Payment Posting Primary, Secondary and Beyond

1. Payment PostingPrimary, Secondary and Beyond LeeAnn Pavlick RCM Consultant

2. Agenda • Setup Requirements for Posting • Insurance Carrier • Transaction Column Set(s) • Adjustment & Payment Types • Insurance Group(s) • Payer Literal(s) • Override Standard Payer Name • Posting Primary Insurance Payment • Required Data Fields for Electronic 2nd • Hardcopy 2nd & EOB • Posting Interest Payments • Posting PLB Adjustments

3. Insurance Carrier Must assign a Transaction Column Set to every Insurance Carrier

4. Insurance Carrier Error Message when Transaction Column Set no Assigned

5. Standard or Customized per Carrier Ability to assign specific Payment Types, Adjustment Types, Transfer notes

6. Transaction Column SetsRequired Columns

7. Actual Allowed & Contractual Adjustment Columns Amounts populated in Actual Allowed automatically populate in the Contractual Adjustment Amounts populated in Contractual Adjustment automatically populate in the Actual Allowed

8. Payment & Residual Columns Specific Payment Types can be assigned to each of the Transaction Column Sets (Breaks out each on Daily Transaction Reports) Determines during Electronic Remittance Posting if balance on Line Item should be adjusted, transferred, split or no action

9. File to Insurance & Line Information Columns Check in this column determines if a specific procedure will appear in the Claim File or Hard Copy Claim Ability to complete the adjudication information at line level (Such as the Contractual-CO45 & Patient Responsibility (PR-1,2,3)

10. Adjustment & Payment Types Adjustment Types by Carrier tracking withholds tracking Capitation tracking Bad Debt tracking sequestration adj tracking PLB adj Payment Types by Carrier for NSF checks for Refunds Affected Reports Daily & Monthly Transaction Daily & Monthly Financial

11. Insurance Groups Ability to link carriers together that appear in same Electronic Remittance File or on the same paper EOB. Ability to link carriers together that use the same ID numbers or filing requirements. Ability to link carriers together that need to use the same Fee Schedules.

12. Payer Literal(s) Additional setup required for Electronic Remittance Payer Literal -Found in Actual 835 Remittance Files - Must be entered on all Carriers included on EOB

13. Finding Payer Literal(s) • ISA*00* *00* *28*14001 *29*ABC075623 *121226*2135*^*00501*000000134*0*P*:~GS*HP*14001*MEA075623*20121226*21351089*361000134*X*005010X221A1~ST*835*000000134~BPR*I*812.64*C*ACH*CCP*01*081517693*DA*00000152302016745*1751532981**01*211272520*DA*4014001079*20121227~TRN*1*EFT0589819*1751532981~DTM*405*20121226~N1*PR*NHIC, CORP~

14. Override Standard Payer Name Used when there are multiple instances of the same payer with different names to define the different plans

15. Payment Entry

16. Payment Entry Source transaction amounts will be applied to Insurance balance Batch Financial period where transactions will appear Insurance Group vs Insurance Carrier If multiple payers appear on the same paper EOB

17. Payment Entry Deposit Date - If Date of Entry is different than actual deposit date - Searchable in Transaction Management - Used in Deposit Slip & Daily Balance Reports Amount - Total of Check or EFT to be deposited in the bank - All transactions in Check Remittance should balance to this amount Method - Check used for either Check or EFT - Check Date - Required for Electronic secondary

18. Payment Distribution

19. Actual Allowed Payment & Adjustment Transfer Amounts Actual Allowed - Auto populates the Contractual Adjustment Payment(s) - Enter Amount paid, if zero (0.00) always enter in 0.00 Transfer - Amount to be transferred to the Patient Balance Transfer Notes - Pull Down for Quick Notes or Free Text Line Information – Report Contractual and Patient Responsibility Codes from EOB (CO, PR, OA) for Electronic secondary

20. Line Information Code Qualifier - HC for UB or CMS1500 / Medical AD for ADA / Dental Adjudication Date - Date of remittance / check Code / Modifiers - CPT codes paid Group Codes – CO – Contractual PR – Patient Responsibility OA – Other Adjustment Reason Codes – 45 Contractual adjust by carrier 253 sequestration adj –Medicare 1 Deductible 2 Co Insurance 3 Deductible

21. Balancing the Line Information Most frequent error in Electronic secondary claims is balancing. Each Line filed to secondary should balance Payment + Contractual Adjustment + Patient Responsibility = Fee 60.00 + 5.00 + 10.00 = 75.00

22. COB Information Payer Paid Amount only for those procedures selected as “File to Insurance” . If utilizing the GE Centricity File creator for 2nd claims the Remaining Patient Liability is also required.

23. Current Carrier & Visit Status The Asterisk next to the carrier name indicates the carrier that the visit is currently assigned. Visit Status – normally File Succeeded if electronically filed.

24. OK /OK & More vs File Next Moves visit to In-Progress Secondary for approval & batching Moves visit to Filed Secondary when Primary has sent crossover

25. Paid in Full by Primary Insurance Payer Uncheck the “File Next” box and click OK. Visit will move to “Paid” or “Waiting Patient Payment” if there is a balance still owed by the patient.

26. Rejected by Primary Insurance Payer Before clicking OK – change visit status to “File Rejected” if additional follow-up is required. Also add the ICN from the primary payer Uncheck the “File Next” box and click “Cancel”. Visit will now be in “File Rejected Primary”

27. Medicare UB04 Secondary claim after a commercial payer payment • Payment made by primary payer • Requires value codes and amounts in Filing (2) tab. • 12, 41 and 43 with amount paid • 44 with Actual Allowed Amount for procedures being filed

28. Medicare Secondary claim after a $0.00 payment by commercial payer • $0.00 Payment or denied by primary payer • Requires value codes and amounts in Filing (2) tab. • 12, 41 and 43 with amount paid • 44 with Actual Allowed Amount for procedures being filed • Occurrence Code with Denial date

29. Medicare Secondary claim after a $0.00 payment by commercial payer • Requires Additional Information on the Notes tab • Formatting of notes and two digit code required

30. Medicare Secondary claim after a $0.00 payment by commercial payer

31. Secondary Hardcopy and EOB

32. EOB Generated from Posting

33. Posting Interest Payments • Create procedure code for Interest • Create Adjustment for Interest • Interest Payments should not be applied to actual CPT procedures

34. Interest Payment Interest payment is added to visit /ticket with $0.00 charge Payment and adjustment are then posted to Interest procedure Will not be reflected in claims sent to secondary payer.

35. Posting PLB Adjustment / Payments • Create a visit/ticket for each check /check date for the PLB patient • Use the date of the check as the date of service for the ticket • Payment is then applied to the PLB procedure code and adjusted with the same PLB adjustment type code. • Create procedure code(s) for different PLB adjustments • Create Adjustment(s) for different PLB’s • Create In-Active Provider for PLB • Create In Active facility for PLB • Create PLB Patient with appropriate carrier

36. Posting PLB Adjustment / Payments • Create procedure code(s) for different PLB adjustments • Create Adjustment(s) for PLB’s

37. PLB Visit created & Posted

38. Questions ?

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