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. CHCS MSA/DD7A Itemized Billing Business Rules . .
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1. CHCS MSA/DD7A Itemized Billing Business Rules Charlene C. Colon, SAIC
UBO-UBU Conference 2003
28 April 2003
3. 3 Processes to Capture Charges CHCS File and Table Maintenance
Staff Roles and Responsibilities
Clinic Front-Desk Processes
Accurate and Complete Charge Capture
4. 4 How Are Charges Captured? Outpatient charges for procedures and services billed by CHCS MSA and Monthly DD7A will be captured as a by-product of day-to-day operations using:
CHCS Ambulatory Data Module (ADM) or CHCS II Encounters Written-Back to ADM
CHCS Laboratory (LAB)
CHCS Radiology (RAD)
CHCS Pharmacy (PHR)
5. Steps in the MSA/DD7A Billing Process Assign Patient Category in CHCS
Verify Billing Address Information
Capture Procedures & Services in CHCS
MSA/DD7A Calculates Itemized Charges
Review/Verify Billed Charges
Submit MSA Invoice & Receipt (I&R) or DD7A
7. 7 Step 1: Capture patient billing data in CHCS:
The Patient Category assigned in Mini or Full Registration in CHCS determines whether a patient is MSA or DD7A Billable or whether OHI can be entered and the services billed in TPOCS.
Patient Billing Address is not a required field in CHCS Registration, but is required to submit an MSA Invoice and Receipt (I&R). Billing Process Step 1
8. 8 Patient Category is Key CHCS does not provide the ability to correct Patient Categories associated with Outpatient services as it does for Inpatients via Correction Management:
The Patient Category is associated with the ADM Encounter, when the ADM record is created.
The Patient Category is associated with Ancillary services (LAB, RAD and PHR) when the services are entered into CHCS for the Date of Service:
Laboratory Specimen Accessioned
Radiology Exam Performed/Radiology Film is Interpreted
Pharmacy Order is Processed
Patient Category can be changed in Full or Mini-Registration for future use
If the Patient Category associated with the services is incorrect, the services would need to be manually entered or excluded
9. 9 Step 2: Capture Outpatient Clinic Services and Procedures in ADM, LAB, RAD & PHR sub-systems in CHCS:
ADM Encounters with a Status of COMPLETE and Completed LAB, RAD & PHR services will be automatically assigned a BILLING Flag by CHCS
CHCS will automatically transfer Billable services for processing to TPOCS, CHCS MSA or the DD7A, based on the Billing Flag assigned by CHCS
Services MUST be associated with a Billable Provider Billing Process Step 2
10. 10 Provider Specialty in CHCS
For an Encounter that is subsequently Admitted, Itemized Charges would be calculated and Manually appended to the Inpatient Claim.
Modifier needed for DME Services to calculate charges.For an Encounter that is subsequently Admitted, Itemized Charges would be calculated and Manually appended to the Inpatient Claim.
Modifier needed for DME Services to calculate charges.
11. 11 Billing Process Step 3 Step 3: CHCS MSA/DD7A will automatically calculate charges based on multiple DoD Standard Rate Tables:
CHAMPUS Maximum Allowable Charge (CMAC) Rate Table (per CPT/HCPCS and CMAC Geographic Locality)
Dental Rates based on Common Dental Terminology Codes (CDT) and Rates (HCPCS D Codes)
National Drug Code (NDC) Rate Table (Pharmacy Billing)
Anesthesia Rate Table
Durable Medical Equipment (DME)/Supplies Rate Table
Immunizations/Injectibles (HCPCS J Codes) Rate Table
Pharmacy Dispensing Fee
Calculation Factor for Inter-Agency (IAR) and International Military Education & Training (IMET) Rates
12. 12 Step 4: Verify billed charges, DEERS Eligibility, and Military Service prior to Finalizing the MSA I&R or Monthly DD7A Report
Billing compliance requires documentation of all services billed, to support the verification of coding and billed charges.
Verify Military Service and Medicare Eligibility (E, D and L) for DD7A Billable Patients
Billing Process Step 4
13. 13 Step 5: Submit Charges for Payment
MSA Invoice & Receipts
Monthly DD7A Report
Billing Process Step 5
14. 14 Itemized Billing Time-Line
15. 15 MSA Account Status Processing New MSA Account Status support the Itemized Billing process:
New MSA Accounts will be created and remain in a P Pending Review Status during the 14 day billing hold period.
An Interim MSA I&R can be created when the Account is in P Status to inform the patient of Pending Charges
MSA Accounts will remain in P Status for 14 days, unless the MSA User changes the account status to B Bill.
MSA Accounts changed to a B Status will be removed from the MSA Preview Report.
After the 14 day billing hold, the MSA Account will automatically become Final and the Account Status will be changed by the system to O Open.
MSA Accounts in O Status become Active Accounts Receivable for the Fiscal Year of the Services rendered.
16. 16 Updating MSA/DD7A Charges CHCS MSA requires a 14 day billing hold period in addition to the 3 day OHI hold, to allow for the validation of billed charges, prior to Finalizing the MSA I&R.
CHCS MSA will accept encounter coding updates from ADM, during the 14 day hold period, prior to the Finalizing I&R or monthly DD7A.
MSA charges may be manually Appended for a specific Date of Service, Patient and Treating DMIS ID.
CHCS MSA will NOT allow MSA/DD7A users to edit/update of ADM encounter coding, however, billed charges may be Excluded.
One Time Charges (OTCs) may be added to any MSA Account or the DD7A.
17. 17 What is the Date of Service?
18. 18 Who Bills?
19. 19 MSA/DD7A Rate Calculations
20. MSA Daily Workflow Review/Verify Billed Charges
Review Exceptions Report and Notify Roster
Manage MSA Accounts
Exclude Invalid Charges (Cancel Account)
Submit an Invoice & Receipt (I&R)
Finalize the Monthly DD7A Report
21. 21 Appending MSA Charges Charges may be Appended to an MSA Account during the 14 day billing hold period, before the charges are finalized.
Charges may only be appended to an MSA Account for the Same Patient, Same Treating DMIS and Date of Service.
Charges may be appended to an MSA Account that is manually created, for any Patient Category.
Appending LAB, RAD or PHR charges requires that the services be complete in CHCS LAB, RAD or PHR Sub-systems
Appending charges for ADM Encounters will require manual calculation of charges and entering charges as a Variable Rate using the One-Time Charge Option in MSA or DD7A
Other charges that may be manually appended include:
Durable Medical Equipment/Services (DME/DMS)
22. 22 Excluding MSA Charges MSA/DD7A charges may only be excluded during the 14 day billing hold period, before the charges are finalized.
Excluded Charges require the MSA/DD7A User to enter a Reason why the charges were excluded.
MTFs may add reasons to the NEW MSA Excluded Charges Reason Table, to meet local needs or address Data Quality issues.
Excluded Charges in included on the new MSA Excluded Charges Report.
Only OIB charges may be Excluded.
One Time Charges (OTCs) that were manually entered in error to an MSA Account can still be Backed-Out by entering a -1 in the Quantity Field and the amount to be Backed Out, prior to MSA Account being Finalized (Account Status changed to O Open).
23. 23 CHCS DD7A Processing The Monthly DD7A Report has been modified to exclude Medicare Eligible DD7A billable patients. Available to all sites now to process DD7 and DD7A charges since 1 October 2002.
The Monthly DD7A will report both Summary and Detailed Line Item Charges, by patient, captured by CHCS ADM, LAB, RAD and PHR.
The DD7A cannot be Finalized until the Calendar Month is completed. Current Month data will then be listed in the DD7A Preview.
The Finalized DD7A Report will include only those billable services that have met the 14 day billing hold.
The Finalized DD7A for TWO Prior Months can be reprinted.
The Final Detail DD7A can only be sent to a printer or to an Electronic File (CHCS SPOOL File).
24. 24 MSA/DD7A Jeopardy!!! Patient Category
25. Questions???& Rumor Control