Lesson 5 Testing and Posting the 835 Remittance Advice

Lesson 5 Testing and Posting the 835 Remittance Advice

Lesson 5 Topics • Overview of 835 Transaction • HIPAA-Compliant Codes • Before You Get Started • Set Up Electronic Process with Insurers • Set Up RPMS • Retrieve 835 ERA File from Insurer • Load and View 835 ERA File for Batching • Process 835 ERA File in Accounts Receivable

What is the 835? • HIPAA-compliant format that allows for receiving third party reimbursement payments and adjustment informationin an electronic format • Full name: Health Care Payment & Remittance Advice • Also know as Electronic Remittance Advice or ERA • Current HIPAA-compliant version • ANSII Standard X12 835 Version 4010 Addenda A

Benefits of 835 Transaction • Retrieved and posted electronically into RPMS system by batch mode • Allows for faster and more accurate posting of payments • Contains codes that can be posted directly into RPMS • Standard Adjustment Reason Codes (also called Claims Adjustment Reason Codes) • Remittance Advice Remark codes • NCPDP Reject/Payment codes • Denied claims can be manually posted

Overview of 835 ERA Process • ERA files retrieved from insurer • ERA files loaded into RPMS • Files batched based on local procedures • ERA files posted to Accounts Receivable • Payments/adjustments rolled back to RPMS Third Party Billing • ERA reconciled with payment received

What Does It Mean For You? Site Manager:“The lag time has been cut from weeks to days.”

HIPAA-Compliant Codes • Three types • Standard Adjustment Reason (also called Claims Adjustment Reason) • NCPDP • Remittance Advice Remark

Standard Adjustment Reason Codes • Each insurer is required to recognize HIPAA-compliant Standard Adjustment Reason Codes table for implementing 835 ERAs • Table standardizes posting and denial codes

Local Codes Not Recommended • Strongly recommended that sites no longer create or use local codes • In past, RPMS Accounts Receivable allowed sites to add new codes specific to their sites • With 835 ERA, site-specific codes must be mapped to HIPAA-compliant Standard Adjustment Reason Codes

RPMS and Codes • IHS OIT has mapped HIPAA-compliant Standard Adjustment Reason Codes to RPMS • 100s of RPMS types were added • Adjustment codes were given a 600 or a 700 number • Local codes are 1000 and above • See Appendix A of Accounts Receivable Version 1.7 Patch 5 User Manual

NCPDP Codes • NCPDP Reject/Payment Codes apply to pharmacy claims • See Appendix C of Accounts Receivable Version 1.7 Patch 5 User Manual

Remittance Advice Remark Codes • Used within 835 transaction to: • Convey information about remittance processing • To provide a supplemental explanation for an adjustment already described by a Claim Adjustment Reason code • This is industry code list • Periodically updated and RPMS modified to include updates

Remittance Advice Remark Codes (cont’d) • See Appendix B of Accounts Receivable Version 1.7 Patch 5 User Manual

What Does It Mean For You? Management Program Analyst:“This is a challenging program . . . We have to build support systems to address all the issues.”

Set Up a Log • Keep a log of 835 ERA files and steps completed • Two important reasons for this: • There is a lot to remember and it is easy to forget a step • RPMS assigns a 4-digit number to the file when it is imported • 4-digit number is utilized throughout 835 ERA auto-posting process • Need to be able to associate two files to recall downloading and importing system problems that may occur and there may not be a hard copy to refer to • See IHS HIPAA web site for a sample log

Testing the 835 • Must test 835 process before beginning production • See Lesson 2: Establish a Relationship with the Insurer • See Lesson 3: Test Mode • Contact insurer’s EDI department • Request guidance on procedures and documentation requirements before receiving files • Determine test and production requirements • Complete required applications

Test Procedures • Quick Reference Guide provides procedures for three major insurers • Trailblazer Medicare Part A • Trailblazer Medicare Part B • PNC Bank • Procedures for other insurers may be different • Contact local Area IT or IHS OIT to see if those insurers have already been tested

Set Up RPMS • Must have RPMS Accounts Receivable v1.7 Patch 5 or latest release installed • Check with Site Manager for current version and patch • One-time setup required • Through Site Parameter Menu • See Quick Reference Guide for setup instructions

Retrieve the File • Using procedures established with insurer, check regularly to retrieve 835 ERA files • Check every other day • In last week of month, check daily • To allow time for month-end reconciliation • See Quick Reference Guide for more information

Load and View the 835 ERA File for Batching • Once retrieved from insurer, electronic 835 ERA files are processed through A/R Menu option • Four steps to create batched files to send to Finance • ERA, NEW: Load imported file from established secure directory into RPMS • ERA, RPT: Generate claims report • ERA, View: View file header information • Batch files

#1 ERA, NEW • To load imported file from established secure directory into RPMS • If file is not HIPAA-compliant 835 file: • Error message will display • File will not load

#1 ERA, NEW (cont’d) • If file is acceptable, RPMS will assign it 4-digit file name • Write this number in your log • You will have to use this 4-digit number throughout 835 auto-posting process • System will then import file into RPMS • There are four stages to this process • Download process cannot be interrupted or accuracy of file may be corrupted • For specific instructions on loading imported file, see Quick Reference Guide

#2 ERA, RPT • To generate claims report for selected check of 835 file • Option used for: • Providing reports for batching purposes • Auto-posting • Reviewing appropriate close out of claims listed under the “Not Match or Match” side of the report

#2 ERA, RPT (cont’d) • Enter: • List of Claim Status(s) you desire to print • In sequence they should be printed out C - Claim Unmatched R - Reason Unmatched N - Not to Post M - Matched P - Posted X - Claim & Reason Unmatched A - All Categories Example: CRXN Enter response: CRXN Select the type of report: (D/B/S): Summary - Totals Only Select one of the following: P PRINT Output B BROWSE Output on Screen Do you wish to: P// [RET]RINT Output Output DEVICE: HOME//[RET]

#2 ERA, RPT (cont’d) • Select type of report you want • Detail, Brief or Summary • For batching purposes, select • “A” (All Categories) and “D” (Detail). C - Claim Unmatched R - Reason Unmatched N - Not to Post M - Matched P - Posted X - Claim & Reason Unmatched A - All Categories Example: CRXN Enter response: CRXN Select the type of report: (D/B/S): Summary - Totals Only Select one of the following: P PRINT Output B BROWSE Output on Screen Do you wish to: P// [RET]RINT Output Output DEVICE: HOME//[RET]

#2 ERA, RPT (cont’d) • For unmatched claims you can: • Print a report • Research the information • Then manually post these claims

#2 ERA, RPT (cont’d) • Set denials and partial payments to “Not to Post” • Reasons for setting denials and partial payments to “Not to Post”: • Inappropriate close outs • Differences between amount insurer closed them out to and A/R facility-approved close out • Inability to reverse a close out due to A/R RPMS version installed

#2 ERA, RPT (cont’d) • See Quick Reference Guide for instructions on generating and viewing reports +-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+ | ACCOUNTS RECEIVABLE SYSTEM - VER 1.7 | + ERA Posting + | UNSPECIFIED SERVICE UNIT | +-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+ User: USER,DEMO BUSINESS OFFICE 23-OCT-2003 9:42 AM NEW Load New Import VIEW View Import Header REV Review Postable Claims PST Post ERA Claims RPT Report ERA Claims Select ERA Posting Option: RPT Select file: 1006_ERA_10/16/2003 ACL partb dt1008.txtCHK: 881685516 1) CHECK #: 881685516 BATCH: ** no RPMS match ** ITEM: A/R ACCOUNT: BATCHED AMT: 0.00 BALANCE: 0.00 Please enter the LINE # of the check you wish to REPORT: 1// [RET] Reports for: 1006_ERA_10/16/2003 ACL partb dt1008.txt CHK: 881685516

#3 ERA, View • To view file header information • Information in file header • Number of claims in file • Payment amount • Check/EFT numbers • Payee and provider information • Control numbers • Provider-level corrections • Any interest payments or penalty adjustments

#3 ERA, View (cont’d) • Must view header information in order to verify: • Total Provider Payment • Check Issue/EFT Effective Date • Check or EFT Trace Number (Check #) • Reference Identification (Provider #) • Information in this header file only shows what is located on Paper Remittance Advice in header information section

#3 ERA, View (cont’d) • Header information may vary from insurer to insurer • Each may populate this data differently • At minimum, you must find: • Total Provider Payment • Check Issue/EFT Effective (Date) • Check or EFT Trace Number (Check #) • Reference Identification (to show proof of the location of the deposit) • Penalty amounts taken (total amounts only show)

#3 ERA, View (cont’d) • File header information is very useful when providing report to Finance for batching • You can only capture this report by screen-printing necessary data information • You can print whole “View” report but report is long and you don’t need it

#3 ERA, View (cont’d) • See Quick Reference Guide for instructions on viewing imported file’s header information +-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+ | ACCOUNTS RECEIVABLE SYSTEM - VER 1.7 | + View Import Header + | LITTLE BUILDING HEALTH CENTER | +-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+ User: BUSINESS OFFICE 29-JUL-2004 3:16 PM Select file: ? Answer with A/R EDI IMPORT NAME, or DATE/TIME, or HOST FILE NAME, or CHECK NUMBER, or CHECK/EFT TRACE Choose from: 1001_ERA_02/13/2004 WWH partb dt1008.txt CHK/EFT #: 440277960 1002_ERA_03/04/2004 835TEST.txt CHK/EFT #: R0000000 1003_ERA_03/26/2004 835TEST.txt CHK/EFT #: R0000000 1004_ERA_05/17/2004 835 4010 Test File. CHK/EFT #: 053900225 CHK/EFT #: 21443AA0051SY 1005_ERA_07/22/2004 THP00001F_20040503.txt CHK/EFT #: 036571083 CHK/EFT #: 081644675 Select file: 1005_ERA_07/22/2004 THP00001F_20040503.txt CHK/EFT #: 036571083 CHK/EFT #: 081644675

#4 Batching • In order to auto-post successfully, Finance needs to batch checks • To do so Finance needs: • Paper Remittance Advice • 835 Report • PNC Daily deposit • Business Office provides printed RPT and VIEW report to Finance for batching • Cannot send files to Finance because they will not have capability to retrieve this data information

#4 Batching (cont’d) • To batch, checks MUST be entered into the Accounts Receivable RPMS Collection Point • This establishes Collection Batch and Item # • Check number, payer name, and dollar amount will tie this remittance advice to A/R Collection Batch

#4 Batching (cont’d) • Your facility should have pre-defined procedures for creating batches • Process for creating Collection batch remains unchanged for 835 ERA file posting

Warning! • If an 835 file is downloaded before batching the payment, the ERA Review and Posting options will not allow the EDI file to identify a unique payment batch for posting. • The files will not tie together.

#4 Batching (cont’d) • See Quick Reference Guide for additional instructions on assembling files for batching

Overview of Processing the 835 File in A/R • When you receive batch from Finance, review it • Verify that balance available is still outstanding • Highlight any claims that you do not wish to post • Best to set following claims as “Not to Post”: • Zero payments • Negative payments • Unusual close outs • Cross over payments that involve “B” or “C” claim (auto-posting will post payment into primary claim and set balance off)

Attention • If you notice that information you receive from Finance is incorrect, have them fix it before you REV file in RPMS • If Finance cannot fix error, follow local procedures for posting these accounts

Processing 835 ERA File in A/R • Three steps • ERA, REV (review postable claims) • ERA, PST (initiate auto-post) • Master Menu, ROL (roll back bills to third party)

#1 ERA, REV • Mandatory: Review Postable Claims • Make sure that claims you want auto-posted say “Postable” • Change claims you do no want auto-posted to “Not to Post” • ERA, REV only shows claims that can be matched to A/R bill number • If claim number could not be matched to bill number: • Claim will not display • Claim will not be posted electronically

#1 ERA, REV (cont’d) • Reasons for unmatched claims • Payment belongs to another facility • Claim number information is not separated by dashes • Dates of service do not match

Lesson 5 Testing and Posting the 835 Remittance Advice

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