How to Deal with Rejections

1. How to Deal with Rejections Are you having a tough time dealing with rejection? Claim rejection, that is? Sending Corrected Claims, Appeals, and Managing your Rejections. LeeAnn Pavlick RCM Consultant

2. Agenda • Corrected / Adjusted claims • Voided Claims • Out of Balance Secondary • Proof of Timely Filing • Appeals / Vis-Forms

3. Corrected/Adjusted vs Original Send Corrected / Adjusted Send Original No adjudication /EOB Front End rejection from either Clearinghouse or Payer Rejected - changes to: Change to Insured ID Change to Provider ID’s Change to Date of Service Change to Procedure • When a claim has been inappropriately adjudicated • Requires ICN / DCN number • Some institutional payers require Condition codes • Some payers require additional Notes / documentation

4. Corrected / AdjustedUB04 / Institutional • Entered in transaction distribution or on Visit Info tab • Change the last digit of the Type of Bill on Filing (1) tab to “7” • ICN /DCN number required

5. Corrected / AdjustedUB04 / Institutional When changes are made to the original adjudicated claim, one of the following Condition Codes may be required. Condition Codes must be setup in Administration.

6. Corrected / AdjustedCMS1500 / Professional ICN / DCN number required Entered in transaction distribution or on Visit Info tab Resubmission code “7” is added on Filing (1) tab Additional information is added to the Notes tab of the visit with Claim Header Note Type of “Additional Information”

7. Voiding a Claim Voiding a Claim • When a claim has been adjudicated and needs be refunded or canceled • ICN / DCN number required

8. Voiding a Claim Voiding a Claim • UB04 /Institutional • Change last digit of Type of Bill to “8” (Filing (1) tab) • CMS1500 / Professional • Update Resubmission Code to “8” (Filing (1) tab)

9. Voiding a Claim Voiding a Claim • Some institutional payers require Condition codes • Condition codes must be setup in Administration • Some payers require additional Notes / documentation

10. Out of Balance • Line Information does not equal • Line Information missing • Lines selected as “File to Insurance” incorrect • COB – Payer Paid Amount missing / invalid • Payment posted under wrong payer name • $0.00 payments not entered

11. 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

12. 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 Co-Pay

13. COB Information Payer Paid Amount only for those procedures selected as “File to Insurance”

14. Payment posted under wrong Payer Name Primary Payer name displayed on Visit Information tab of Visit does not match name that appears on Transaction tab of Visit. Occurs when payments for multiple payers appear on the same EOB. (Carriers should be part of a group and posted under group)

15. Payment posted under wrong Payer Name To correct, create an additional payment under the correct carrier with a 0.00 payment in the line items and re-enter the line information.

16. Timely Filing • Many Carriers now have timely filing limits of 60-90-120 days • Know the timely filing limits of each of your major payers • Post remittance / EOB’s in timely manner • Review outstanding claims in Billing Window on a regular basis • Follow-up with calls / inquiries when visits show accepted by payer

17. Timely Filing Re-arrange columns to sort by date of service or last filing date May want to possibly sort by Visit Insurance Balance to pull out high dollar tickets as well

18. Proof of Timely Filing Centricity EDI Clearinghouse

19. Proof of Timely Filing ClaimRemedi Clearinghouse

20. Appeals • Numerous payers will accept a written / hardcopy appeal. • Carriers have specific forms required, some will accept information on provider’s letterhead. • Reasonable explanation of timely filing are often accepted. • Some will accept the claims electronic with the appropriate “Delay Reason Code” and documentation.

21. Delay Reason Codes • Filing (1) tab of Visit

22. VisForms • System Generated Appeal Forms • Can pull Patient Information, Insurance and Facility Information from registration and visit • Located in the Patient Registration Component

23. VisForms Once created, printed, electronic copy is saved within the Patient Demographics Several Custom forms have already been created and are being utilized by our RCM team to expedite the processing of an appeal

24. VisForms After form selection the system displays all of the visits for the specific patient. Select tab for “Last 10 visits” or Search for a specific date / visit.

25. Vis Form Examples BCBS of Texas Claim Review Form You can add or change any data shown as well as enter comments

26. VisForm Examples UnitedHealthcare Request for Reconsideration

27. VisForm Examples Excellus BCBS Timely Review Form

28. VisForms • When completed you can save a draft that can be modified at a later date or save & finalize the form • Any saved forms will be listed on the main VisForms Screen

29. Questions ?

30. Download all conference presentations at visualutions.com/ug14conference Thank you. Join our newsletter and stay up to date! visualutions.com/newsletters