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    1. What is EDI?

    EDI stands for Electronic Data Interchange which facilitates the exchange of electronic files. The term EDI is the industry standard terminology for electronic transactions.

    2. Where can I get the EDI specifications for my MassHealth electronic claims?

    The EDI specifications for MassHealth electronic claims are based on the following documents:

    • Implementation Guide
    • Companion Guide
    • Billing Instructions
    • Provider bulletins
    • Message texts
    • MassHealth-specific documents can be found on the Internet at .

    3. How do I know that my claims file was received and accepted by MassHealth?

    MassHealth will generate a 999 acknowledgement. The 999 will contain data indicating the number of transaction sets received in your file, and their status. A status of "A" in IK501 indicates that the transaction set was accepted, a status of "R" indicates that the transaction set was rejected. The AK9 segment conveys the overall compliance of the file; in addition to statuses “A” and “R”, it may include a status of “P” for partially accepted in AK901.Only the transactions that are rejected need to be corrected and resubmitted. Please comply with MassHealth billing guidelines to ensure timely processing of your transaction.

    Verifying that a 999 is downloaded and reviewed for each submitted file is the responsibility of the submitter. The 999 should be downloaded from the Provider Online Service Center (POSC). The 999 can also be obtained via the healthcare transaction service (HTS) formerly known as system-to-system.

    The 999 should be available for download no later than one business day of receipt of your file. If you cannot download a 999 within that time frame, you should contact the  at 1-800-841-2900 for assistance.

    4. What is a 997?

    The 999 is a HIPAA-defined transaction that indicates acknowledgement of receipt and status of each functional group in an EDI X12 File containing transactions.

    5. I didn't receive a 997, what do I do?

    If you haven't received a 999 within 24 hours after submission of your 270/271, 276/277 or 837 file, you may contact the  Center at 1-800-841-2900 to inquire upon the status.

    6. How do I interpret the 997 transaction information?

    MassHealth has created a helpful billing tips flier to explain how to read your 999. For more information, you can review the 999 Transaction Implementation Guide, the HIPAA regulations and implementation guides can be found on the Internet through the following links.

    7. What documents should I have available for successful healthcare transaction processing?

    You should have a copy of the Companion Guides that are specific to your transaction type, i.e.; 270/271, 276/277, 820, 834 Inbound, 834 Outbound, 837I, and 837P.

    Please contact the MassHealth Customer Service Center at 1-800-841-2900 for a copy of the guide or email

    8. What do the different electronic transaction numbers mean?

    The following transactions are supported:

    • 270/271: Health Care Eligibility/Benefit Inquiry and Information Response
    • 276/277: Health Care Claim Status Request and Response
    • 820: Health Care Premium Payment
    • 834: Health Care Benefit Enrollment and Maintenance Outbound
    • 835: Health Care Payment/Advice
    • 837I: Health Care Claim: Institutional
    • 837P: Health Care Claim: Professional

    9. What is the Transaction Implementation Guide and where can I get one?

    Each transaction has an Implementation Guide that specifies the official government set of general rules surrounding the transaction. All covered entities must abide by these constraints. HIPAA regulations and implementation guides can be found on the Internet at:

    10. What is a companion guide and how can I get one?

    A companion guide is used in conjunction with the ASC X12 HIPAA Implementation Guide. It details how a specific payer interprets the data elements, and the information they require for processing claims.

    For a copy of the  please contact the MassHealth Customer Service Center at 1-800-841-2900 or email  


     


    11. What is a MassHealth Trading Partner Agreement and do I need one?

    A Trading Partner Agreement (TPA) is "an agreement between the covered entities (HIPAA Regulations: 45 CFR Part 162.915) that are engaged in EDI transactions. TPAs specify the rules and responsibilities of each party involved in the transaction in addition to indicating requirements such as communications, and financial arrangements (which entity is responsible for telecom costs).

    All MassHealth participating providers are required to complete and submit a TPA even if they do not plan to submit claims electronically. You can get the   from the Provider Forms link under the MassHealth Regulations and Other Publications section.

    12. How do I arrange to receive the 835 transaction?

    Contact the MassHealth Customer Service Center at 1-800-841-2900 or email to coordinate the necessary setup for receipt of the 835 transaction. Depending on whether you are a provider using a clearinghouse or billing intermediary, a provider submitting your own claims, or an organization managing multiple providers, there are unique sets of information that are required to complete the registration process.

    13. What documents should I have available for successful 835 transaction processing?

    The management of your 835 transaction processing will be specific to your organization. Your IT staff may process the 835 file and use it for posting, or you may be responsible for interpreting claim results.

    The following are the reference tools available to successfully manage your 835 transaction processing. Depending on how your organization manages the 835 processing, you may need to have a copy of the following documents that are specific to your transaction type:

    • 835 Implementation Guide
    • 835 MassHealth Companion Guide
    • 837 Implementation Guide
    • 837 MassHealth Companion Guide
    • The MassHealth provider manual specific to your provider type
    • All MassHealth bulletins that have been issued for your provider type.
    • Copy of related MassHealth Remittance Advice, available for download from the POSC.
    • (Claim Adjustment Reason Code/ Remittance Advice Remark Code)

     For a copy of the  please contact the MassHealth Customer Service Center at 1-800-841-2900 or email .

    This information is provided by .

    Important Note: The information on this page applies to all providers, except dental providers who are not oral or maxillofacial surgeons. Dental providers who are not oral or maxillofacial surgeons must contact the MassHealth Dental Customer Service Center at 1-800-207-5019 if they have any questions about MassHealth.

    If you currently submit batch transactions directly to MassHealth (270/271, 276/277, 820, 834, 835, 837) and are interested in submitting batch transactions to NewMMIS via the automated Healthcare Transactions Services (HTS) method (that is, system-to-system), please contact MassHealth Customer Service.

    The NewMMIS HealthCare Transaction Services (HTS) Developers' Guide has been updated. Use this document to quickly view the latest updates to the guide. These revisions are also summarized in the developers' guide itself.

    MassHealth Customer Service
    1-800-841-2900
    E-mail:

    This information is provided by

    Commonwealth Care Alliance pays clean claims submitted within specified contractual timeframes for covered services provided to eligible members. In most cases, Commonwealth Care Alliance pays clean claims within 30 days of receipt. Filing limits are strictly adhered to and are specified in your contract.

    Commonwealth Care Alliance accepts both electronic and paper claims with accepted standard diagnosis and procedure codes that comply with the Health Information Portability and Accountability Act (HIPAA) Transaction Code Set Standards.

    Commonwealth Care Alliance accepts the following standard claims forms:

    • CMS 1500
    • CMS 1450 (UB-04)
    • ADA

    **Please note** If the standard claims forms (mentioned above) are not used, Commonwealth Care Alliance has created an invoice that we will accept instead. The invoice can be sent to you electronically.

    Providers shall not seek or accept payment from a Commonwealth Care Alliance One Care Plan member for any covered service. Providers must accept Commonwealth Care Alliance payment as payment-in-full as detailed in our provider agreement (contract). Certain providers are responsible for obtaining prior authorization from the primary care team before providing services. Please consult your contract to see whether prior authorization is required.

    Submitting claims electronically (referred to as electronic data interchange or EDI), usually results in fewer errors, lower costs, and increased efficiency for businesses on both ends of the transaction. EDI is our preferred process for submitting claims. Commonwealth Care Alliance offers three options of submitting EDI claims to our provider network:

    Option One: Clearinghouse Submitters

    Standard 837 file submission through a clearinghouse where Commonwealth Care Alliance would supply you with our specific payor identification number (PIN). This PIN is the identifier at the clearinghouse to route claims files directly to the Claim Operations Department.

    Option Two: Direct Submitter

    This option is for those entities that choose to create their own 837 file and submit that file directly to the Commonwealth Care Alliance Web Portal. The secure portal will provide two layers of initial screening of all input claims data (File Structure Validation and Claim Data Validation) to improve the quality of submitted claims.

    Option Three: Single Claims Submitters

    This option is for those vendors that do not have the technical capabilities of creating an 837 file for batch submissions. Providers are given the opportunity to enter single claims directly into Commonwealth Care Alliance secure web portal and are provided a detailed training via WebEx with technical support provided to assist in the transmissions.

    **Please note** Options 2 & 3 allow vendors to use our automated secure web portal interface to transmit HIPAA compliant claims for processing and the ability to view member, provider data, and submitted claim processing status data (as permitted by their level of authorization).

    Claims sent via EDI must comply with HIPAA transaction requirements. EDI claims are sent via modem or via a clearinghouse. The claim transaction is automatically uploaded into the claims processing system.  to review the Companion Guide for Commonwealth Care Alliance. This document has been prepared as a guide to the data elements and segment requirements for electronic claims submissions. The guide should be used in coordination with the provider’s billing practices to ensure accuracy and completion of all necessary data requirements.

    To submit claims electronically to Commonwealth Care Alliance an  must be completed.

    For additional information regarding EDI with Commonwealth Care Alliance, please call 1-800-306-0732.

    Providers utilizing Option 2 or 3 of the EDI process as explained above may check claims status, member eligibility, and provider status on their secure website. Additionally, providers may request information on the status of a claim, eligibility/benefits and an explanation of payment codes by calling the toll free number with the appropriate prompts:

    1-800-306-0732

    Prompt 1  – Benefits and Eligibility

    Prompt 2  – Status of Claim

    Prompt 3  – Refunds and Escalations

    Prompt 4  – New Providers and Contracting

    Commonwealth Care Alliance also offers electronic claims payment and HIPAA compliant 835 electronic remittance advices. These mechanisms provide significant improvements to the efficiency and accuracy of your claims posting operations by eliminating paper processing and the physical handling of checks. These services are provided through JPMorgan Chase’s Healthcare Link.

    Advantages of the Healthcare Link

    • Automates electronic and paper payments to reduce costs and errors
    • Helps providers transition from paper to electronic methods of payment and explanation of benefits (EOB) in an efficient and secure manner
    • Allows providers to manage the receipt of payments and EOBs more efficiently
    • Provides a secure web site for providers to obtain copies of EOBs and to update payment instructions

    If you are interested in electronic funds transfer, please call 1-800-306-0732.

    If a provider disagrees with Commonwealth Care Alliance’s decision of denial or reimbursement of a claim, the provider can file an appeal for reconsideration by following the procedure below:

      1. The provider claim appeal must be made in writing within 30 calendar days of receiving the claim denial, and must be accompanied by documentation supporting the provider’s position on the issue(s) in question. Appeal request should be sent to:
    Commonwealth Care Alliance
    P.O. Box 22280
    Portsmouth, NH 03802-2280
    1. When substantial new information is provided, the Claims Appeal area will review the request for appeal and notify the provider in writing of its decision or provide notice to the provider that the appeal is pending.
    2. Commonwealth Care Alliance reviews all appeals within 60 days. Commonwealth Care Alliance is not responsible for a decision if the appeal request does not contain all supporting documentation. The original denial will remain in effect.

    Members are never required to pay for authorized covered services. In the event that a member suffers an injury covered by Workers Compensation, the Workers Compensation insurer would be the primary payer. If a balance remains, providers should submit the initial claim with the explanation of payment (EOP) from the primary insurer to Commonwealth Care Alliance within 90 days of the EOP date. Claims submitted without an EOP will be denied.

    In the event of a motor vehicle accident, the motor vehicle insurer is the primary payer for the full ,000 person injury protection (PIP) coverage. Once the provider has received a PIP exhaustion letter, if further payment is requested, the provider should submit a bill and copy of the PIP letter to Commonwealth Care Alliance within 90 days of the date the motor vehicle insurer issued the EOP.

    If the member has other primary coverage, the claim must be submitted to the primary carrier first. Once payment and/or denial have been made, the claim can be submitted to Commonwealth Care Alliance. Please note that a secondary claim form should be submitted alone with a copy of the primary carrier’s explanation of benefits (EOB) in order to be considered. Please submit all documentation to the following address below:

    Commonwealth Care Alliance
    ATTN: Appeal Department
    P.O. Box 22280
    Portsmouth, NH 03802-2280

    According to the National Quality Forum (NQF), serious reportable adverse events (SRE) – commonly referred to as “never events” – are errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, and that indicate a real problem in the safety and credibility of a health care facility. Therefore, in an effort to reduce or eliminate the occurrence of SREs Commonwealth Care Alliance will not provide reimbursement or allow hospitals to retain reimbursement for any care directly related to the never event. Commonwealth Care Alliance has adopted the list of serious adverse events in accordance with the Centers for Medicare & Medicare Services (CMS).

    Commonwealth Care Alliance will require all participating providers to report SREs by populating present on admission (POA) indicators on all acute care inpatient hospital claims and ambulatory surgery center outpatient claims, where applicable. Otherwise, Commonwealth Care Alliance will follow CMS guidelines for the billing of “never events”. In the instance that the “never event” has not been reported, Commonwealth Care Alliance will use any means available to determine if any charges filed with Commonwealth Care Alliance meet the criteria, as outlined by the NQF and adopted by CMS, as a Serious Reportable Adverse Event.

    In the circumstance that a payment has been made for a SRE, Commonwealth Care Alliance reserves the right to re-coup the reimbursement as necessary. Commonwealth Care Alliance will require all participating acute care hospitals to hold members harmless for any services related to never events in any clinical setting.

    According to CMS, hospital acquired conditions (HACs) are selected conditions that were not present at the time of admission but developed during the hospital stay and could have been prevented through the application of evidence-based guidelines. Therefore, in an effort to reduce or eliminate the occurrence of HACs, Commonwealth Care Alliance will not provide reimbursement or allow hospitals to retain reimbursement for any care directly related to the condition. Commonwealth Care Alliance has adopted the list of HACs in accordance with the Centers for Medicare & Medicare Services (CMS).

    Commonwealth Care Alliance will require all participating providers to report present on admission information for both primary and secondary diagnoses when submitting claims for discharge. Hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case would be paid as though the secondary diagnosis were not present. Commonwealth Care Alliance will require all participating acute care hospitals to hold members harmless for any services related to HACs in any clinical setting.

    To view the PDF files above, you may need to download a free copy of  software on your computer. (This link takes you away from the Commonwealth Care Alliance website pages.)  for more information about Adobe Acroba t.

    Last Updated 07/30/2013

    BILLING USERS GUIDE

    V 8.0.47

    ©

    eClinicalWorks, 2009. All rights reserved

    CONTENTS

    List of New Features _________________________________________ 11 List of Enhancements ________________________________________ 13

    ABOUT

    Product Documentation ______________________________________ 15 Finding the Documents ___________________________________________ 15 Getting Support_____________________________________________ 15 Conventions _______________________________________________ 16

    ENCOUNTERS

    About the Encounters Window ___________________________________ 17 Processing Completed Encounters ________________________________ 18 Reviewing Incomplete Encounters ________________________________ 19 Viewing Non-Billable Visits ______________________________________ 19 Claims IPE _____________________________________________________ 19 Running Claims IPE from the Encounters Window ___________________ 19

    CLAIMS

    About the Claims Lookup Window ______________________________ 24 Identifying Claim Status________________________________________ 30 Identifying Encounters without Claims ____________________________ 32 Viewing Pending Claims ________________________________________ 32 Reviewing Rejected Claims______________________________________ 33 Claim Processes _________________________________________________ 33 About Creating Claims _________________________________________ 33 Creating a Claim without an Encounter ____________________________ 34 Creating a Claim from an Encounter ______________________________ 36 Modifying a Claim _____________________________________________ 37 Deleting a Claim ______________________________________________ 38 Viewing the Claim Summary for a Claim___________________________ 38 Printing the Claim Summary for a Claim ___________________________ 39 Billing Processes ________________________________________________ 39 Adjusting Medicaid Claims ______________________________________ 39 Splitting Claims ______________________________________________ 40 Creating Multiple Claims from Encounters at Once ___________________ 41 Creating a Batch______________________________________________ 41 Printing Claim Forms from the Claims Window ______________________ 42 Changing the Claims Date ______________________________________ 42 Changing Claim Status _________________________________________ 43 Transferring Claim Balances to the Patient _________________________ 43 Writing Off Multiple Claims at Once _______________________________ 44 Writing Off Claims for a Capitation Plan ___________________________ 45 Voiding and Recreating Multiple Claims at Once _____________________ 46 Deleting Multiple Claims at Once _________________________________ 50 Reassign Provider Numbers on Claims ____________________________ 50

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    Reassigning CLIA IDs for Multiple Claims at Once____________________ 51 Copying Insurance Types to Claims _______________________________ 52 Transferring Claims to Collections ________________________________ 52 Removing Claims from Collections ________________________________ 53 Viewing the Claims Report ______________________________________ 53 Claims IPE Processes _____________________________________________ 54 Running Claims IPE from the Claims Window _______________________ 54 Lock/Unlock Processes ____________________________________________ 56 Locking a Single Claim _________________________________________ 56 Locking Multiple Claims at Once__________________________________ 56 Locking Filtered Claims _________________________________________ 57 Unlocking Multiple Locked Claims at Once __________________________ 57 Unlocking a Locked Claim_______________________________________ 58 Viewing the Claim Lock Status Log for a Single Claim ________________ 58 Viewing the Claim Lock Status Log for Multiple Claims ________________ 59 Professional (HCFA) Claims ___________________________________59 Submitting Electronic Claims Using the CMS 1500 Form _________________ 59 Printing Paper Claims Using the CMS 1500 Form _______________________ 59 Printing Batches of Paper Claims Using the CMS 1500 Form ___________ 60 NDC Codes on the CMS 1500 Form _________________________________ 60 About the Professional (HCFA) Claim Window__________________________ 61 CMS-1500 Form Mapping _______________________________________ 69 About the Claim CPT Details Window______________________________ 70 Viewing and Responding to Rule Validation Warnings _________________ 74 CodeCorrect ____________________________________________________ 75 Checking Errors on Claims with CodeCorrect________________________ 75 Claim Header ___________________________________________________ 76 Completing the Claim Header____________________________________ 76 Claim Data _____________________________________________________ 78 Completing Claim Data _________________________________________ 78 Managing EPSDT ______________________________________________ 81 Claim Options___________________________________________________ 82 Viewing Claim Logs____________________________________________ 82 Viewing the Claim Submission Log _____________________________ 82 Viewing the Charges Log _____________________________________ 83 Viewing the Claim/CPT Adjustments Log _________________________ 83 Viewing the Line Refunds Log _________________________________ 83 Viewing the Claim/CPT Payment Posting Log _____________________ 84 Viewing the Claim Lock Log ___________________________________ 84 Viewing the Claim Status Log _________________________________ 84 Viewing the Claim Transfer Log ________________________________ 85 Viewing the Claim Assigned To Log _____________________________ 85 Viewing Finance Charge Logs _________________________________ 85 Viewing the Claim Collection Log _______________________________ 86 Viewing and Printing a Claim Summary__________________________ 86 Reloading Insurances from Demographics to Claims __________________ 86 Reapplying Modifier Percentages on Claims _________________________ 87 Reassigning Provider Numbers on Claims __________________________ 87 Converting HCFA Claims to UB Claims _____________________________ 87 Converting HCFA Claims to Dental Claims __________________________ 87 Deleting a Claim from the Claim Window __________________________ 88

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    Locking a Claim from the Claim Window ___________________________ 88 Unlocking a Locked Claim from the Claim Window ___________________ 88 Configuring My Settings on Claims _______________________________ 88 Printing HCFA Forms _____________________________________________ 89 Printing Claims Using the CMS 1500 Form _________________________ 89 Viewing and Printing Claims on Other Forms _______________________ 90 Adding NY Medicaid Form Data __________________________________ 90 Viewing and Printing ERAs Associated with a Claim __________________ 91 Selecting State Medicaid Forms __________________________________ 91 Entering Financial Adjustments _____________________________________ 92 Entering an Adjustment on a Claim _______________________________ 92 My Claims _____________________________________________________ 94 Viewing the Assigned Claims Log_________________________________ 94 Entering Claim Follow Up Details _________________________________ 94 Using the My Claims Window ____________________________________ 96 Institutional (UB) Claims _____________________________________97 About the Institutional (UB) Claim Detail Window ______________________ 98 Fields 1-31 tab and General Tab _________________________________ 99 Fields 32-49 Tab _____________________________________________ 101 Fields 50-75 Tab _____________________________________________ 102 Fields 76-85 Tab _____________________________________________ 104 Error Log Tab _______________________________________________ 105 About the UB-04 Claim Form ___________________________________ 105 Viewing the Batch Print Log ____________________________________ 107 Dental Claims _____________________________________________107 Patient Setup for Dental Claims _________________________________ 107 Configuring Insurance Companies for Dental Claims_________________ 107 Creating Dental Claims________________________________________ 107 Printing and Transmitting Dental Claims __________________________ 107 Downloading Dental Claims Reports _____________________________ 108 About the Dental Claim Detail Window ______________________________ 108 Patient Coverage Information Tab and General Tab _________________ 109 Charges Tab ________________________________________________ 111 Billing Dentist Tab____________________________________________ 113 Error Log___________________________________________________ 114 Miscellaneous Claim-Related Actions ___________________________115 Recovering the NSF Fee Charged by the Bank _____________________ 115 Moving a Credit _____________________________________________ 116 Hard Closing Claims_____________________________________________ 118 ANSI File Status ___________________________________________119

    PAYMENTS

    About the Payments Window _________________________________121 Adding Received Payments ___________________________________124 Payment Batches _______________________________________________ 124 Starting Payment Batches _____________________________________ 124 Looking Up Payment Batches ___________________________________ 125 Ending a Payment Batch ______________________________________ 126

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    Fast Payments _________________________________________________ 126 Entering Fast Payments _______________________________________ 126 Patient Payments _______________________________________________ 128 Adding Patient Payments ______________________________________ 128 Adding Paper Payments from Insurance Companies _________________ 132 Performing Actions on Payments ______________________________136 Updating Payments ___________________________________________ 136 Deleting Payments ___________________________________________ 137 Copying the Payment List to a Text or Excel File ___________________ 137 Configuring Payment Default Options ____________________________ 138 Locking Payments ____________________________________________ 139 Unlocking Payments __________________________________________ 139 Posting Payments __________________________________________140 Posting Patient Payments_________________________________________ 140 Posting Insurance Payments ______________________________________ 148 Posting Capitation Payments ___________________________________ 151 Hard Closing Payments ______________________________________154 Miscellaneous Payment-Related Actions _________________________155 Charging for Returned Checks __________________________________ 155

    ERA

    ERA (Electronic Remittance Advice) ____________________________157 About ERAs ___________________________________________________ 157 Which Payers Provide ERA? ____________________________________ 157 How are Payments Posted? ____________________________________ 157 Setting Up ERA within eClinicalWorks ____________________________ 158 Using ERA with WebMD/Emdeon ________________________________ 158 Importing an ERA from WebMD/Emdeon __________________________ 158 Importing an ERA from another Clearinghouse or Third-Party Vendor ___ 159 Exporting ERAs ______________________________________________ 160 Posting ERAs __________________________________________________ 160 Posting Payments Using the ERA ________________________________ 160 Marking an ERA as Posted _____________________________________ 161 Viewing ERAs __________________________________________________ 162 Viewing an ERA______________________________________________ 162 Viewing an ERA Exception Report _______________________________ 162 Using ERAs with Claims __________________________________________ 163 Showing ERA Reason Codes ____________________________________ 163 Printing ERAs from the Printed Claims Window _____________________ 164 Printing ERAs at the Claim Level ________________________________ 165

    REFUNDS

    Refunds __________________________________________________167 About the Refunds Window _______________________________________ 167 Looking Up Refunds __________________________________________ 168 Refund Procedures ______________________________________________ 168 Generating a Refund __________________________________________ 168 Viewing a Log of Refund Activity ________________________________ 170

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    Posting a Refund Associated with a Claim _________________________ 170 Posting a Refund Associated with a Payment ______________________ 172 Voiding a Refund ____________________________________________ 173 Deleting a Refund ____________________________________________ 173 Locking a Refund ____________________________________________ 174 Unlocking a Refund___________________________________________ 174 Hard Closing Refunds ___________________________________________ 175

    ACCOUNTS LOOKUP

    About Accounts Lookup _____________________________________177 Looking Up Patient Accounts ___________________________________ 177 Viewing a Patient Account _____________________________________ 179 Accounts Lookup Procedures _________________________________182 Viewing Payor Invoices ________________________________________ 182 Viewing Guarantor Statement Jobs ______________________________ 183 Setting Patient-Specific Alerts from Accounts Lookup ________________ 183 Copying the Patient Account List ________________________________ 184 Creating Patient Refunds from Accounts Lookup ____________________ 184 Collection Management from Accounts Lookup________________________ 185 Transferring Patient Accounts to Collections _______________________ 185 Removing Patient Accounts from Collections _______________________ 186 Excluding a Patient Account from a Collection Run __________________ 187 Transferring Claims in an Account to Collections____________________ 188 Generating Statements __________________________________________ 189 Configuring Patient Statement Options ___________________________ 189 Generating Printed Patient Statements ___________________________ 190 Generating Electronic Patient Statements _________________________ 191 Generating Paper Guarantor Statements __________________________ 192 Generating Electronic Guarantor Statements_______________________ 193 Transferring Patient Balances into eClinicalWorks _________________194 Transferring Patient Debit Balance _______________________________ 194 Transferring Patient Credit Balance ______________________________ 195

    BATCHES

    Batch Creation_____________________________________________197 Creating and Submitting a Batch ________________________________ 197 Batch Management _________________________________________201 Saving Batch Files Locally _____________________________________ 201 Previewing Batches___________________________________________ 202 Changing the Claims Status of Batches ___________________________ 202 Regenerating a Batch _________________________________________ 203 Copying Batch Information to a Text or Excel File __________________ 203 Viewing the ITS Transaction Log ________________________________ 204 Assigning Tracking Numbers to Batches __________________________ 204

    COLLECTION MANAGEMENT

    About the Collection Management Console_______________________205

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    Using the Collection Management Filters __________________________ 205 Using Other Collection Management Features ______________________ 206 Collection Management Procedures ____________________________207 Generating Collection Letters ___________________________________ 207 Searching for Accounts Ready for Collection Management ____________ 208 Using Patient Details Options ___________________________________ 208 Entering Collection Status Notes for a Patient ______________________ 209 Viewing and Setting Patient Alerts from Collection Management _______ 1aea 210 Transworld Collection Management ____________________________211 Configuring Transworld Information ______________________________ 211 Setting Up Collection Cycles for Transworld________________________ 211 Transmitting Accounts to Transworld _____________________________ 212 Removing Accounts from Transworld _____________________________ 213 Claim-Based Collection Management ___________________________214 Using Claim-Based Collection Management ________________________ 214 Transferring Claims into and out of Collections _____________________ 215 Claim Collection Logs _________________________________________ 215

    ALERTS

    Billing Alerts ______________________________________________217 Billing Alert Recalls _____________________________________________ 217 About the Billing Alert Recall Window ____________________________ 217 Setting Billing Alerts for Patients ________________________________ 219 Recalling Patient Accounts using Billing Alerts ______________________ 222 Using Billing Alerts for Insurance Follow-up________________________ 223 Recalling Patient Accounts with Payment Plans _____________________ 223

    CLEARINGHOUSES

    McKesson Reports ______________________________________________ 225 Medical Statement Reports___ lzsoqkgl. Breitling Blackbird__________________________________ 228 Payer Reports (CPR601.01) ____________________________________ 228 Claim Category Status ________________________________________ 228 Uploading Claims to McKesson __________________________________ 229 Downloading Reports from McKesson_____________________________ 230 Saving McKesson Reports ______________________________________ 231 Reviewing the McKesson Reports ________________________________ 231 Clearinghouse Dashboard ________________________________________ 232 Accessing the Clearinghouse Dashboard __________________________ 232

    ACCOUNTS RECEIVABLE MANAGEMENT

    AR Management ___________________________________________233 Account Analysis Summary Reports ________________________________ 234 Account Summary Aging ______________________________________ 234 Patient Balance Aging Summary ________________________________ 234 Guarantor Summary Aging _____________________________________ 234 Insurance Analysis Reports _______________________________________ 235 Insurance Claim Aging - Summary ______________________________ 235 Insurance Claim Aging - Detail _________________________________ 235

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    Managing AR using Claim Filter Options _____________________________ 235 Finding Aging Accounts Using Filter Options _______________________ 235

    REPORTS

    Report Sets _______________________________________________237 End of Day Reports (Crystal Reports) _______________________________ 237 Accessing Crystal Reports _____________________________________ 237 Day Sheet - Payments ________________________________________ 238 Provider Payments Based on Posting _____________________________ 238 Day Sheet - Charges _________________________________________ 238 Charges by Service Date ____________________________________ 238 Charges by Service Date and User ____________________________ 238 Charges by Claim Date _____________________________________ 239 Charges by User __________________________________________ 239 Adjustment by User ________________________________________ 239 Refund Summary ____________________________________________ 239 Billing Summary _____________________________________________ 240 Configuring Billing Summary Options __________________________ 240 Out of Office Billing Summary __________________________________ 241 OB - Active Pregnancies _______________________________________ 241 Labels _____________________________________________________ 241 Reminders __________________________________________________ 242 Transactions Reports__________________________________________ 242 EMR Reports ________________________________________________ 242 Cancelled Visits ___________________________________________ 242 Patient Data Logs__________________________________________ 243 Unlocked Visits Report ______________________________________ 243 Access Log Report _________________________________________ 243 Day Sheet - Pathology Detail_________________________________ 243 Scheduling - Provider Productivity Report _________________________ 243 Using the Report Console ______________________________________ 244 PM Scheduled Tasks Status ____________________________________ 244 View Claim Scrub Logs ________________________________________ 245 View Security Logs ___________________________________________ 245 Reconcile Transactions ________________________________________ 245 End-of-Month Reports (APL Reports) _______________________________ 246 Accessing APL Reports through eCW _____________________________ 246 Day Sheet Summary _________________________________________ 246 Charges-Payment Summary ____________________________________ 247 Insurance Claim Aging Detail ___________________________________ 247 Insurance Charges-Payments ___________________________________ 247 Insurance Cross-Tab Analysis ___________________________________ 248 Procedure Code Production Analysis _____________________________ 248 Charges-Payment/Claim Rendering Provider _______________________ 248 Unposted Payments __________________________________________ 248 Payments without Claims ______________________________________ 249 List Refunds ________________________________________________ 249 List Write-offs/Adjustments ____________________________________ 249 A/R Management Report ______________________________________ 249 Daily Financial Summary ______________________________________ 250

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    APPENDIX A: STATE BILLING EXCEPTIONS

    _________________________ 251

    APPENDIX B: NOTICES ____________________________ 255

    Trademarks _________________________________________________ 255

    GLOSSARY

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    List of New Features

    List of New Features

    Splitting Claims ____________________________________________________ 40 Changing the Claims Date ___________________________________________ 42 Writing Off Multiple Claims at Once ____________________________________ 44 Deleting Multiple Claims at Once ______________________________________ 50 Reassign Provider Numbers on Claims __________________________________ 50 Reassigning CLIA IDs for Multiple Claims at Once_________________________ 51 Copying Insurance Types to Claims ____________________________________ 52 Locking Filtered Claims ______________________________________________ 57 CodeCorrect® _________________________________ 2bc8 ____________________ 75 Viewing Finance Charge Logs _________________________________________ 85 Reloading Insurances from Demographics to Claims _______________________ 86 Reapplying Modifier Percentages on Claims ______________________________ 87 Reassigning Provider Numbers on Claims _______________________________ 87 Converting HCFA Claims to Dental Claims _______________________________ 87 Printing Claims Using the HCFA 1500 Form______________________________ 89 Adding NY Medicaid Form Data _______________________________________ 90 My Claims ________________________________________________________ 94 Dental Claims ____________________________________________________ 107 Hard Closing Claims _______________________________________________ 118 ANSI File Status __________________________________________________ 119 Payment Batches _________________________________________________ 124 Fast Payments____________________________________________________ 126 Hard Closing Payments _____________________________________________ 154 Exporting ERAs ___________________________________________________ 160 Voiding a Refund__________________________________________________ 173 Hard Closing Refunds ______________________________________________ 175 Viewing Payor Invoices _____________________________________________ 182 Viewing Guarantor Statement Jobs ___________________________________ 183 Viewing Payor Invoices _____________________________________________ 183 Creating Patient Refunds from Accounts Lookup _________________________ 184 Transferring Claims in an Account to Collections_________________________ 188 Configuring Patient Statement Options ________________________________ 189 Viewing the ITS Transaction Log _____________________________________ 204 Transworld Collection Management ___________________________________ 211 Claim-Based Collection Management __________________________________ 214 Clearinghouse Dashboard ___________________________________________ 232

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    List of New Features

    Adjustment by User _______________________________________________ 239 Configuring Billing Summary Options__________________________________ 240 OB - Active Pregnancies ____________________________________________ 241 Labels __________________________________________________________ 241 Reminders _______________________________________________________ 242 EMR Reports _____________________________________________________ 242 Scheduling - Provider Productivity Report ______________________________ 243 Using the Report Console ___________________________________________ 244 PM Scheduled Tasks Status _________________________________________ 244 View Claim Scrub Logs _____________________________________________ 245 View Security Logs ________________________________________________ 245 Accessing APL Reports through eCW __________________________________ 246

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    Contents

    List of Enhancements

    List of Enhancements

    About the Encounters Window _______________________________________ 17 About the Claims Lookup Window _____________________________________ 24 Creating a Claim without an Encounter _________________________________ 34 About the Professional (HCFA) Claim Window ____________________________ 61 About the Claim CPT Details Window___________________________________ 70 Completing the Claim Header_________________________________________ 76 Completing Claim Data ______________________________________________ 78 Entering Financial Adjustments _______________________________________ 92 About the Institutional (UB) Claim Detail Window_________________________ 98 About the Payments Window ________________________________________ 121 Posting Patient Payments ___________________________________________ 140 Posting Insurance Payments_________________________________________ 148 Posting Payments Using the ERA _____________________________________ 160 Viewing ERAs ____________________________________________________ 162 Showing ERA Reason Codes _________________________________________ 163 Printing ERAs from the Printed Claims Window __________________________ 164 Printing ERAs at the Claim Level _____________________________________ 165 Posting a Refund Associated with a Claim ______________________________ 170 Looking Up Patient Accounts ________________________________________ 177 Generating Electronic Guarantor Statements ____________________________ 193 Creating and Submitting a Batch _____________________________________ 197 Using the Collection Management Filters _______________________________ 205 Generating Collection Letters ________________________________________ 207 Using Patient Details Options ________________________________________ 208 Entering Collection Status Notes for a Patient ___________________________ 209 Viewing and Setting Patient Alerts from Collection Management ____________ 210 Setting Billing Alerts for Patients _____________________________________ 219 Billing Summary __________________________________________________ 240

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    List of Enhancements

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    ABOUT

    This guide provides step-by-step procedures for routine billing tasks. It is intended for billing managers, office managers, and any other staff members responsible for the day-today processing of claims, posting of payments, crediting of refunds, collecting delinquent accounts, and generating financial reports. This guide does not provide procedures for setting up the system, performing scheduling tasks, document management, or EMR. For detailed information about these tasks refer to the respective user guides. The System Administration Users Guide V 8.0.47 consolidates all the setup information for Front Office, EMR, and Billing features.

    Product Documentation

    The following documentation supports eClinicalWorks Electronic Medical Record (EMR), Practice Management (PM), and/or Patient Portal software applications: Billing Users Guide Electronic Medical Records Users Guide Front Office Users Guide Patient Portal Users Guide Registry Guide System Administration Users Guide Release Notes eClinicalMessenger Users Guide

    Finding the Documents

    eClinicalWorks Documentation is available from the following: The eClinicalWorks Support Portal: http://support.eclinicalworks.com eCliniWiki A Living Guide to eClinicalWorks: http://www.ecwiki.com/

    Getting Support

    Send messages directly to eClinicalWorks Support through the eClinicalWorks Support Portal: http://support.eclinicalworks.com You may also call or e-mail eClinicalWorks Support: Phone: (508) 836-3663 E-mail:

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    Conventions

    About

    Conventions

    This section list typographical conventions and describes the icons used to call out additional information and to indicate item keys, new features, and enhancements to the application. The following typographical conventions are used in this guide: Bold Italic Monospace Identifies options, keywords, and items in a description. Indicates variables, new terms, and concepts, foreign words or emphasis. Identifies examples of specific data values, and messages from the system, or information that you should actually type.

    The following icons are used to highlight new features and indicate enhanced features and Item Keys:

    Icon

    Description Indicates this is an Item Key.

    Identifies New Features.

    Indicates an Enhanced Feature. Points out helpful tips or additional information.

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    ENCOUNTERS

    Encounters are simply documented patient visits. As soon as you book a patient visit in the schedule, an encounter is created. Once a patient has visited the physician and the Progress Notes are complete, you can create a claim. You can create a claim for an encounter only if the physician has clicked the Done button on the Progress Notes Billing window.

    About the Encounters Window

    The Encounters window is accessed by clicking the Encounters button from the Billing band:

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    # 1 Purpose Check the All box to display encounters for all providers, or uncheck the All box and click the More (...) button to checking the boxes next to the individual providers whose encounters you want to display. Multiple providers can be selected at once. 2 Select a specific date range for the encounters you want to display using the Service Date(s) drop-down calendars, or select a general date range (last 30, 60, 90, or 120 days) for the encounters you want to display from the No of Days drop-down list. Click one of the following radio buttons to select the status of the encounters you want to display: Progress Notes Done/Locked - Displays only encounters with Progress Notes that have been marked Done or have been locked. Non-Billable Visits - Displays only encounters that have been marked as non-billable. Progress Notes Incomplete - Displays only encounters with Progress Notes that have not been marked Done or been locked. Progress Notes Locked - Displays only encounters with Progress Notes that have been locked. Visit Status Codes: Non-Billable - Displays only encounters with Visit Status Codes that are marked as non-billable.

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    Encounters

    # 4

    Purpose To display encounters for specific insurance companies, Insurance Groups, facilities, or Facility Groups, click the More (...) button next to the appropriate field and select the desired item. To alternate between selecting facilities or Facility Groups, select the desired option from the gray drop-down list on the left.

    5

    Once the filters have been set and the Lookup button has been clicked, click one of the following buttons to perform an action: Copy - Copies the information displayed on this window to a text or Excel file. Progress Notes - Opens the Progress Notes for the highlighted encounter. Claims IPE All - Creates claims for all applicable encounters. Claims IPE Selected - Creates claims for all encounters currently displayed in the list.

    Click the Lookup button once all filters have been set as desired in order to view encounters that match the selected criteria.

    Processing Completed Encounters

    The following steps can be performed to process completed encounters into claims. To process completed encounters: 1. From the Billing band, click the Encounters icon. The Encounters window opens. 2. Click the Progress Notes Done/Locked radio button. OR Click the Progress Notes Locked radio button. 3. Set the remaining filters at the top of the window as desired. 4. Click the Lookup button. All encounters that match your search criteria display 2779 in the window. 5. Click the Claims IPE Selected (F6) button. The Claims IPE Selected (F6) button only processes the encounters in the list. 6. Continue submitting the claims as you would normally. For more information on submitting claims, refer to the section titled Running Claims IPE from the Encounters Window on page 19.

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    Encounters

    Reviewing Incomplete Encounters

    The following steps can be performed to review incomplete encounters. To review incomplete encounters: 1. From the Billing band in the left navigation bar, click Encounters. The Encounters window opens. 2. Click the Progress Notes Incomplete radio button. 3. Set the remaining filters at the top of the window as desired. 4. Click the Lookup button. The Encounters window displays all Progress Notes that have not been marked as Done by the provider. 5. To open the Progress Notes for an encounter: a. Highlight the encounter you want to review. b. Click the Progress Notes (F3) button. The Progress Notes for the selected encounter opens. Note: The Copy (F2) button can be used to copy the list for the provider to resolve the incomplete Progress Notes.

    Viewing Non-Billable Visits

    All visits marked as non-billable can be filtered and viewed by clicking one of the two nonbillable radio buttons on the Encounters window: Non-Billable Visits Visit Status Codes: Non-Billable The results of these filtered searches are based on marking the appointment as Non-Billable or Visit Statuses that are marked as Non-Billable.

    Claims IPE

    The eClinicalWorks Claims IPE is an integrated processing engine. Claims IPE greatly streamlines claims processing and dramatically improves your efficiency. Run the Claims IPE from the either the Encounters window or from the Claims window.

    Running Claims IPE from the Encounters Window

    Use this procedure to run the Claims IPE for all encounters without claims. To run Claims IPE from the Encounters Window: 1. From the Billing band, click the Encounters button. The Encounters window opens.

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    Encounters

    2. Set the filters as desired and click the Lookup button. Encounters that match the selected criteria display. 3. Click the Claims IPE All (F4) or Claims IPE Selected (F6) button. A confirmation window opens. 4. Click the Yes button. The Claims IPE window opens showing the pending claims that have been assigned to a payer:

    The IPE makes each encounter into a claim and changes the status of each claim to Pending. 5. Use the Select Claim Type drop-down list to select Electronic, Paper, or All claims. 6. Click the Process Claims (F2) button. This action causes the following to occur: All error-free claims with insurances set to Electronic claims are automatically placed in the Claims Ready for Electronic Submission pane. All error-free claims with insurances set to Paper claims are automatically placed in the Claims Ready for Paper Submission pane. All error-free claims with errors are listed at the bottom of the window, and each is indicated in the list by an error icon: 7. Perform the required step: For claims with this status... Pending with Errors

    Then... 1. 2. Click the View Claim button. The errors are listed under the Errors tab. Resolve the errors and submit the claim.

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    Encounters

    For claims with this status... Claims Ready for Electronic Submission

    Then... 1. 2. 3. Click the Set Elec. Status (F4) button. Click the Submit Batch button. The Batch Claims (Electronic) window opens. Click the Submit Batch button. The batch is submitted. Click the Set Paper Status button. Click the Print Batch button. The Batch Claims (Paper) window opens. Click the Print HCFA button. The batch opens in MS Word. Print the batch as needed from MS Word.

    Claims Ready for Paper Submission

    1. 2. 3. 4.

    Note: UB Claims can be created using Claims IPE, but setting their status and submitting them must be performed manually. For more information, refer to the section titled Claims on page 23.

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    CLAIMS

    Claim information derives from current information on the Patient Information window (also known as Patient Demographics), Provider Information, the Provider Number on the Insurance window, and Facility information at the time the claim is created. When you create a claim, eClinicalWorks puts the following information together: Patient Insurance information Encounter information Facility/Physician information Unique eCW-generated claim number IMPORTANT! If there is a change in the patient's information after a claim has been created, or, if you need to update a provider number, the claim will not automatically update to reflect the change. You will need to reload or reassign this updated information to affected claims. For more information, refer to the sections titled Reloading Insurances from Demographics to Claims on page 86 and Reassigning Provider Numbers on Claims on page 87. eClinicalWorks provides flexibility in how you can prepare claims. You can work in the way you are most comfortable and familiar. For example, you can: Create claims from data in the system gathered during the doctor/patient encounter. Create claims from scratch (starting with patient information only). Create bulk claims using the Claims IPE (integrated processing engine) feature. Day-to-day processing of claims is done by accessing the billing options from the Billing band, such as: Looking up encounters Viewing claims and payments Processing ERAs Logging refunds Viewing account information Running batches Printing claims Managing your collection process Recalling patient accounts


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