Billing
Things to review while working claim edits
Call the payer, review SOP's/Tip sheets, google, reach out for assistance
CPT/DX comes back denied from the payer
Send to coding for review of any changes
Diagnosis inconsistent with the procedure?
Send to coding to review any other dx to add/change
True or False:
You can change the bundled episode dates without sending to the TFC
True
True or False:
You should use a claims tracker, regardless of payer, to assist in bundle billing
True
Claim has denied for COB/EOB, what are your next steps?
Reviewing eligibility on the portal and if the transplant case is still active reach out to the patient to call the payer and correct the order for primary/secondary. You could also ask the TFC to review to ensure no changes have occurred
Rendering provider not eligible to perform the service billed
Send to RI if there's another physician to add
Escalate to payer with supporting documents to prove it's been underpaid
Outpatient bill types
Inpatient bill types
Bonus: Inpatient Interim bill types
Outpatient 131/137
Inpatient 111/117
Bonus: Inpatient Interim billed 112/113/114 +200pts
It's within a global period and/or needs review by the biller.
Claim has denied for coding, coding dept has reviewed and states no changes, what could be the next step?
If it's under $50 it can be adjusted, appeal for medical necessity with medical records, ask the payer to send back to reprocess the claim
CPT has an inappropriate number of units for the procedure billed
Send to RI to review units and correct as needed
Denial for lack of authorization
Review documents/link referrals/history to see if its listed anywhere
Reach out to the TFC to review if an auth was received
Send to Pre Access for retro auth if payer allows
How long you have to submit the PR to the self-pay bucket for patient
1 year from the last remit deposited date
You send the Transplant HAR for settlement when...
The account has been paid in full and physician charges have been linked appropriately
How long should we wait for a payment to post to an account?
EFT - 14 days
Paper check - 30 days
Two or more accounts need to be combined/uncombined
Send to billing
Denied for Medical Necessity for OP and IP
OP: Send to coding to review for dx changes, appeal for medical necessity via reconsideration
IP: Send to coding to review for dx changes, send to Denials team in EIQ for review.
When should you undo the billing?
If the claim needs to be split or for Optum if a claim has rejected and changes have been made and sitting in the pre-bill bucket
Medicaid coverages within the global period need what added to the UB04?
Rev Code 960 for physician charges
Where should you request medical records
in EIQ under action log choose medical records requested
There are 2 diagnosis that cannot be billed together unless they are unrelated to each other
in EIQ submit to DRG Validation Review
Denial as it was received without a valid NDC number
Send to Research team
What information do you need in your notes at all times
Ensemble Collections, your name/signature, phase of care, expected reimbursement, what is going on with the claim/claim information, and next steps