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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

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lesson 5 testing and posting the 835 remittance advice
Lesson 5

Testing and Posting the 835 Remittance Advice

lesson 5 topics
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
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
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
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
What Does It Mean For You?

Site Manager:“The lag time has been cut from weeks to days.”

lesson 5 topics1
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
hipaa compliant codes
HIPAA-Compliant Codes
  • Three types
    • Standard Adjustment Reason (also called Claims Adjustment Reason)
    • NCPDP
    • Remittance Advice Remark
standard adjustment reason codes
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
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
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 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
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
Remittance Advice Remark Codes (cont’d)
  • See Appendix B of Accounts Receivable Version 1.7 Patch 5 User Manual
lesson 5 topics2
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 does it mean for you1
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
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
lesson 5 topics3
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
testing the 835
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
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
lesson 5 topics4
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
set up rpms
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
lesson 5 topics5
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
retrieve the file
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
lesson 5 topics6
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
load and view the 835 era file for batching
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
#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
#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
#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
#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 d1
#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 d2
#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 d3
#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 d4
#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
#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
#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 d1
#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 d2
#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 d3
#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
#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
#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 d1
#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
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 d2
#4 Batching (cont’d)
  • See Quick Reference Guide for additional instructions on assembling files for batching
lesson 5 topics7
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
overview of processing the 835 file in a r
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
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
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
#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
#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
1 era rev cont d1
#1 ERA, REV (cont’d)
  • Option is check number specific
    • 835 ERA file may contain more than one Check/EFT number
    • So option lists each check number individually
  • System automatically matches Check/EFT numbers to Collection Batches/Items
  • If more than one match is found, system will prompt user to make batch selection
1 era rev cont d2
#1 ERA, REV (cont’d)
  • Scroll through all claims to validate accuracy
  • If some claims should not be posted, change status to “Not to Post
    • Manually post later through A/R, PAY

Once status on claim has been changed to “not to post,” it cannot be changed back

1 era rev cont d3
#1 ERA, REV (cont’d)
  • See Quick Reference Guide on how to review postable claims

+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+

| ACCOUNTS RECEIVABLE SYSTEM - VER 1.7 |

+ Review Postable Claims +

| UNSPECIFIED SERVICE UNIT |

+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+-+

User: USER,DEMO BUSINESS OFFICE 20-OCT-2003 12:22 PM

Select file: 1001_ERA_10/01/2003 OKMCD835.txt

There are 2 check(s) for the file 1001_ERA_10/01/2003

CHK: 1501

CHK: 555000

Now matching check/EFT Trace #’s on ERA to Check # of Collection Batch/Item..

Check 1501 does not match any existing batch/items.??

Check 55000 previously match to batch ITSC-MEDICAID-09/29/2003-2 Item: 1

A/R Acct: NEW MEXICO MEDICAID for: 1,000.00 Bal: 915.68

Done matching check/EFT Trace # of ERA to check # of collection Batch/Item.

Enter Return to continue: [RET]

1) CHECK #: 555000 BATCH: ITSC-MEDICAID-09/29/2003 ITEM: 1

A/R ACCOUNT: NEW MEXICO MEDI BATCHED AMT: 1,000.00 BALANCE: 915.68

Please enter the LINE # of the check you wish to REVIEW: 1//

2 era pst
#2 ERA, PST
  • Posts payment amounts in an imported and loaded file to matching Accounts Receivable bills
  • Displays information that is relevant to batch and posting results of file
2 era pst cont d
#2 ERA, PST (cont’d)
  • PST screen displays reviewed checks
  • For check selected to post, make sure file matches with what was batched:
    • Check/EFT numbers
    • Batch name
    • Item numbers assigned to check number and amount
  • If nothing matches:
    • System problem due to version on RPMS
    • Must manually post batch
2 era pst cont d1
#2 ERA, PST (cont’d)
  • During posting, if system detects that posting to bill will result in negative balance in RPMS system:
    • Warning message displays
    • Prompts user to choose whether or not to post that bill
  • If ERA file contains claim cancelled in RPMS Third Party
    • Cannot be posted electronically
2 era pst cont d2
#2 ERA, PST (cont’d)
  • Set appropriate time for auto-posting
    • Only one user can auto-post at a time
    • If more than one user tries to access same claim within file, RPMS will automatically go into an error mode and sign off all users
    • Good communication is essential
  • For specific instructions on how to post a payment batch, see the Quick Reference Guide
roll back bills to third party
Roll Back Bills to Third Party
  • Rollback must be done every time auto-posting is done
  • Master Menu option
  • Rolls back updates to Third Party Billing package for all posted accounts whose balances are now zero (0)
roll back bills to third party cont d
Roll Back Bills to Third Party (cont’d)
  • This option will roll back 50 bills at a time
    • If your facility does not roll back payments on a timely basis, the older paid bills will be rolled back first
  • See Quick Reference Guide for specific instructions on how to use this Master Menu option
after posting
After Posting
  • Delete downloaded file from established directory when done
  • Large files quickly fill up space on yourdrive
what does it mean for you2
What Does It Mean For You?

Financial Management Officer:“We get them down, we post them, and we walk off. It’s that easy.”

lesson 5 lessons learned
Lesson 5 Lessons Learned
  • 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