# Presentation: 779483

## RPMS Third Party Billing

- Table Maintenance

## Who should have access

- Designated users
- Business Office Manager
- Site Manager
- Programming staff
- Designated Area staff

## Who should not have access

- Non billing users
- New users
- Everyone!

## Basics

- Options should be accessed only when
- Setting up or troubleshooting
- Maintenance
- Auditing
- Some site parameters are unique to facility logged in to
- Entries should never be deleted unless otherwise specified

## What to Expect

- Most changes take effect right away!
- Form Locator Override edits
- Insurer file edits such as ICD/CPT procedure code display in Claim Editor
- Changes that impact claim generator will be effective when claim generator runs.
- Deleting or adding unbillable clinics
- Changes in back-billing limits

## Site Parameters

- Controls how..
- Claims are generated
- Claim editor looks
- Bills are printed
- Bill are displayed
- Locked with ABMZ SITE SETUP

## Site Parameters

- Facility to Receive Payments
- Pulls location entry from LOCATION file
- Mailing address to send checks to
- Location fields are audited
- Printable Name of Payment Site
- Prints location of payment receiving facility
- This field is audited too

## Site Parameters

- Days Inactive Before Purging
- Indicates when a claim will be ‘canceled’ from the claim editor.
- Canceled claims can never be retrieved.
- Canceled claims have an impact on bills that are reprinted.

## Site Parameters

- Select Default Unbillable Clinics
- Add clinics that are unbillable regardless of payer.
- No claims will be generated if clinic is on PCC visit.
- Ensure data entry does not use that clinic code for valid visits (make sure coding correctly!)
- Field should be audited at least once a year

## Site Parameters

- Select Dflt Invalid Prv Disciplines
- Add provider class that are unbillable regardless of payer.
- No claims will be generated if primary provider holds unbillable provider class is on PCC visit.
- Ensure data entry does not use that primary provider for valid visits (make sure coding correctly!)
- Field should be audited at least once a year.

## Site Parameters

- Orphan Visit Lag Time
- Lets Claim Generator know when orphan visit can be generated.
- Recommended to be set to number of days that data entry is entering forms plus 5 days
- Setting number too low results in duplicate claims generating in the Claim Editor
- Recommended to be monitored every one to two weeks

## Site Parameters

- Uncoded DX Lag Time
- Lets Claim Generator know when visits containing a diagnosis code of .9999 can be generated
- Usually for EHR visits
- Recommended to be set to number of days that data entry is completing visits plus 5 days
- Setting number too low results claims generating in the Claim Editor that are uncoded
- Recommended to be monitored every one to two weeks

## Site Parameters

- User A/R Parent/Satellite Set Up
- Used only when adding new billing locations
- Home, school, local hospital locations
- Location must be set up in A/R Manager option prior to use.
- Huge impact on where claims are generating
- Should never be modified unless sure that it should be turned on
- Claims generated in one location cannot be moved

## Site Parameters

- Medicare Part B?
- Allows system to generate one or two claims for Medicare depending on billing guidelines
- Only: One Medicare claim generates with Professional Component (999) visit type
- Intended to bill to Medicare Part B
- Yes: One Medicare claim generates with an Outpatient (131) visit type
- Intended to bill to Medicare Part A
- No (or blank): Two Medicare claims generate
- Intended to bill to Medicare Part A and Part B

## Site Parameters

- Default Dental Code Prefix
- Used to add either an ‘S’, ‘D’ or number ‘0’ to an ADA code
- Adds for all payers
- Doesn’t display in claim editor but prints on claim forms
- May be set up for individual payers in ‘Dental Remap Table Maintenance’ option

## Site Parameters

- RX Dispense Fees
- Only used if billing for pharmacy in 3P’s Claim Editor (not POS)
- Check with POS staff to see if needs to be populated
- Defaults to dispense fee that displays in Claim Editor

## Site Parameters

- Insurers W/O 837 PRV Segment
- New in Version 2.5 Patch 10
- Removes all PRV segments (taxonomy code) from selected insurers 837 files
- Note: NPI requires taxonomy codes to be submitted on 837

## Insurer File

- Controls how claims are generated
- Controls how claims are printed/exported

## Insurer File

- Two Insurer files
- Patient Registration
- Shared by all visit locations on one database
- Includes fields such as Insurer Name, Street, City, State Zip Code
- Data stored in the INSURER file
- Third Party Billing
- Parameters unique to each visit location
- Options covered in this demo
- Data stored in the 3P INSURER file

## Insurer File

- Mailing Address vs. Billing Address
- Mailing address used by billing, registration, CHS staff to look up insurers
- Billing address used to print on claims forms
- If no billing address entered, then mailing address is used

## Insurer File

- AO Control Number
- Used as a electronic payer identifier
- Provided by payer
- Populates in the EMC File Name generated by RPMS
- Ex: E_00400_01.44
- Populates in ISA08 and GS03 on the 837 export mode
- Exception is Medicare which uses combination of AO Control Number and Visit Type

## Insurer File

- Insurer Status
- Billable: Allows claim to generate if the patient has open eligibility
- Unbillable: Does not generate a claim even if the patient has this insurer as open eligibility
- Unselectable: Allows claim to generate if the patient has open eligibility.  Used if insurer has been merged to a Billable insurer.  Registration staff will not see this entry

## Insurer File

- Type of Insurer
- Places insurer into class of insurer
- Determines allowance categories (federal sites only)
- Used for:
- Reporting purposes
- Claim generation process
- Printing/exporting bills (display)

## Insurer File

- All Inclusive Mode
- Used for “Flat Rate Billing” to allow for flat rates to display in Claim Editor or print on paper/electronic formats
- Visit Type must be set up with Flat Rate
- Turns on prompts in Visit Type to allow entry of default Revenue Code, Default Bill Type and Default CPT Code
- Should never be turned off if flat rates are entered and being used

## Insurer File

- Backbilling Limit
- Prevents claim from generating if Date of Service exceeds limit
- Prevents old claims from generating if not needed
- Should be set to insurance filing limit, if known.
- If blank, defaults to Site Parameter’s Backbilling limit

## Insurer File

- Dental Bill Status/RX Billing Status
- Allows claim to generate if that service is covered by insurance
- Prevents insurer from displaying on claim if not billable for service
- If using POS, RX Billing Status must reflect for the POS insurer
- For now, does not prevent the generating of POS claims

## Insurer File

- Select Clinic Unbillable
- Add clinics that are unbillable a specific insurer
- No claims will be generated if clinic is on PCC visit for this insurer
- Ensure data entry does not use that clinic code for valid visits (make sure coding correctly!)
- Field should be audited at least once a year or when billing guidelines issued

## Insurer File

- EMC Submitter ID/EMC Password/EMC Test Indicator
- Used when billing electronically
- Populates on 837:
- EMC Submitter ID = ISA06 with a ‘ZZ’ indicator
- EMC Password = ISA04 with an ’01’ indicator
- EMC Test Indicator = ISA15

## Insurer File

- Group Number/Provider PIN#
- Used for Medicare Part B billing only
- Allows Part B group and individual provider numbers to print on paper/electronic formats
- Used only when billing with Professional Component (999) Visit Type
- NPI will replace entries in these fields

## Insurer File – Visit Types

- Visit types allow for different billing scenarios
- Allows for certain entries to default
- Export mode
- Facility group numbers
- Impacts claim generator – allows Visit Type to be generated on claim
- If not in insurer file, defaults for OUTPATIENT (131) for all outpatient services excluding Dental
- Used for reporting purposes

## Insurer File – Visit Types

- Billable Status
- The following status’ can be applied:
- Yes: Allows claim to generate for this type of service
- No: Does not generate a claim if it falls under this category.
- 	*Remember that if you have other insurer types set up (i.e. Dental) the system looks at those properties first
- Billable-Billed Elsewhere: Does not generate a claim

## Insurer File – Visit Types

- Do You Want to Replace with Another Insurer?
- Used to bill for services without adding eligibility to the patient’s file
- Sends claim to another insurer
- Triggered by visit type
- Mainly for services such as DME, pharmacy, etc. where the patient’s policy holder ID remains the same

## Insurer File – Visit Types

- Procedure Coding
- Used to identify procedure coding for claim/visit
- ICD: Does not allow for itemization of charges
- Used mainly for Flat Rate billing
- CPT: Allows for itemization of charges
- Not used for Flat Rate billing
- Mainly used for Private Insurance billing
- ADA: Allows for billing of dental codes
- Displays Page 6 (Dental) and allows for billing of dental charges

## Insurer File – Visit Types

- Fee Schedule
- May be used to link to specific insurer
- If linked, remember to update when fee schedule is updated yearly
- Once has been linked, claim generator will pull charges for future claims

## Insurer File – Visit Types

- EMC Submitter ID #/EMC Reference ID
- Used for billing 837
- EMC Submitter ID populates the ISA06 segment of the 837.
- Mainly used for insurers that use different ID numbers based upon type of service

## Insurer File – Visit Types

- Auto Approve
- Automatically generates claim, then approves it into a bill
- Uses the individual who turned on the claim generator as the approving official
- Utilizes ‘Beneficiary Patient’ as the active insurer
- Use with caution!

## Insurer File – Visit Types

- Export Mode
- Allows for entry of default export mode
- Ideal for site to enter as default
- Saves time for biller

## Insurer File – Visit Types

- Block 24k, Block 29, Block 33 PIN #
- Used if export mode is HCFA-1500
- Is populated only if Payer Assigned Provider Number populated for provider
- Located in New Person File

## Insurer File – Visit Types

- Itemized UB92?
- Displays only when export mode is UB92 or 837I
- Allows for itemization of the UB92
- Prints CPT or NDC codes on UB92

## Insurer File – Visit Types

- DME Contractor?:
- DME Group Name/Number
- If DME Contractor? is answered YES, displays and allows entry of default group name/number to print on paper/electronic forms
- CLIA # Required:
- Allows for default CLIA number to print if billing for DME services
- Required for certain DME carriers

## Coverage Type

- Used to provide further clarification of the patient’s benefits
- Must be added to Coverage Type file for Private Insurance
- Affects how claims are generated
- Unbillable Clinics
- Unbillable Provider Disciplines

## Fee Schedule

- Fee schedules are maintained individually by location
- Ensure that HCPCS, Dental and Anesthesia codes are included

## Provider File

- Provider file entries are stored in File 200 (New Person file)
- Users can access menu options with the PETM (Provider Number Edit)
- Medicare Provider Number
- Medicaid Provider Number
- UPIN
- Licensing State and Number
- Payer Assigned Provider Number

## Provider Taxonomy

- Describes the provider class using an X12 transaction code
- Crosswalk built into Third Party Billing package
- Uses provider class to match to Taxonomy code
- Taxonomy code comes from the 3P Provider Taxonomy file

## NPI

- NPI updates to be released in Third Party Billing version 2.5 Patch 11
- Sites already entering NPI into New Person file
- Changes sent in Kernel Patch 8.0*1013
- Sites testing NPI and entries into the Institution file
- Changes sent in Kernel Patch 8.0*1014

## Form Locator Override

- Allows for overriding of form locators on the HCFA-1500 only
- Can override fields such as
- Block 10 – Reserved for Local use
- Block 11 – Box 11C (Insurance Plan/Program Name)
- Block 24 – Line Items
- Block 32 – Where services were rendered
- Block 33 – Billing information

## CPT/ICD Updates

- Updates released annually for CPT and ICD updates
- ICD released in September
- CPT released in December
- Patch 1 released in January or February
- Contains HCPCS codes

## Questions?