deductible
Plug-ins are hard coded to post a reason code of 1 (e.g. PR1) to the first deductible type column it finds
• The name field is a free text field therefore cannot be used for posting• When posting ERA ALWAYS set the action to None. If you set the action to Transfer, that
amount will be moved to the patients responsibility even if there is another insurance to bill.
Transaction Column Set (TCS) Setup
Co-Insurance
Plug-ins are hard coded to post a reason code of 2 (co-insurance) and 3 (co-pay) to the first Co-Insurance type column it finds
• The name field is a free text field therefore cannot be used for posting• When posting ERA ALWAYS set the action to None. If you set the action to Transfer, that
amount will be moved to the patients responsibility even if there is another insurance to bill.
Transaction Column Set (TCS) Setup
Residual
Once a CLP segment is processed, any remaining balances goes to the residual columnThe residual column looks for another payer to bill.- Yes, then leave the balance in insurance then
move it to the next payer- No, then move the balance to the patient• Enter a general note to explain the patient
transfer. It should be inclusive of deductible, co-pay, and co-insurance. - This is not required.
• Check off option to Show notes on statement if you want your note to be shown.
Transaction Column Set (TCS) Setup
Residual
If Residual is set to NOT Transfer- The payment will post- The balance remains in insurance
responsibility- The visit remains in the status it
was in prior to the ERA being processed
Example of a possible exception:Some Medicaid Carriers do not bill their patients no matter what – you would create a separate TCS just for Medicaid Remittance and set your residual to none. This will prevent any balances being accidentally transferred to the patient.
Transaction Column Set (TCS) Setup
Line Information
Captures EOB group and reason codes required for billing electronic secondary claims. All elements post automatically from ERA.
Transaction Column Set (TCS) Setup
Line InformationMin required electronic fields:- *Adjudication date*- Group- Reason- Amount
*Minimum when procedure paid in full*
Researching your Reason Codes
Researching your Reason Codes
- Decide if the reason code and action require a Visit Owner
Reject to Review is most common used for corrections or decisions
Setup can differ between practices, insurance carriers, and preferences
• Adjust this code off• Reject to Review then make a decision• Transfer this to the patient• None
- Setup quality is dependent on preparation- Use EOB’s to list current payer responses- Make a list of reason codes to setup- Decide on actions for the reason code:
Researching your Reason Codes
Make a list of reason codes to setup
Insurance Carrier Setup
• Insurance Carrier Payer Literals tell Centricity which plans are in an ERA
• Review multiple ERA files with the same payer literal. ERA files can be created by LOB: PPO, HMO, Medicare, Medicaid etc… You may file two carriers to two different addresses but get paid on the same ERA
• Insurance carriers in the ERA WITHOUT a literal WILL NOT post
• Look at ACTIVE and INACTIVE carriers when researching payer literals
**Insurance Carrier Payer Literals are Very Important **
Insurance Carrier Setup
Look at ERA files with the same payer literal
• N1*PR*NOVITAS SOLUTIONS, INC.
Determine which insurance carriers could be in the file
ISA*00* *00* *ZZ*12502 *ZZ*2826751 *150803*1328*
…
N1*PR*NOVITAS SOLUTIONS, INC.
…
CLP*001617 Medicare Part B
…
CLP*001756 Medicare Part B
…
CLP*001875 Medicare Secondary
The ERA file contains Medicare Part B and Medicare Secondary claims.
Both carriers will need to be set up with the same payer literal and TCS
Insurance Carrier Setup
Insurance Carrier Setup
All like insurance carriers – Transaction Column Set
Every insurance carrier in your ERA needs a TCS that is setup for ERA
Insurance Carrier Setup
All like insurance carriers – Payer Literal
Each insurance carrier in an ERA file must be setup on the insurance carrier EDI tab Payer Literal section
Literal means that it must be exactly as it appears in the ERA file, punctuation included
N1*PR*NOVITAS SOLUTIONS, INC.
Insurance Carrier Setup
All like insurance carriers – Response ProcessorEDI Tab- Response Processors- New/Modify- Claims Processor
Clearinghouse Settings button
Insurance Carrier Setup
Processing Options
We recommend you select Process Claim Level Codes
All like insurance carriers – Response Processor
Insurance Carrier Setup
Post $0 Amounts For
We suggest you select Allowed & Payment to post $0.
$0 Payment is required for secondary filing. A blank payment representing $0 will cause a file level rejection.
Copay & Deductible are mapped from the plug-in but $0 has no impact on them.
All like insurance carriers – Response Processor
Insurance Carrier Setup
If Actual Allowed Differs from Allowed
Used to manage differences in allowed amounts between the payer and your CPS fee schedule setup• Recommend to Log in
Remittance Report File• You can select Reject Visit• You can assign a Visit Owner
– e.g. Remittance AllowableIf you do not have your procedure fee schedules set up with accurate allowed amounts ~ We strongly suggest not selecting this option. It would report every ticket in the remit_ report.
All like insurance carriers – Response Processor
Insurance Carrier Setup
Post Actual Allowed for Primary Insurance Carrier Only
Select Post Actual Allowed for Primary Ins Carrier only• Actual Allowed triggers the
Contractual Adjustment. Usually we only adjust on a primary payment.
All like insurance carriers – Response Processor
Insurance Carrier Setup
Ignore B6 Amount and Calculate Actual Allowed Amount
Payers do not always include all expected adjustments in the actual allowed. Here is an example where we must ignore the payer’s Actual Allowed• Medicare sometimes returns two CO
45s on one procedure, but the actual allowed only includes one
• Ignoring the B6 and calculate on all 45’s will take the correct adjustment
Please note that if you select this option it will ignore ALL actual allowed (B6)
All like insurance carriers – Response Processor
Insurance Carrier Setup
Override Standard Payer Name
If you use this field – you will have to populate the exact name on each carrier that has the same payer literal.
All like insurance carriers – Response Processor
Insurance Carrier Setup
Override Standard Payer Name
In this case, all payments linked to the payer literal NOVITAS SOLUTIONS, INC. would have Medicare B-CMS1500 as the payer
Use the override property to enter Medicare
All like insurance carriers – Response Processor
Insurance Carrier Setup
Procedure Code Bundling/Unbundling
CPS can post SOME bundling situations
Check Ignore SVC06 Bundling and Post Payment
All like insurance carriers – Response Processor
Insurance Carrier Setup
All like insurance carriers will need to have which plugin you are using to process your 835 files.
You will need to drop down to the appropriate plugin in the Processing 835’s Using box.
All like insurance carriers – Response Processor
Insurance Carrier Setup
Most Commonly Used 835 Processor by Filing Method
• Professional (HCFA) - VisClaims File Processing PI
• Everything will post; payment, adjustment, line info, etc…
• The balance remaining after posting will NOT get put into the residual column
• Reject Visit property will not affect the residual column
• Sometimes used to process partial payments to the next step for the procedures that adjudicated successfully
If you use this option – make sure to look at your visits in any status. If the claim happens to be a crossover – your visit could potentially be in a Sent Secondary status. STRONGYLY SUGGEST USING NONE ACTION TYPE INSTEAD OF IGNORE.
Example: Your claim has 3 procedures; 1 denied for CO 96 and the other two paid. If you setup the reason code 96 with Ignore and Reject Visit:• Claim will move to a Filed Rejected status; flagged to be
worked• Procedure with 96 stays in insurance responsibility• The other 2 procedures go to residual column and move
• Everything will post; payment, adjustment, line info, etc…
• The balance remaining after posting WILL get put into the residual column
• Setting Reject Visit with an action of none will stop all balances in the residual column from transferring
• Used to stop the claim and allowing an update
Insurance Carrier Setup
Non Payment Reason Code – None
Example: Your claim has 3 procedures; 1 denied for CO 97 and the other two paid. If you setup the reason code 97 with None and Reject Visit:• Claim will move to a Filed Rejected status; flagged to be
worked• Procedure with 97 moved to residual column• Since one of the procedures in the residual column has
an action of Filed Rejected, the action of transfer is stopped for the whole claim and the column is grayed out
CPS posts payments based on procedure level information.
However some functionality exists at the claim level.
You can:• Stop all payment posting from
occurring• Log in the Remit_ Report• Assign a visit owner
The Reject Visit property is automatically selected
Processing an ERA File
Processing an ERA File
• Open EDI Response Management
• Select Clearinghouse• Recommend to enter Date
Received• Use Search Field to Find
- Check Number
- Check Amount
Caution: If using check amount to search for files, do not include ending zeroes: e.g. enter 2300 not 2300.00 or 546.1 not 546.10
Processing an ERA File
Viewing an ERA File
Locate your remit file in EDI Response Management
Right Click and View the remittance Advice Report to verify information in the 835 file
Processing an ERA FileViewing an ERA File
• When you right click and view - the file will open the generic XML file viewer
• Select Record Type N1 then select the Next button
N102 Value column contains the Payer Literal
Processing an ERA FileViewing an ERA File
• Select Record Type BPR then select the Next button
- BPR02 Value Column contains the Check Amount
- BPR16 Value Column contains the Check Date
For some clients, if there is a next button after selecting BPR, that means there is more than one check in the ERA file.
Processing an ERA File
Place a check next to the file you want to process
Select the Process button
Processing an ERA File
Remittance Processing
Batch Options• Automatically create a new batch for
each check• Use Default Batch• Use Specific Batch **Best Practice**
– Select a batch name• Ask for a batch name for each file can be checked if processing more than one file
Processing an ERA File
Viewing the Remit_ Report- Date and file processed- Check number and Insurance used to
post the ERA- Detailed Log of posting
Once you review the Remit_Report – it will need to be Archived
Processing an ERA File
Typical Issues:• Bundling• Cannot find a match• Payer Literal is missing• Check Number already posted• Ticket does not exist
Viewing the Remit_ Report
Unapplied Key word• Could not post or • Could not complete
posting
Processing an ERA File
Transaction Management
Transaction Management will show the transactions for the file and amounts that were posted
Use the Remit_ report to help identify the Un-applied funds
Double click on the transaction line to open Payment Entry
Processing an ERA FilePayment Entry• Verify Transactions in the bottom window pane• Double click on line items to edit a transaction• Compare this to your EOB and reconcile:
– Payment– Adjustment– Transfer to insurance or patient
Processing an ERA FilePayment Entry
Claims that should deny but transferred have a reason code that is not setup.
Report these instances to your Billing Manager so that they can update the Non Payment Reason Codes setup
Processing an ERA FileSUGGESTION… Once you have gotten a feel for your setup and you think everything is posting as it should and you think its safe to just spot check your transactions
– Sort your Transfer column; if you find there were large amounts transferred to the patient - look to see if a reason code was not setup, therefore it transferred that balance to the patient.
– Review the reason code and decide if there is an action you would like to take place and set it up
– Report these instances to someone in your Practice (Billing Manager) that can update the Non Payment Reason Code setup on the Insurance Carrier
Processing an ERA File
Review posted information
From Payment Entry you can drill into the Transaction Distribution to make any updates required.
You can also see the line information and COB information for secondary filing or researching a denial.
Processing an ERA File
Review posted information
You can also see the Line Information and COB information for secondary filing or researching a denial.
Processing an ERA File
What do you do if you realize you have posted to a wrong DOE or wrong batch? How do you move those transactions?
Processing an ERA File
Transaction Management – Move Transactions
• Select Checkbox next to Batch • Click Move
Processing an ERA File
Transaction Management – Move Transactions
- Create a New Batch with the correct DOE
- Or locate the batch you have created already and say OK
Processing an ERA File
Transaction Management – Move Transactions
Processing an ERA File
Review Remittance Reject Visits
Review the visits that had denials you setup to flag for review:• Status of: Filed
Rejected• Owner of: Remittance
Review or whatever Owner you have set up for your reason codes; you CAN select more than one
• All Dates
Processing an ERA File
Review Remittance Reject Visits
Drill into the visits you need to review to find out the reason for the denial:
Processing an ERA FileReview Remittance Reject Visits
Go to the Claims tab to see the messages posted by the ERA transaction:• Date and File Name
give processing information
• Description contains the Remark Codes and reasons for any action taken on the visit
In this case:• MA01, MA18
(crossover codes)
Let’s Review
Let’s Review
Every carrier that could be in the remit MUST have the Payer Literal; it must be listed exactly how it is in the ERA – including punctuation
Assign a Transaction Column Set (TCS) that is for remittance processing to ALL CARRIERS
ALL CARRIERS must have the Response Processor Plugin selected if it has the same payer literal; this does include Inactive Carriers
If you are using a Payer Override Name – ALL “Like” carriers must have the SAME override name populated
If a procedure post in the residual and transfer to the patient; this means this reason code needs to be set up. Notify your Billing Manager or whomever is responsible for the administration setup in your practice
ERA processing is not 100% however if your setup is correct it should be pretty close; you still have to spot check and verify the posting
Let’s ReviewElectronic Open EDI Response Management (1 click) Search and locate my check using check # or amount (populate at most 3
fields - select okay) so we will say (4 clicks including OK) Check box for file you want to process (1 click) Select process button (1 click) Click yes I do want to process (1 click) Select batch option (depending on option selected this could be 1 click -
however we will go with the most clicks including OK 5 clicks) Go into Transaction management (1 click) Pull up the batch (6 clicks to really narrow down your criteria) Open the transaction (2 clicks) Review the payment entry (1 click) If non-payment reasons not set up - move monies back to the insurance
carrier – (1 click) OK (1 click) Payment is posted
GRAND TOTAL - 25 CLICKS TO PROCESS AND VERIFY AN ERA PAYMENT
Let’s ReviewManual Open Payment entry (1 click) Select batch you are posting to (4 clicks) Enter check amount (5 clicks) Check # (check# has 10 numbers so 10 clicks) Check date (8 clicks) Enter the ticket number (6 clicks) New (1 click) If an alert note popup (1 click) Actual allowed on each code - 3 codes - 6 clicks each so (18 clicks total) Payment on each - 3 codes - 6 clicks each so 18 then 1 code was $0 so 1
click – (total of 19 clicks) Populate copay on 3 codes - 6 clicks each – (18 clicks) Populate deductible on 1 code – (6 clicks) Populate line level information on each code for electronic 2ndary filing and
also needed for denial review - 28 clicks for 2 code, 38 clicks for 1 code, 15 clicks on 1 code -the $0 pay (total of 109 clicks)
Manual Continued on next slide
Let’s ReviewManual – Continued COB info ( 17 clicks) ICN # (15 clicks) File next carrier (1 click) OK (1 click) Payment is posted
GRAND TOTAL - 240 CLICKS TO POST THE SAME PAYMENT MANUALLY
WOW!!! 25 to 240 clicks!!!
BONUS** Active ReportWe have an active report called Copy Response Processor Settings that will copy over your response processor settings from one carrier to another carrier(s).
1. Set up your “Source Carrier” response processor settings in Administration>>Insurance Carriers
2. Open up Reports and run the Copy Response Processor Settings Active Report
3. Select that Source Carrier
4. Select the Destination Carrier(s) you wish to copy settings to
BONUS** Active Report
What is a “Source Carrier”?
This will be your original carrier you set up. You will use this carrier to copy to other “LIKE” carriers. For instance, you would set up a Medicare carrier – you would then use this carrier as your “Source Carrier” to copy to other Medicare carriers. Remember when copying – if you have the override name populated – this will populate to all carriers you select as your Destination Carrier(s).
I suggest setting up one Medicare, one Medicaid, and one commercial “Source Carriers” and then copying those settings to other Medicare, Medicaid, and commercial carriers.
Questions
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