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Payment Posting Primary, Secondary and Beyond. LeeAnn Pavlick RCM Consultant. 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

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Payment posting primary secondary and beyond

Payment PostingPrimary, Secondary and Beyond

LeeAnn Pavlick

RCM Consultant


Agenda
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


Insurance carrier
Insurance Carrier

Must assign a Transaction Column Set to every Insurance Carrier


Insurance carrier1
Insurance Carrier

Error Message when Transaction Column Set no Assigned


Standard or customized per carrier
Standard or Customized per Carrier

Ability to assign specific Payment Types, Adjustment Types, Transfer notes


Transaction column sets required columns
Transaction Column SetsRequired Columns


Actual allowed contractual adjustment columns
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


Payment residual columns
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


File to insurance line information columns
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)


Adjustment payment types
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


Insurance groups
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.


Payer literal s
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


Finding payer literal s
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~


Override standard payer name
Override Standard Payer Name

Used when there are multiple instances of the same payer with different names to define the different plans



Payment entry1
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


Payment entry2
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



Actual allowed payment adjustment transfer amounts
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


Line information
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


Balancing the line information
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


Cob information
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.


Current carrier visit status
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.


Ok ok more vs file next
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


Paid in full by primary insurance payer
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.


Rejected by primary insurance payer
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”


Medicare ub04 secondary claim after a commercial payer payment
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


Medicare secondary claim after a 0 00 payment by commercial payer
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


Medicare secondary claim after a 0 00 payment by commercial payer1
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


Medicare secondary claim after a 0 00 payment by commercial payer2
Medicare Secondary claim after a $0.00 payment by commercial payer




Posting interest payments
Posting Interest Payments

  • Create procedure code for Interest

  • Create Adjustment for Interest

  • Interest Payments should not be applied to actual CPT procedures


Interest payment
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.


Posting plb adjustment payments
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


Posting plb adjustment payments1
Posting PLB Adjustment / Payments

  • Create procedure code(s) for different PLB adjustments

  • Create Adjustment(s) for PLB’s




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