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Implementation and Training

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  1. Implementationand Training Provider Taxonomy Changes for HIPAA 837 Claims Processing Audience for Training Database Administrators Clinical users • The following slides will be discussed during the training session: • mapping of CHCS specialties to HIPAA Provider Taxonomy- p. 8 • multiple taxonomy codes per provider- p.8 • screen shot of provider specialty field- p. 10 • example of HIPAA Taxonomy Code table- p. 11 • Please print presentation with notes pages. Go to Print→Print What→Notes Pages

  2. Implementationand Training Provider Taxonomy Changes for HIPAA 837 Claims Processing Electronic Billing of Third Party Insurance Claims 27 October 2003 ACS Federal Healthcare, Inc.

  3. HIPAA Compliance of 837 Claims Purpose The Purpose of the HIPAA 837 Claims Processing training is to ensure that all the required data for the X12 837 Professional and Institutional Claims are provided to TPOCS. This will provide compliant 837 transaction for claims processing. TPOCS is the MHS standard system for the processing of third-party claims for outpatient services, and supports billing processes. TPOCS sends the data captured to the clearinghouse to allow electronic billing for claims.

  4. HIPAA Compliance of 837 Claims Benefits of Electronic Billing • Standardizes Data Requirements & Format • Increases Patient, Insurance, Coding and Billing Data Accuracy • Increases security of Patient Health Information • Eliminates costs and delays associated with paper documents • Reduces initial claims rejections and increase collections • Shortens waiting periods for reimbursement to MTF

  5. MTF Revenue Cycle F. EOB Patient Access 1. Appointment Scheduling 2. Pre-Registration 3. Walk-in A. Scheduling Paper EOB/Payment MTF B. Verification Third Party Payer Verification 1. Insurance Confirmation 2. Insurance Verification 3. Pre-Cert Requirements C. Patient Care Clearinghouse D. Disposition HIPAA 837 Transaction Health Information Mgmt. 1. Documentation 2. Diagnosis/Procedure Coding Billing/Collections Billing/Collections 1. Claims Submission 2. Follow-up 3. Claims Status E. Coding TPOCS Electronic file transmission TPOCS CHCS /ADM

  6. HIPAA Compliance of 837 Claims Processing Overview Business Process Issues & Concerns • CHCS Data Quality Requirements • Provider Files-Provider Taxonomy

  7. HIPAA Compliance of 837 Claims Processing Overview Data Requirements from CHCS Users • Information Required to Allow Electronic Billing on TPOCS with 837 HIPAA Compliant Claims Processing • CHCS Data Quality Requirements • Provider Files-Provider Taxonomy

  8. HIPAA Compliance of 837 Claims Processing HIPAA II Taxonomy Phase II Project Overview • The CHCS System has been enhanced to store multiple HIPAA Provider Taxonomy values in the HIPAA Provider Taxonomy Code field of the Provider file. • The CHCS Data Administration Provider Enter/Edit screen has been modified to permit users to designate a Primary HIPAA Provider Taxonomy value for a provider. • The Provider ASCII file download to TPOCS (Third Party Outpatient Collection System) has been modified to reflect multiple HIPAA Provider Taxonomy values for a provider and to designate the Primary HIPAA Provider Taxonomy value and allow for appropriate billing.

  9. HIPAA Compliance of 837 Claims Processing ADM Priority I Phase II Overview (use of HIPAA Provider Taxonomy III table)- summer 04 • Residents have been mapped to their respective specialties on the taxonomy table, thus associating GME with a CMAC Provider class and CHCS Specialty Code (billable.) • Residents will continue to occupy Appointment Provider field in ADM and Supervising Provider will occupy second field (residents require supervising provider since GME is mapped to a non privileged provider status) • ADM Priority I Phase II, upon conversion, will trigger all billable events involving residents (for prior x months) to be pushed to TPOCS and be billed. Billers will see a one time higher volume of resident billable events upon conversion.)

  10. HIPAA Compliance of 837 Claims Processing Ambulatory Data Module Overview of Changes - Provider *If the information applies, it needs to be completed to allow electronic billing* CA-DAA-CFT-CFM-PRO

  11. PROVIDER: QUARLES,GARY DA PROVIDER EDIT Name: QUARLES,GARY Provider Flag: PROVIDER Provider ID: 944690606 Provider Class: PHYSICIAN SSN: 444-69-0606 Select PROVIDER SPECIALITY: + CARDIOLOGIST Primary Provider Taxonomy: CMAC Provider Class: Select PROVIDER TAXONOMY: Location: CLARK CENTER HCP SIDR-ID: 108116 Branch of Service: Rank: CIVILIAN Help = HELP Exit = F10 File/exit = DO Entering a Specialty will auto-populate the Primary Provider Taxonomy, CMAC, and Select PROVIDER TAXONOMY fields INSERTOFF

  12. PROVIDER: QUARLES,GARY DA PROVIDER EDIT Primary Provider Taxonomy: ?? CMAC Provider Class: 01 - MEDICAL DOCTOR/DOCTOR OSTEOPATHY Select PROVIDER TAXONOMY: +207RC0000X Location: CLARK CENTER HCP SIDR-ID: 108116 Branch of Service: Rank: CIVILIAN Help = HELP Exit = F10 File/exit = DO 204C0000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/NEUROMUSCULOSKELETAL MEDICINE/ 204D0000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/NEUROMUSCULOSKELETAL MEDICINE & OMM 204E00000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/ORAL & MAXILLOFACIAL SURGERY 204F00000X PHYSCIIANS/ALLOPATHIC/OSTEOPATHIC/SURGERY/TRANSPLANT SURGERY + + Make choice = SELECT Exit = F10 INSERTOFF

  13. PROVIDER: QUARLES,GARY DA PROVIDER EDIT Name: QUARLES,GARY Provider Flag: PROVIDER Provider ID: 944690606 Provider Class: PHYSICIAN SSN: 444-69-0606 Select PROVIDER SPECIALITY: + CARDIOLOGIST Primary Provider Taxonomy: 207RC0000X CMAC Provider Class: 01 - MEDICAL DOCTOR/DOCTOR OSTEOPATHY Select PROVIDER TAXONOMY: +207RC0000X Location: CLARK CENTER HCP SIDR-ID: 108116 Branch of Service: Rank: CIVILIAN Help = HELP Exit = F10 File/exit = DO Hitting <ENTER> in front of code will give a description including taxonomy code and CMAC. INSERTOFF

  14. PROVIDER: QUARLES,GARY DA PROVIDER EDIT #2A HIPAA Provider Taxonomy Code: 207RC0000X HIPAA Provider Taxonomy Description: PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/INTERNAL MEDICINE/CARDIOVASCULAR DISEASE CMAC Provider Class: 01 - MEDICAL DOCTOR/DOCTOR OSTEOPATHY This is the Provider’s Primary Taxonomy. It cannot be edited or deleted.

  15. HIPAA Compliance of 837 Claims Processing Provider Personnel File CA-CLN-Facility Quality Assurance-PRO-PER

  16. PROVIDER PERSONNEL FILE Page 1 Provider: QUARLES,GARY SSN: 444-69-0606 Class: PHYSICIAN ============================================================ Branch: Corps: Rank: CIVILIAN Date of Rank: Primary Hospital Location: CLARK CENTER Department/Service: ORTHO CARE DEPT FE MEPRS:: BGAA Military Occupation Code: Flying Status: NO Provider Specialty(s): CARDIOLOGIST RESIDENT SURGEON SURGERY CONSULTANT Primary Division: NH PORTSMOUTH, VA Allowable Divisions: User File Reference: QUARLES, GARY Help = HELP Exit = F10 File/Exit = DO Personal Data - Privacy Act of 1974 (PL-93-579) Selecting a SPECIALTY and pressing <ENTER> will take you to a background screen and display additional information, including a description of the Provider Specialty and Taxonomy Code. INSERT OFF

  17. PROVIDER PERSONNEL PROFILE Provider: QUARLES,GARY =============================================================== Provider Specialty Code: 014 Provider Specialty Description: CARDIOLOGIST HIPAA Provider Taxonomy Code: 207RC0000X HIPAA Provider Taxonomy Description: PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/INTERNAL MEDICINE/CARDIOVASCULAR DISEASE CMAC Provider Class: 01 - MEDICAL DOCTOR/DOCTOR OSTEOPATHY Press <RETURN> to continue Help = HELP Exit = F10 File/Exit = DO Personal Data - Privacy Act of 1974 (PL-93-579) INSERT OFF

  18. HIPAA Compliance of 837 Claims Processing Provider Specialty Type CA-PAS-Managed Care-FMCP-PTAB-SPEC

  19. PROVIDER SPECIALTY TYPE Enter/Edit Provider Specialty Type: CARDIOLOGIST Code Description 012 ALLERGIST HIPAA Provider Taxonomy Code: 207KA0200X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/ALLERGY & IMMUNOLOGY/ALLERGY 014 CARDIOLOGIST HIPAA Provider Taxonomy Code: 207RC0000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/INTERNAL MEDICINE/CARDIOVASCULAR DISEASE <- Enter Provider Specialty Enter Provider Specialty to add to Provider Specialty Type. Use the SELECT key to delete any Provider Specialties entered in error.

  20. PROVIDER SPECIALTY TYPE Enter/Edit Provider Specialty Type: CARDIOLOGIST Code Description 012 ALLERGIST HIPAA Provider Taxonomy Code: 207KA0200X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/ALLERGY & IMMUNOLOGY/ALLERGY 014 CARDIOLOGIST HIPAA Provider Taxonomy Code: 207RC0000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/INTERNAL MEDICINE/CARDIOVASCULAR DISEASE DERMATOLOGIST <- Enter Provider Specialty 080 DERMATOLOGIST Are you adding ‘080’ as a new PROVIDER SPECIALTIES (the 3rd for this MCP PROVIDER SPECIALTY TYPE)? Y

  21. PROVIDER SPECIALTY TYPE Enter/Edit Provider Specialty Type: CARDIOLOGIST Code Description 014 CARDIOLOGIST HIPAA Provider Taxonomy Code: 207RC0000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/INTERNAL MEDICINE/CARDIOVASCULAR DISEASE 080 DERMATOLOGIST HIPAA Provider Taxonomy Code: 207N00000X PHYSICIANS/ALLOPATHIC/OSTEOPATHIC/DERMATOLOGY <- Enter Provider Specialty Enter Provider Specialty to add to Provider Specialty Type. Use the SELECT key to delete any Provider Specialties entered in error.

  22. HIPAA Compliance of 837 Claims Processing Individual Provider - Place of Care Within Group CA-PAS-Managed Care-FMCP-PTAB-PROV

  23. INDIVIDUAL PROVIDER - PLACE OF CARE PROFILE WITHIN GROUP Provider: QUARLES,GARY Group: CLARK GROUP Place of Care: CLARK CENTER Select Specialty ------------------------------------------------------------------------------------------------------ CARDIOLOGIST RESIDENT SURGEON SURGERY CONSULTANT Help = HELP Exit = F10 File/Exit = DO ============================================================= Selecting one will give a description including taxonomy code and CMAC. INSERT OFF

  24. INDIVIDUAL PROVIDER - PLACE OF CARE PROFILE WITHIN GROUP Provider: QUARLES,GARY Group: CLARK GROUP Place of Care: CLARK CENTER Specialty Code: CARDIOLOGIST Accepts Specialty Referrals Accepts PCM Assignments Associated with Specialty associated with Specialty at this Place of Care at this Place of Card YESNO HIPAA Provider Taxonomy Code: 207RC0000X HIPAA Provider Taxonomy Description: PHYSICIANS/ALLOPATHIC/OSTEPATHIC/INTERNAL MEDICINE/CARDIOVASCULAR DISEASE CMAC Provider Class: 01 MEDICAL DOCTOR/DOCTOR OSTEOPATHY Help = HELP Exit = F10 File/Exit = DO ======================================================================= INSERT OFF

  25. HIPAA Compliance of 837 Claims Processing Summary *If the information applies It needs to be completed To allow electronic billing* • Data Requirements • Provider Files-Provider Taxonomy

  26. HIPAA Compliance of 837 Claims MILITARY HEALTH SYSTEM (MHS) HELP DESK The MHS Helpdesk provides support for U.S. Military Health Information systems, worldwide, 24 hours a day, 7 days a week. They are the single Point of Contact for your MHS Application needs. CONUS: 800-600-9332 Direct: 210-767-5250 OCONUS: Belgium: 0800-72115 Germany: 0800-1011129 Greece: 00800-12-5629 Guam: 1-866-637-8725 Italy: 800-782407 Japan: 00531-1-20743 Korea: 00798-14-800-5242 Netherlands: 0800-0228847 Panama: 001-800-151-1005 Portugal: 800-8-12305 Turkey: 00-800-151-1005 United Kingdom: 08-005871786 Spain: 900-951895 Trouble tickets can be entered directly by authorized users on the internet at http://www.mhs-helpdesk.com/ and use the HELPNOW tool. To open a trouble ticket through e-mail, send to HELP@MHS-Helpdesk.com You can also submit a ticket using Customer Service Fax number at 210-767-0449