Electronic, claims submission will make you practice more efficient and will improve the speed of collection of your funds, in turn diminishing the A/R of your practice. The system offers the ability to transmit electronic claims to major insurance carriers; however, at the present time we are only supporting electronic transmissions to Medicare, Medicaid and Blue Cross Blue shield. Hereafter we will cover how to select and transmit claims electronically for the fore named.
First, from the main menu of the program you will find a column designated for “Electronic Claims Processing” You will have the following options to choose from:
I. Select Services for Electronic Transmission
II. Select Individual Service for Electronic Transmission
III. Print List of Claims selected for Transmission
IV. Un-select Claims
V. Send Claim to Host
VI. Electronic Remittance Notice Process
VII. Place A Service Call
VIII. Set Transmission Parameters
I. Select Services for Electronic Transmission
The first step in transmitting claims electronically is using your mouse click from the main screen of the program the “Select Services” button located in the Electronic Claims Process column. To select the claims, as desired by your office, go into the function of this menu labeled "Select Data for Transmission". Once you have selected this option the system will prompt you with the following questions from which the system will base its selection of claims for transmission.
Enter the ID numbers, separated by comma, of the patients whose form you wish to print. Otherwise, if you wish to print forms for all patients that have transactions within a certain period of time leave this field blank and the system will search based on the rest of the criteria specified hereafter.
Enter Starting Date
Self-explanatory. This is a self-formatting, date field, which is prompting for the starting date of the period of time for which you are selecting claims. Remember, this date refers to posting date, the same that is displayed on the patient ledger through the execution of function <F5>.
EX. You wish to select all claims for services posted from 5/5/89 through 5/10/89. Your entry here will be : 050589
Enter Ending Date
Self-explanatory. This is a self formatting date field which is prompting for the ending date of the period of time for which you are requesting the selection of services posted to the patients account. The date of selection is based on the posting date of the claim not necessarily the service date.
EX. You want to select all transactions with an effective posting date ranging from 5/5/89 through 5/10/89. Your entry here will be:
Enter Classifications to Include
If you wish to execute this function for all of your patients; regardless of their classification, simply press return. Otherwise, in the event that you will like to execute this function for a specific class, or classes of patients, enter here the applicable internal patient classification codes, separated by commas. If at this time you do not remember the classification code needed at this time, you can click on the drop down arrow located in this field to see a list of your internal classifications codes. Choose your code accordingly.
Example: You want to execute this function only for all of your Private Insurance and Relative patients. The internal system codes are: PRIV, and REL, respectively.
Enter Classifications to Exclude
If you wish to execute this function for all of your patients, regardless of their classification, simply press return. However, in the event that you want to execute this function for all of your patients, except one or several patient classifications, then enter here the internal system codes that correspond to the patient classifications you wish to exclude. If at this time you do not remember the classification code needed at this time, you can click on the drop down arrow located in this field to see a list of your internal classifications codes. Choose your code accordingly.
Example: You wish to exclude from this function all those patients whose classification is FRIEND.
Note: You may leave both the Include and Exclude patient classification fields blank, and the system will base its selection on all patients that match the rest of the criteria. However, when you include only certain patient classifications, then consequently there exist nothing to exclude. The same happens when vice-versa, you decide to exclude certain patient classifications. For if you use or instruct the system to do both, include and exclude, that is really a contradictory statement, which would not be understood by the system.
If you wish to generate claims only for one insurance company, then you may do so by entering the appropriate insurance company code in this field. “Carriers to Include”, can be used to transmit claims for patients with certain carriers, not all. This prompt allows you control of the carriers to be transmitted. That is, the system will only transmit claim forms for patients requested. In the event that your office transmits claim forms for all patients; regardless of their carriers simply skip over this field leaving it blank. If at this time you do not remember the carrier needed at this moment, you can click on the drop down arrow in this field for a list of your internal codes for the carriers.
Physician to Include
The next prompt, Physicians to Include, can be used to transmit claims for patients seen by certain physicians, not all. This prompt allows you control of the claim forms to be transmitted. That is, the system will only transmit claim forms for patients requested. In the event that your office submits claim forms for all patients; regardless of their physician simply skip over this field leaving it blank. If at this time you do not remember the physician needed at this moment, you can click on the drop down arrow in this field for a list of your internal codes for this physician.
Enter Type of Service to Include
Enter in this field the appropriate internal system type code, which corresponds, to the type of service entries that you want to select for billing. In the case that you wish to bill transaction with a type of "I", then your entry here should be "I". Click on the drop down arrow if you are not certain of your available choices.
Select Primary or Secondary Carrier
Enter 'P' if your office wants to bill the primary or “S” if the secondary insurance carrier.
Do you wish to reselect claims?
If this is a reselection of insurance claims already transmitted enter 'Y'; otherwise, enter 'N'.
Note: If this is a reselect it will only transmit insurance forms for all of those services already marked or flagged by the system as having been billed.
Only Unpaid Services
This field will be disregarded by the system if you “N’ to reselect, if you entered “Y” then you will be allowed access to this field. This option will only be available for those practices using the line item posting function of the program. By answering "Y", the system will only transmit claims for those services, which have not been flagged as completed. Please refer to the section of the manual entitled "Transaction Management", specifically how to enter payments, for more information on how to mark services completed or incomplete.
Print an HCFA-1500 for each Claim.
In the event that your office wants to print an AMA (HCFA-1500) form for all those claims selected for electronic transmission enter "Y" in this field. The claims will print with the wording electronically transmitted on it. Otherwise, if your office does not like to maintain individual paper claims for all those services submitted electronically, since after all, the entire claim information is stored by the system, reply "N" to this field. This is an option that you can decide to use in your system depending on the convenience of your practice.
Once you are content with the information that you have entered here, click on the OK button on this screen, or cancel in you do not want to continue with this transaction. Once you click on OK the system will commence preparing the report. You will see a window pop up and progressively see the report reach 100%. You have a button that gives you the option to print what you have selected. “Transmission Edit List” later explained in this chapter.
Using your mouse click on the button that reads “Select Individual” from the Online Process column in the
program. The system will bring up a screen asking for Patient Id# and Sequence #.
Enter here the patient id number, for the patient that you wish to transmit an individual claim for. If you do not know the patient Id number, go through the method previously explained in this manual.
Enter here the sequence number of the service that you wish to transmit a claim for, If you do not the sequence number using the step previously described in this manual find the sequence number you need.
Once this information is entered click on the okay button on this window and the claim will be selected. It will now show up on your Transmission Edit List and will be ready to transmit.
III. Print Transmission Edit List
To access this function, click on the button that reads “Print Edit List” in the Online Process column of the program. The system will bring up a window that will ask you if you want to print this list Alphabetically, make your choice and click on the OK button. This system will then bring up a preview of the report on your screen, you can review it from here. If you want to print this report, there is a tool bar located on the top part of the screen that you click on in order to print the Transmission Edit List. If you want to close this there is also a button on the tool bar to close the preview.
The following is a list on Error Messages that can appear on your Transmission Edit list. These Errors and there meanings are explained below.
Inv. HIC : This error message means that the patient's Medicare Insurance number is incorrect. It could be that there are digits missing from the number, or the letter at the end of the number is missing. Also if you use the hyphens to separate the numbers the system will not accept that entry due to Medicare regulations.
Inv. Sex: This means that the letter of the patient sex in the patient's demographic record is incorrect or it does not contain a letter.
Inv. Name: The invalid name message means that either the patients name is incomplete or there is an unacceptable character in the patient's name. When entering the patients name in the demographics screen you cannot use any periods (.), commas (,), hyphens (-), only letters. For example, if the name of the patient is "John Smith Jr." enter
John Smith Jr
Notice that there is no period after the "JR". Another example, if the patients name is "CHRIS EVERT-LLOYD" you cannot use a hyphen. Your entry should be the following
ENTRY: CHRIS EVERT LLOYD
Inv. Address: The system will not accept special character in the address field. For example, if you have an address with an apartment number do not enter the number sign "#" and the apartment number, just limit yourself to entering the apartment number. Do not use periods (.), or commas (,), or anything other than letters and numbers.
Inv. City: This field works the same as the address field you cannot have any special characters. The only exception is the comma (,) after the city. The format of the address entry on the patients record should be the following:
MIAMI, FL 33124
WINTER HAVEN, TX 45278 etc......
Note: It is of extreme importance that you enter the (,) after the city, as said serves to denote within the Medicare city, which is the patient's city, verse the state. Also note that when entering the state it consists exclusively of the postal two-character code set. Do not use abbreviations, such as: FLA for Florida.
Inv. State: In the area for the state you can only enter the two-letter abbreviation for the state of the patient. The system will not accept points after the state. For example:
FL. -- Incorrect
FL -- Correct
Inv. zip: The system will only accept five digits on the area for the Zip Code. There must be no special characters, only the five-digit number of the patients Zip Code. For Example:
Inv. UPIN: The system will display invalid UPIN if the claim does not contain a valid UPIN number. The UPIN number is stored in the physician codes file, refer to the section of the manual entitled "File Maintenance". Also verify that the service screen contains a physician code.
Inv. Assg.: If the assignment question is not answered on the service entry screen to be either "Y" or "N", the system will not accept this claim for transmission. Given that you are including no instructions as to the form of payment your office will accept, for the services rendered.
The service screen is always defaulted to an assignment, in the case that you blank the field out, for any reason, and the system detects said to be blank for a particular service transaction is when you will see this error message.
Inv. Sign.: In the "Additional Patient Information" file that is located in the Patient Management section of the manual the questions of Approval #1, #2, must have the letter , “A” which signifies that the patient’s signature is on file. Every patient account will be defaulted to the letter "A", but in the case that you change this information the system will not accept the claims, for electronic transmission. For more detailed information about the "Additional Patient Information" file, refer to the Patient Management section of this manual.
Inv. Total: The system will not accept any claims submitted for a total amount of "0". If you have entered any services and have posted a charge of "0" amount, the system will not accept the claim for electronic transmission.
Inv. Proc.: If you have entered a CPT Number which does not match the standard five digit code verification into one of your internal procedure system codes, the system will not accept the claim. All CPT#'s must be five digits long. The system will only verify that it is five digits long, but it cannot verify that it is the proper procedure code number.
Inv. Amt: When you get this error, it means that one of the procedures entered to the claim being selected carries a value of 0.00. That is, the entire claim may have a face value of $356.00, which is the result of 4 procedures rendered, but one or several of the 4 procedures rendered carry a value of 0.00. This is unacceptable, and the claim should be re-entered properly, as otherwise, it would be automatically discarded by the Medicare system.
Inv. LOS: This stands for invalid Location of Service. If when entering a service you leave blank the Location of Service; otherwise known as the place of service, the system will advise you when you attempt to transmit the claim. Refer to the Transaction Management section of this manual for further reference on how to specify the proper place of service.
Inv. Phys.: If you have not entered a physician code when entering the service, then the system will advise you that the claim has an "Inv. Phys."
Inv. No. of trts: When entering a service if you incorrectly entered into the system that the number of treatments is "0" then the system will advise you that the number of treatments are invalid. Number of treatments is entered through the amount field of the service entry where you may specify 2S, or .5S, etc...
Inv. PRO #: If the Prior authorization number that you have entered while entering the service has an incorrect format, from that expected by Medicare, the system will advise you of it.
This was a list of all the possible error messages that could appear when doing a "Transmission Edit List". The error messages and requirements hereby set forth are based on Medicare requirements and idiosyncracies. The reason for this report is to make sure that your claims are filed in accordance to Medicare standards, such that they do not discard your claims for following improper format or missing required information.
If when you print your "Transmission Edit List", the list displays no error messages, you may then transmit the data to the host computer. To execute this function simply select "Transmit Data to Host Computer". The system will now prepare the data for transmission and then send it to the host computer, which awaits the arrival of the claims.
To transmit data to host computer select "Transmit data to host computer" form the "On-line transmission processing" menu. The system will now prepare the modem for transmission and submit the data to the host computer.
In the case that you have some errors on the Edit list then your first step must be to correct these errors, prior to transmitting the claims electronically. Some errors you may fix by simply retrieving the entry that you made; others require that you delete the original entry and re-enter with the corrected information.
When you print the "Transmission Edit List", it contains the sequence numbers associated to the claims selected for electronic transmission. When you need to fix any information on a claim, whether it is re-entering the service or just modifying the already entered information, you must first remove this claim from your list of selected claims. To remove a claim from the selected list of claims choose;
IV. Un-Select Claims
From the On-line processing menu, click on the button that reads “Un-select Claims”. The system will now prompt you for the sequence number of the claim to delete. Enter here the appropriate sequence number for the claim that you wish to un-select. You can find this number on your edit list. If you want to Un-select All claims in this field type in <ALL>. Once you have entered this information, click on the field that says patient, when you do this the system will bring up how many claims you un-selected and the amount. If this is what you want to delete, click on the DELETE button on this window and the claims will be unselected. If you no longer wish to un-select these claims instead of click on OK click on the EXIT button and the system will bring you back to the main menu of the program. Once you have un-selected now you can correct the claim. Here is a list of the errors and what steps you must follow to correct them.
Errors that need to be erased or deleted, in order to re-enter them, correctly.
Inv. No. of trts.
Inv. PRO #
For these error messages you need to erase or delete the already entered service record and re-enter it with the correct information.
Error messages that need Editing not re-entering
Remember to correct a claim you must first Un-select the claim from the Transmission Edit list. Now you must either re-enter the claim or do the proper editing.
Once you have finished editing or re-entering the incorrect claims you must add these claims back to your Transmission Edit list. To place these claims back on the edit list you must select the "Select data for transmission" function of the on-line transmission processing section of the system. When you are going to select you only need to select the claims that you have corrected. For information on how to select go to the beginning of the on-line transmission processing. Once you are done selecting and have added the claims to your list again, you should print another "Transmission Edit list", for verification. At this point if there are still error messages on your list, then you need to repeat the above procedure. If at this time there are no error messages then your next step is to transmit the information to the host computer.
Note: When selecting the claims corrected, not the ones deleted and re-entered, remember that said were already marked by the system, while editing, as having been billed or selected. Therefore, on the prompt that asks if this is a resubmission, you must reply 'Y'. Otherwise, the system will never select said claims.
If you had errors that required both, simply editing, or deleting and re-entering of services, you will find yourself doing two-selection process for the specific claims required. One you will specify this is a re-submission (only editing), the other this is not a re-submission (deleted and re-entered).
To transmit the data to host computer select;
From the On-line processing menu. By selecting this option the system will now prepare the data for transmission and tell you that “This procedure will transmit data which has been selected for transmission. It is recommended that an edit list report be printed before transmitting data and any errors found be corrected. Do you which to continue with this transmission?” Answer yes or No accordingly. If you answer Yes a window will pop up telling you how many claims you are going to send and the amount, to proceed with sending these claims click on “Send claims File” and your claims will be sent, this window will stay open and you can view the status at any time during transmissions to the host computer. , if you do not want to send the claims do not click on Send claims file, just click on Exit.
When the system has completed transmission you will get an On-screen acknowledgement that the host has received your claims. If there is a phone line interruption and the transmission does not come through, then you simply need to tell the system do "Transmission”(click on this button again) and the system will attempt again.
Once your transmission has been completely sent the next step is to print out the "Transmission exception report". After the claims have been sent the system will prompt you with a question asking you if you want to print out this report answer yes or No accordingly. This report is further explained below.
Transmission Exception Report
This report will give you a list of claims that were rejected by the host computer for invalid information. This report will assure that you do not transmit any claims with incorrect information. If you failed to fix a claim that had an error message it will appear on this report. If no report appears, that means that there are no rejections for the previous transmission.
1. Make sure that you computer modem is turned on prior to attempting to transmit claims.
2. Always correct any claims that have error messages prior to transmitting. Follow the correct procedures to do this as explained in this section of the manual.
3. After you transmit always print the post-transmission reports
A- Transmission Exception report
B- Print any received documents
4. If there are any rejections in your "Transmission exception report" make sure to correct them and re-transmit those claims.
5. If you have claims that were not selected, refer to the Reasons Why an Insurance Claim will not print section of this manual. Be aware that therein it is instructed to look at the set up of the insurance company code for the patient, and if it says for on-line transmission, 'Y', it needs to be changed to 'N', or the form to print. However, since in this case you are selecting for filing electronically, the answer therein, in order for the system to properly select the claim, should be 'Y'.
Follow these guidelines and you will find that Electronic transmission can be of great benefit and a time saver, to your practice.
VI. Electronic Remittance Notice Process
This section is used to process the automatic remittance payments from your insurance companies. This function will allow you to receive your payments, from those companies that you transmit claims electronically to, and provide for the capability through an electronic file. Lets go over how to process your remittance payments.
Note: Prior to begin using the remittance system, you must make sure that you are transmitting electronically the transaction sequence numbers as the reference, rather than patient ID numbers. Refer to the section of the manual titled "SYSTEM MANAGEMENT" for instructions on how to set this function. Also please be advised that the proper authorization from the insurance companies, and Budget Computer Systems is necessary prior to implementing this function in your system. Please contact Budget Computer Systems for further instructions.
The automatic remittance electronic payments can be requested by simply transmitting electronic claims. If the system detects that you have pending files here to be processed it will automatically send them to your system. If you wish to request the file but do not have any claims to transmit, then you can transmit a file with zero claims. Once you have received your remittance file you must proceed with the following steps.
First click on the button that reads “Remittance “ from the main menu of the program in the Online Process file. Then you will have the following steps:
1. Convert (remittance data)
This function will take your electronic remittance file, and convert them to a standard file layout that your program can read. To execute this function just select "Convert remittance data" from the Remittance processing menu. The system will now proceed to convert the file.
Once the file has been converted the next step is the following;
2. Print (remittance summary report)
This function will give you a report of the file that was just converted. This report will give you a listing of all the payments that where received. This report will be as detailed as your E.O.B. from the insurance company. This report should be reviewed in detail before going on. It is very important that you verify all the amounts approved and paid for their accuracy. Please note that this report will also include rejections, and denials. If you select to have the system post this payment file, any claims that were denied, the system will automatically write off the entire amount. Therefore if you do not want to have the system write off denied claims, you must remove them from this report prior to processing the automatic payment posting. To delete any posting entry from the remittance posting menu select "Delete One” The system will then ask you the following;
Enter the record number to delete
Enter the record number associated to the entry that you wish to delete. The record number can be found on the left hand side of the report.
Once the file has been edited the next step is to post the remittance file to the systems main files. To execute this function, select from the Remittance processing menu the following;
3. Post Data to Main Files
Once you have reviewed, revised, and/or made any necessary changes to your remittance file, select this function. The system will ask you some questions as which to guide it on how you wish to handle the automatic posting of your remittances. Please refer to figure 7-4 for an example of this posting selection screen. Lets go over the following questions on that screen.
Enter Posting Date
Enter the date that you want this payment to be posted in your system. The date here should be the same as the date that you are depositing the payment, for purposes of balancing your entries.
Creating Disallowance Adjustments
By answering "Y" to this field the system will automatically create a disallowance adjustment for all the payment entries in your remittance file. The disallowance amount that the computer will post is based on the difference between the amount billed, and the amount approved.
Create GRH Adjustment
Enter here "Y" if you want the system to automatically create a Gramm-Rudman disallowance for any payment entry that one has been applied to. Gramm-Rudman is percentage of the amount paid that Medicare deducts, per a law passed by the government, with the intent of balancing the budget. Please refer to your Medicare manuals for more details on this law. Answer "Y" to have the system automatically create the adjustments, otherwise enter "N".
Post allowed amounts to Procedure
If you wish to have the system automatically update the allowed amounts in your procedure file based on the remittance payment, then answer "Y" here, otherwise answer "N". By answering "Y" the system will merely update your procedure files with the current allowed amounts, base on your remittance payment file.
Then the system will prompt you with the "DONE" prompt. Answer "Y" to have the system begin automatically posting your payments, and adjustments as per your request. The system will then proceed to post all transactions to your patient files. This payments and adjustments will appear on your patient files exactly like if they had been posted manually. They will also appear on your daily reports.
The "Automatic Remittance Posting" is a time saving and efficient feature of the program. What may take, by manually entering, hours to process, the system could process in a matter of minutes. It will also be more accurate, taking into consideration that having the system automatically create the transaction entries eliminates human error. For more details and specifications on how to join the remittance program, contact Budget Computer Systems, Software Support Department.
To access this function click on the button that reads “Service Call” in the Online Processing column of the program. Once you click on this a window will pop up requesting you to enter you name, or the name of the person Budget Computers should call back. If you logged in by using your operator name/code that name will appear here automatically. The next field asks you to “Enter a brief description for the problem or question” Enter the information desired here. Once you have finished entering this Click on the button on this window that reads “Send”, your service call is now being sent to Budget Computer System, if you do not want to proceed click Exit.
This section of the package is where it is specified to the system the communication parameters it is to use. Those offices transmitting Medicare claims electronically, such that the system knows the number to call, the login information for the user, etc..., hereby use the information. The information requested by this section of the package will be entered or provided by Budget Computer Systems, Inc.
We have now completed covering the "Insurance Claim Processing" section of the manual. You will find the functions in this section of the package very helpful in the quick submission of claims, and as tools with which to effectively collect from the insurance companies. This section will also decrease the amount of errors that are made when doing manual insurance claims, due to the fact that the system will be printing the claims, and also when submitting electronic claims the system will look for any mistakes during entry for which Medicare will automatically discard a claim.