ABILITY EDI Support Workshop

Welcome to EDI Support's Refresher Course!

This course is designed to go over many common issues that you may come across on the phone or via email, composed from escalated cases and questions from Ambulatory Chat.

It's recommended to use this course on Google Chrome as that's what the course was built with.

Let's get started!

 

Healthcare EDI Common Terminology

Terminology Information

Words and Acronyms Are a Part of what We Do

Throughout your career at ABILITY network, you're going to come across and have to understand many terms that are exclusive to both the medical and billing world. Here are just a few you may come across while working with clients over the phone or via email.

Entities

ANSI - (American National Standards Institute) This is the organization that governs ANSI (electronic) formats and transactions.

Clearinghouse - An entity in the billing process that receives claims, may edit and/or review them and sends them on to the payer. Payers may contract with certain clearinghouses and require that ABILITY go through them as well. Other payers may have their own internal clearinghouse that they manage. AKA: a "middleman".

CMS - (Centers for Medicare and Medicaid Services) A branch of the US Department of Health & Human Services that regulates Medicare and Medicaid as well as other federally-funded programs.

Insurance Company - An organization that pays for medical and surgical expenses incurred by an insured patient. Health insurance can reimburse the insured for expenses incurred from illness or injury, or pay the care provider directly. AKA: Payer, Payor, Carrier.

NUBC - (National Uniform Billing Committee) This organization created, designed and governs the UB-04 form. Their logo is printed at the bottom-right of a UB-04 claim form.

NUCC - (National Uniform Claim Committee) This organization created, designed and governs the HCFA 1500 form. Their full name is printed at the top-left of a HCFA 1500 claim form.


Compliance-Related Terms

HIPAA - (Health Insurance Portability and Accountability Act) One of the most important terms that you need to know. HIPAA is a piece of United States legislation that provides data privacy and security provisions for safeguarding medical information. This includes, but is not limited to:

  • A patient's right to see or get a copy of their medical record and other health information
  • A patient's right to learn how their health information is used and shared by their doctor or health insurer.
  • The Privacy Rule does not require providers to eliminate all incidental disclosures because, let's face it, humans are not perfect.
  • The Privacy Rule does not prevent a provider from reporting child abuse.
  • The secure exchange of PHI between various healthcare entities.

EDI-Related Terms

EOB - (Explanation of Benefits) This is the paper form of an ERA and shows providers how much they were paid for each patient and each service line. Clients may receive their payment on a check included with this document. EOBs also contain rejections and other factors that affect a provider's payment. AKA: Remit, Remittance, Coordination of Benefits.

ERA - (Electronic Remittance Advice) This is the electronic form of an EOB and shows providers how much they were paid for each patient and each service line. This also contains rejections and other factors that affect a provider's payment. AKA: .835, Remit, Remittance, Coordination of Benefits, Explanation of Benefits (incorrect, but often used).

EFT - (Electronic Funds Transfer) This is the term used to describe payments that are electronically sent from one bank account to another. AKA: Direct Deposit, e-Check

999 - This report, sent from either a secondary clearinghouse or the payer, simply states that claims were acknowledged by the sending entity.

277 - This report, sent from either a secondary clearinghouse or the payer, also confirms a claim was received by the sending entity. This report, however, shows if there was an error(s) in the file that was received.



Format-Related Terms

Professional Claims:

HCFA 1500 - (Health Care Financing Administration, now CMS) This paper form is the most common claims form you will come across. There are two versions: 1500-0212 and 1500-0805, the latter being the older of the two. Both forms contain 6 service lines and 33 boxes total. AKA: CMS-1500

837p - The electronic version of a 1500 form that looks like code if read in its raw format. AKA: 5010p

Institutional Claims:

UB-04 - (Uniform Billing) This paper format is mainly used for inpatient facilities and hospitals and are much more complex given inpatient care is also just as complex to bill for. The older version of this form is known as a UB-92. This form is easily recognized for having 81 fields and 22 service lines. AKA: CMS-1450

837i - The electronic version of a UB-04 form that looks like code if read in its raw format. AKA: 5010i

Quiz Start

Here we go...

Now that you are more familiar with the information from the previous slide, use your knowledge and resources to complete the following questions...

Fill in the Blanks

Jenny is a biller who bills electronic institutional claims. Simply speaking, Jenny would send  claims to the payer. Today, she had a claim reject on a  report. The payer informed her she needs to bill these claims on a paper claim. This means Jenny needs to use a  form. A few weeks later she receives a deposit in her bank account, also known as a(n) . Accompanying the deposit is an electronic coordination of benefits, also known as an .

True or False?

  • HIPAA allows providers to disclose information to family members without the patient's consent
  • A payer, under HIPAA, can refuse to talk and discuss PHI with a verified clearinghouse partner
  • HIPAA allows a doctor to share information with other healthcare entities as long as it's regarding best treatment for a patient's condition

Match the correct terms with their correct definitions.

  • HIPAA
    The mandate that governs how our health information is shared and protected.
  • EFT
    Another term for 'direct deposit'; a client will receive this usually if they are enrolled for ERAs.
  • ANSI
    The governing body that created and continually revises the 837 format.
  • COB
    Another term for EOB, this tells the biller how much they are getting paid on each service line on each claim.
  • PMS
    A software used by clients to enter their claims and generate a batch file; this software oftentimes has other capabilities such as reporting and appointment reminders.
  • 999
    A type of report that simply tells us that an entity has acknowledged receipt of a batch.
  • 277
    A type of report that shows if claims were accepted and includes reasons for any rejections that may have occurred.
  • UB-04
    A paper format that is mainly used for hospitals and inpatient facilities.
  • HCFA 1500
    A paper format that is mainly used for doctors' offices; there are two versions of this format: 02/12 and 08/05
  • 5010
    Another term for 837, this is an electronic format that is universally the same across the board and is how we send our claims to payers.

What is a Practice Management System?

PMS Info

Practice Management Systems (PMS)

There are MANY practice management software vendors out there that offer various features. These products can range from free to implementations of over $500,000 for a moderately-sized facility. Given at least half our users have one, let's learn more about what a practice management system is.

What is it?

  • A PMS is a software provided by a third-party that allows providers to manage their patients, billing, health information, and other salient data.
  • When it comes to Link1500 customers, we are their PMS (think of it as “PMS-lite”).
  • When it comes to Weblink customers, they will always have an external PMS .
  • Some PMS software companies also bundle in an Electronic Health Records (EHR) portion to track patient data typically between the physician and patient. We do not deal with EHRs.
  • Some common names you will hear will be: InSync, Eclipse, Lytec, Medisoft, ChiroTouch, OfficeAlly among others.

Why would a client need one?

A PMS can do many more things than MD Online products can. This is not to imply that every PMS can do the following things, but the more "robust" softwares include all, if not more, of the following: 

  • REPORTS – A major way to track money coming from the payers are various A/R and Open Items reports. Because we do not know how much a client received , we cannot do these.
  • BATCH CLAIMS  – PMS software allows clients to batch patients by date of service, payer, etc into one file.
  • PATIENT MANAGEMENT – Clients have the ability to update a patient’s information on-the-fly, rather than sending a new claim to update their info, as in Link1500.
  • APPT. SCHEDULING – There is no way in ABILITY’s products to assist with patient appointment scheduling.

Why do they need ABILITY then?

  • Some PMS vendors allow clients to bill directly from the software but this can be very expensive in the long run and many providers cannot justify the cost for the convenience.
  • Other PMS vendors do not allow EDI billing from the software and rely on the client’s ability to log into multiple payers’ online portals to upload claims – this can be time-consuming and frustrating.
  • Since ABILITY is a one-stop-shop in regards to uploading claims to the correct location, clients simply need to submit their claims through us and the claims are automatically routed to the right place.
  • Smaller practices may not want to purchase an expensive software and then have to pay to send the claims out on top of that, so they opt for something simpler like Link1500.

Accepted formats

A format is how data is arranged within a file. For example, a claim can come over with a .clm file type but can contain a print image or electronic format.

We accept:

  • 837 5010 Inst and Prof
  • 837 4010 Inst and Prof*
  • HCFA 1500-0212
  • HCFA 1500-0805
  • UB-04
  • UB-92*
  • NSF*

(* indicates an older format not typically used)

Accepted file types

A file type refers to the file itself and what extension it ends in. For example, a photo can have multiple file types but it's still a photo (eg. ABILITY_image.jpg). ".jpg" would be the file type.

We accept:

  • .clm
  • .tmp
  • .837
  • .txt
  • .dat
  • Many other editable-text file types.

(Note: FTP will only process .clm files)

When do I refer clients back to their PMS?*

  • Any issue with file formatting/type that the client did not intend.
  • The raw data that came over is not what the client claims to have put into their PMS.
  • A claim that should have come to ABILITY did not after they did their billing.
  • Any change in patient or medical information needs to be changed from the PMS, not ABILITY.

*Note: PC-ACE Pro 32 is owned and supported by ABILITY as long as it was purchased from us. Check the assets for any SKU that has 'PCA' in it.




Quiz Start

Here we go...

Now that you are more familiar with the information from the previous slide, use your knowledge and resources to complete the following questions...

Which of the following are true or false regarding Practice Management Systems?

  • Every client who has PC-ACE bought it through ABILITY.
  • Type your statement here...

Which of the following is NOT true regarding Practice Management Systems?

  • There are multiple types of PM software vendors out there - from complex to simple.
  • Link1500, in simplest terms, represents MD Online's only "practice management system".
  • All clients who are Weblink submitters must have an external PMS.
  • PC-ACE Pro 32 was developed by ABILITY Networks, not bought.

Which of the following are electronic, or EDI, claim formats?

  • HCFA 1500 02/12
  • UB-92
  • 835
  • 5010i
  • 4010p
  • 837
Check all that apply.

MD Online offers appointment scheduling through Link1500. Yes or no?

  • Yes
  • No

Which of the following formats are considered legacy and typically are not used today?

  • 837 5010
  • 837 4010
  • NSF
  • HCFA 1500 02/12
  • HCFA 1500 08/05

The Lifecycle of a Claim

Lifecycle Information/Diagram

The above is a diagram of the lifecycle of a claim.

(Right-click > Open Image In New Tab to enlarge)
Click here if the above does not work

Quiz Start

Here we go...

Now that you are more familiar with the information from the previous slide, use your knowledge and resources to complete the following questions...

All clearinghouses send back acknowledgments and acceptance reports. (True/False)

  • True
  • False

Put the following steps of a claim's lifecycle in the correct order.

  • Client enters their claims into their PMS or LINK1500.
  • Client uploads their claims to ABILITY.
  • The clearinghouse receives the claims and sends back an acknowledgement report.
  • The payer accepts the claims after validation has completed.
  • The payer adjudicates the claim.

A biller calls in and states that her claims were not received by Medicare. You notice there is a third-party clearinghouse and this is the last message on the claim. What do you do next?

Status in Webman under the claim number.

  • Tell the client to try calling Medicare again since the rep does not know what they are doing.
  • Inform the client that the payer has to have the claim on file, despite their denial of ever getting the claim.
  • Gather all the information you can and escalate your case to the Giants queue to have a CLH ticket opened.
  • Provide the client the information about the clearinghouse and inform them that they need to call the clearinghouse themselves.
See content above question for screenshot.

All claims that go through ABILITY go through another clearinghouse. True or False?

  • True.
  • False.

Secondary Claims & Insurance - Intro

Secondary Claims Flowchart

For a larger image, right click > open image in new tab

Secondary Insurance Basic Info by Product

Link1500

LINK1500 DOES NOT, HAS NOT, AND WILL NOT ALLOW FOR THE SUBMISSION OF SECONDARY CLAIMS.

(Secondary claim information entered in boxes 11a-d WILL NOT be translated to the outbound 837.)

Weblink - Print Image

  • Clients who use Weblink and send PI claims CAN send secondaries via Weblink, but they need a new scanner added
  • Clients who are enabled to send secondary claims will see “Send Secondary Claims” on their account
  • Since print image submitters can include both primary and secondary payer information on the claim, crossover claims (claims that get sent by the primary directly to the secondary) are likely, but rare since payer IDs do not exist on print image claims
  • Since there is no way to report how much the primary payer paid on a traditional HCFA, they would create a new claim with the secondary payer and send it via “Send Secondary Claims”
  • Upon upload, a secondary claims screen will popup, asking the client to enter reason codes and remarks from the EOB, including the primary’s payments
  • The claim will be sent as normal via WebLink to the secondary payer with the primary’s adjudication information visible to the secondary.
  • Secondary information can be found in fields 9d and 11a-d on a HCFA form, 50 on a UB-04.


Weblink - 5010 Submitters

  • Clients who use Weblink and send 837 claims CAN send secondaries via Weblink, but their procedure differs from the print image customers.
  • Since an 837 submitter can include both primary and secondary payer information on the claim, crossover claims (claims that get sent by the primary directly to the secondary) are more common.
  • Even though the claim may include both payers’ information, it will ALWAYS go to the primary payer first.
  • From there, the payer will decide to return the claim with remittance info (EOB) back to the client or send it to the secondary on their behalf – in this case it’s now considered a crossover claim.
  • If the claim gets returned, the client must enter the payment info into their PMS, and send the claim out with this new information just as they would a primary claim. This time, the claim will be routed to the secondary.
  • Regardless of how the claim gets to the secondary, the clients will still get both a primary and secondary EOB, detailing how much each payer paid and what is left to write-off.
  • Secondary payer information is indicated by an SBR*S* segment in an 837 file.

Link1500 supported secondary claims before it MD Online was bought by ABILITY. True or false?

  • True
  • False

Which of the following two claims contains a secondary payer?

Image #1

Right click > Open Image in New Tab for best resolution

Image #2

Right click > Open Image in New Tab for best resolution


  • Image #1
  • Image #2
  • Both
  • Neither

Click on the image to show where information regarding a secondary payer is located in this 837 file.

A crossover claim is...

  • a claim that was sent via paper and then crossed over to the payer.
  • a claim for patients who were injured playing a sport with 'cross' in the name.
  • a claim that is transmitted to the secondary automatically by the primary
  • only available to BCBS members.

Are the following true or false?

  • Link1500 supports secondary claims
  • It's possible for patients to have a third, maybe even fourth, insurance.
  • Fields 11a-d get sent to the payer when entered in Link1500
  • 5010 submitters need a new scanner in order to send secondary claims.
  • Claims that are crossed over are indicated on an ERA/EOB.

Scanners, Print Image, and Mapping Information

Print Image Information

Print Image HCFA 1500

Can you tell which version of the 1500 form this is?

To enlarge image, right click > open image in new tab.

Print Image UB-04

To enlarge image, right click > open image in new tab.


Print Image is just that...the Image that gets Printed.

  • Print image is just one of the many ways to send claims to ability is via Print Image (PI)
  • Print image claims are claims that, once aligned in front of a genuine paper form, should line up precisely.
  • When these claims come to ABILITY, they look like a bunch of ‘floating’ text segments.
  • Essentially, a Print Image claim is a claim that is composed of everything that would go on a genuine paper form, sent electronically, without the form itself behind the text.

Scanners Information

Scanners: What the Heck are They?

  • Exclusive to Weblink customers only, a “scanner” is what “reads” what comes over on a Print Image claim and appropriately converts the information into an 837 format.
  • Scanners, despite their name, are not physical paper scanners located at the office. Rather, they are a series of codes, written by the Scanners Team, that determine where info for a certain field is located within an upload.
  • There are scanners for 837i and 837p formats, but they are a standard format and most clients use the same 837 scanner(s).
  • Scanners are mainly used for clients who submit paper claim formats (UB-04/CMS 1500) in the Print Image format, since these formats can vary from user-to-user.
  • A client can have MULTIPLE scanners on their account but only one scanner per format. (ex. Client can have a 1500 and UB scanner, but cannot have two 1500 scanners)

What Makes a Scanner so Smart?

Since a ‘scanner’ is nothing more than fancy coding that looks at the claim character by character, it essentially picks things up by assigning the characters’ location within the file (E.G. the patient’s name is from character count 52 to 72 – 20 characters total)

Mapping Information

What is the Mapping process?

  • Whenever a client calls in and asks to change the format they’re sending in, or they need modifications done to it, a mapping case is created.
  • If a client is changing to an absolutely new format altogether, they need to pay $99 via a Custom Programming Agreement to have their new format mapped.
  • The client will need to send a few test files to make sure the scanner reads the new info correctly.

What is the client currently mapped for?

  • Upon first opening an account, a list of scanners is listed below the main terminal information.
  • 837_5010 – Claims in either professional or institutional format (type listed to left of scanner)
  • aardy – Used as an example, this can be any arrangement of letters but typically refers to the CMS 1500 0805 (older) format.
  • aardyH – The capital H at the end indicates the client sends in the newer HCFA format, 1500-0212.

Quiz Start

Here we go...

Now that you are more familiar with the information from the previous slide, use your knowledge and resources to complete the following questions...

Using the image below, tell me which format this scanner indicates the client sends in.

Example #1

  • HCFA 1500 02/12
  • HCFA 1500 08/05
  • UB-04
  • 5010 Professional
  • 5010 Insitutional
  • NSF

A client calls in and informs you of a rejection that he's gotten. You notice that the format submitted is the older 1500 08/05 format when the client is setup to send in the 1500 02/12 format. How can you be certain this is the issue?

  • The rejected Print Image claim only has spaces for 4 diagnosis codes.
  • The scanner on the client's account has an "H" after it.
  • Generally speaking, the client will get a lot of rejections and the scanner will be picking things up incorrectly.
  • The rejected Print Image claim has ABCD diagnosis pointers.
Choose all that apply.

Using the image below, tell me which format this scanner indicates the client sends in.

Example #2

  • HCFA 1500 02/12
  • HCFA 1500 08/05
  • UB-04
  • 5010 Professional
  • 5010 Insitutional
  • NSF

Seeing "Old Style Web" next to a scanner indicates it's meant for the older version of that format. True or False?

  • True
  • False

Using the image below, tell me which format this scanner indicates the client sends in.

Example #3

  • HCFA 1500 02/12
  • HCFA 1500 08/05
  • UB-04
  • 5010 Professional
  • 5010 Insitutional
  • NSF

Payer Variants (AKA "Why did my claim go to this payer?")

Variant Information

Variants?

  • A variant is simply a fancy word that referring to the process used to determine the payer ID on a print image claim.
  • Variants apply ONLY to clients who submit Print Image HCFA 1500 forms (both variants) because there is no place on a HCFA to place a payer ID.
    • 5010 submitters can place payer IDs in the file
    • UB submitters place the payer ID in front of the payer name in field 50.

How are variants determined?

This simple formula is all that is needed to know how variants are formed:

"Payer Name" + "Zip Code" = Payer ID


  • Why are there quotes ("") around payer name and zip code?
    • The scanner pulls the EXACT payer name and zip code used to determine a payer ID.
    • If a payer name is off by one character, 'United Healthcare' vs. 'United Health Care', a new variant is immediately created. The same applies to the zip code.
  • A client can have multiple name and zip code combos point to the same payer ID.


What happens when a client gets a variant?

Whenever a client gets a variant, they will see the screen to the right. (Right click > Open image in new tab for a larger view)

A few things to note about variants that customers ask:

  1. There is NO WAY to remove the one claim with a variant and allow others to go through
  2. The ONLY options a customer has is to complete the variant or discard the entire file
  3. Clients CANNOT send any more claims until the variant is addressed.

Managing Variants

Where Variants go to get Managed

One of the most common reasons for editing a variant is that the client has gotten a rejection for sending a claim to the incorrect payer. More than likely the payer IDs offered looked correct but the client chose the first one in the list. Now that list needs to be edited to reflect the correct payer ID.

Clients can access their variants by going to My Account > Manage Insurance Company Variants. This is what they're greeted with upon opening this page.

If a client chooses to edit their variants, they can hit 'edit' off to the right of the payer ID. This is what they will see when they choose this option.

Once here, they can search for the correct payer or payer ID and then choose the blue link for the correct combination. Changes made here are immediate and clients can re-upload their claims as soon as it's changed.

How to read an 837

837 Basic Information

Breaking down an 837

An 837 file is nothing more than a bunch of segments of data, separated by tildes (~), put together in one big file. Breaking down an 837 is simple:

Loops are simply a grouping of segments that all have info regarding a certain part of the claim (Loop 2400 contains claim information)
Segments are bits of info stuffed between two tildes (~) and refers to one part of the entire claim
Elements are the individual bits of info within a segment, and can be named based on their location in a segment. (NM1-02)
Sub-Elements are pieces of information that further the info for an element they belong to. They can also be referred to by their location in a segment (HI-0203)

NM1*85*2*ABILITY HOME CARE*****XX*1649284068

The NM1 is known as the segment, since it begins after a tilde. This is the Name segment.
The * between NM1 and 85 is known as a separator, since it begins the next element in the segment.
The 85 is the first element after the segment listed, and can be referred to as NM1-01.

ISA/IEA Segments

Think of them as...the bread around a hamburger.

ISA and IEA segments, otherwise known as Transaction Headers and Footers, respectively, contain all of the submitter and receiver information as well as:

  • Time file was created
  • Format and version of the file
  • Number of segments

If the information within either of these segments is wrong or corrupt, then the entire file will likely fail. Think of it like this...if your hamburger bun falls apart, eating the burger is gonna be that much more difficult...and messy.

Examples

ISA Segment:

ISA*00*          *00*          *ZZ*AV09311993     *01*030240928      *161114*1616*+*00501*003796667*1*P*>

GS*HC*AV01101957*030240928*20161114*1616*3796667*X*005010X222A1

ST*837*003796667*005010X222A1

BHT*0019*00*000000000000000000000003796667*20161114*1616*CH


IEA Segment:

SE*149*003796667

GE*1*3796667

IEA*1*003796667

NM1 Segment

What is it?

The NM1 segment is a segment that contains data regarding the name of an entity and any affiliated identifying numbers.

Note: You are NOT expected to know what each and every single segment refers to nor are you expected to know all the qualifiers. Knowing the major ones does help, however.

Break it down for me:

NM1*85*2*ABILITY NETWORK HOMECARE*****XX*1649284068

NM1*IL*1*LASTNAME*JEFFREY****MI*165278839

NM1*DN*1*KASI*RAVI****XX*1982832770

NM1*PR*2*BCBS NJ HORIZON*****PI*22099

NM1-01: Who's name is it?

  • *40 – Receiver Name
  • *41 – Submitter Name
  • *71 – Attending Provider
  • *72 – Operating Provider
  • *77 – Service Facility Name
  • *82 – Rendering Provider
  • *85 – Billing Provider
  • *87 – Pay-To Provider
  • *IL – Subscriber Name
  • *QC – Dependent Name
  • *DN – Referring Provider
  • *DQ – Supervising Provider
  • *DK – Ordering Provider
  • *PR – Payer/Insurance Information

NM1-02: Is the name for a group or a person?

  • *1 – Individual
  • *2 – Group

NM1-03: Last Name/Full Organization Name (the next three should be blank if a group name is used)

NM1-04: First Name

NM1-05: Middle Initial

NM1-07: Generation (Jr, Sr, III)

NM1-08: What type of ID are you giving me?

  • *46 – EDI ID
  • *MI – Member ID
  • *PI – Payer ID
  • *XX – NPI

NM1-09: The ID code itself.

SBR Segment

What is it?

The SBR segment refers to information that's applicable to the subscriber, oftentimes the patient themselves, regarding their payer information.

Note: You are NOT expected to know what each and every single segment refers to nor are you expected to know all the qualifiers. Knowing the major ones does help, however.

Break it down for me:

SBR*P*18**BCBS AZ*****BL

SBR*S*18***12****MC

SBR*P*19*97806M******CI

SBR-01: Is this a primary or secondary insurance?

  • *P – Primary Payer
  • *S – Secondary Payer
  • *T – Tertiary Payer (rarely seen, but used)

SBR-02: What is the patient's relationship to the insurance-holder?

  • *01 – Spouse
  • *18 – Self
  • *19 – Child
  • *76 – Dependent

SBR-03: Payer Group ID

SBR-04: Insurance Name (often not used)

SBR-05: Medicare Secondary Payer code (used ONLY when Medicare is secondary)

SBR-09: What category does this payer fall under?

  • *BL – Blue Cross Blue Shield
  • *CI – Commercial Insurance (most common)
  • *MB – Medicare
  • *MC – Medicaid
  • *VA – Veterans’ Administration
  • *WC – Workman’s Compensation
  • *ZZ – Other

CLM Segment

What is it?

The CLM segment contains most, if not all, generalized information about a claim.

Note: You are NOT expected to know what each and every single segment refers to nor are you expected to know all the qualifiers. Knowing the major ones does help, however.

Break it down for me:

CLM*434638201*2355.47***13:A:1**A*Y*Y

CLM*S3755300102*650***12:B:7*Y*A*Y*Y

CLM*CX190365X2*180***53:B:1*Y*C*Y*Y

CLM-01: Patient account/control number

CLM-02: Total claim charge amount

CLM-0501: Place of service code

CLM-0502: Type of claim

  • :A – Institutional
  • :B – Professional

CLM-0503: Claim frequency code

  • :1 – Original Claim
  • :7 – Corrected Claim
  • :8 – Voided Claim

CLM-06: Is there a signature in box 31? (N/A for Inst claims)

  • *Y – Yes
  • *N – No

CLM-07: Accept assignment?

  • *A – Provider accepts assignment
  • *P – Patient refused to assign benefits
  • *C – Non-assigned benefits

CLM-08: Does the provider have authorization to bill this claim?

  • *Y – Yes
  • *N – No

CLM-09: Does provider have permission to release this medical data (for billing purposes)?

  • *Y – Yes
  • *N – No

DTP Segment

What is it?

The DTP segment stands for Date/Time/Period. Given the name, this segment simply provides the date(s) for whatever applicable situation there is.

Note: You are NOT expected to know what each and every single segment refers to nor are you expected to know all the qualifiers. Knowing the major ones does help, however.

Break it down for me:

DTP*096*TM*1454

DTP*472*D8*20160726

DTP*434*RD8*20160726-20160726

DTP*435*DT*201609141558

DTP-01: What does the date/time/period apply to?

  • *090 – Assumed Care Date
  • *096 – Discharge Hour
  • *304 – Latest Visit/Consultation
  • *431 – Onset of Symptoms/Illness (Box 14 on HCFA ONLY)
  • *434 – Statement Date(s) (Institutional Claims ONLY)
  • *435 – Admission Date
  • *439 – Accident Date
  • *444 – First Visit/Consultation
  • *453 – Acute Manifestation Date
  • *454 – Initial Treatment Date
  • *455 – Last X-Ray Date
  • *472 – Date of Service
  • *484 – Last Menstrual Period (Box 14 on HCFA ONLY)

DTP-02: What format is the Date/Time/Period in?

  • *D8 – Date expressed as CCYYMMDD
  • *DT – Date and time expressed as CCYYMMDDHHMM (military time)

  • *RD8 – Date range expressed as CCYYMMDD - CCYYMMDD
  • *TM – Time expressed as HHMM (military time)

DTP-03: Applicable Date/Time/Period

HI Segment

What is it?

The HI segment stands for Healthcare Information. Given the name, this segment simply provides the diagnosis codes for the claim.

Note: You are NOT expected to know what each and every single segment refers to nor are you expected to know all the qualifiers. Knowing the major ones does help, however.

Break it down for me:

HI*ABJ:O471

HI*ABK:O700:::::::N

HI*ABF:O9852:::::::Y

HI*ABK:M5011*ABF:M62412*ABF:M546

HI-0101: What type of code am I being given?

  • *BE – Value Code (Institutional ONLY)
  • *ABK – Primary Dx Code (ICD-10)
  • *ABF – Supplementary Dx Code (ICD-10)
  • *ABJ – Admitting Dx Code (ICD-10)

HI-0102: Code itself.

HI-0109 : Present on Admission indicator (Institutional ONLY)

  • :Y – Present on Admission
  • :N – Not present on Admission

HI-02 thru HI-12: Same as above, just additional codes.

SV1 and SV2 Segments

What is it?

The SV1 and SV2 segments show the procedure and other related codes that providers expect to reimbursed on. SV1 is for Professional claims while SV2 is for Institutional claims.

Note: You are NOT expected to know what each and every single segment refers to nor are you expected to know all the qualifiers. Knowing the major ones does help, however.

Break it down for me:

SV1*HC:98941*140*UN*1***1:2:3:4

SV2*0122**3278*DA*2

SV1 - Professional

SV1-0101: What type of code am I being given?

  • *HC – HCPCS/CPT/Procedure code

SV1-0102: Code itself.

SV1-0103 thru 0106 : Modifiers

SV1-02: Total line charge amount

SV1-03: How is the quantity being measured?

  • *UN – Units
  • *DA – Days (rare on Professional claims)
  • *MI – Minutes

SV1-04: Quantity

SV1-0701 thru 0704: Diagnosis code Pointers

SV2 - Institutional

SV2-01: Revenue Code

SV2-0201: What type of code am I being given?

  • *HC – HCPCS/CPT Code (90837) (G0548)
  • *HP – HIPPS/RUGS Code (1CHRT) (HAR4E)

SV2-0202: Code itself

SV2-0203 thru 0206: Modifiers

SV2-03: Total Line Charge Amount

SV2-04: How is the quantity being measured?

  • *UN – Units
  • *DA – Days
  • *MI – Minutes

SV2-05: Quantity

How to Read an ERA

ERA Basic Information

ERA information

ERAs, the electronic version of an EOB, show a provider how much a payer paid (or didn't pay) on a service line for a particular patient on a specific DOS. While it's not expected for you to be able to read an ERA as if you were the biller, it is important to note how to read one of these documents. An ERA shows not only paid and write-off amounts, it also shows any rejections that were not necessarily received via a message.

Sample ERA

Refer to the diagram above when referencing the below information about what information is where on an ERA when it gets to ABILITY.

Remember, right click > open image in new tab for a larger view.

Let's Break it Down

A - This is the entity that sent the ERA (aka the payer).

B - This is the billing provider that sent the claim to the payer.

C - This area shows the billing NPI that the below claims fall under as well as the check number and date.

D - This is where the Internal/Original Control Number (ICN or OCN)is located. Sound familiar?

E - The money portion of the ERA, this shows various amounts applicable to this claim. Totals are located in the very bottom row of this box as well as in the totals section after the line break.

  • Billed - The amount charged by the provider and sent to the payer.
  • Allowed - The maximum amount payable to the provider under their contractual agreement.
  • Deduct - If the patient has a deductible, aka money that needs to be paid before coverage starts, it will be reported here.
  • Coins - If the patient has a coinsurance amount (a percentage of service that the patient must pay after the deductible is met), say 20%, their portion will show under this column.

F - If there are any rejections, write-offs, or adjustments, these get reported here with a two letter code followed by a number (1 to 3 digits)

G - Coinciding with the codes in field F, this shows the non-covered amounts for the claim. The payer does not get this money and it's deducted from the total check amount.

H - This area shows how much the provider was actually paid for the claim. The total shows at the bottom as well as next to the NET below the claim information. The NET amount is the actual check amount.

I - This area is simply the totals of all the various amounts listed in the ERA, with the check amount listed at the end.

J - If there are any reason codes shown in G, the description of the adjustment or rejection can be found here. A payer will not send a reason code and not list it at the bottom of the ERA.

Common Rejections

Introduction

Ahh rejections....

Rejections are what keep us employed and ABILITY in business. As much as we loathe speaking to customers who are a bit hard-headed on where a rejection came from, it's ultimately our job to help them out.

No two rejections are the same (unless you're a stubborn biller) and the same rejection can have two different causes. That being said, use the following to aid you in finding out what went wrong, rather than using them as a step-by-step guide.

Utilizing your Resources

What are my resources?

The list goes on and on.

It's highly recommended to bookmark or otherwise save the following links/resources in case access to this course is ever interrupted.

  1. Master Ambulatory Knowledge Document (MAKD) - This document shows not only known current issues broken down by those with an ES ticket, Clearinghouse/MD Online/Payer issues, as well as previous issues. Also included are usernames and passwords for sites below (marked with a *), the team schedule, and the support database, which includes docs not in the PDF. The entire document is searchable.
  2. Ambulatory Knowledgebase PDF - This document is stored on the network drive and instructions as to how to create your own shortcut can be found in "Support Database" on the MAKD. This PDF contains not only training material but aids for common scenarios you may come across on the phone. This document is constantly being updated. It's also entirely searchable as well.
  3. ClarEDI* - This tool is used to scan and validate an 837 file against the guidelines by the format's creators. If a rejection is unclear, this can be used to help lead you in the right direction. NEVER use ClarEDI as a first-resort tool. Not all the errors listed in the validator pertain to the rejection. Err on the side of caution when using this.
  4. Find-A-Code* - This tool is used to verify that diagnosis, procedure, and NDC codes are valid as well as if they need to be expanded or include a description. We are not billers, do not tell the client what codes to use directly. State that "My code book indicates to me that...".
  5. Ability Central - If a client is an SSO client or they do not show up in webman, you can always look a client up from here to see if they actually have another product with ABILITY.
  6. National Provider NPI Registry (NPPES) - Use this website to not only verify NPIs that were submitted but also to see what a provider's taxonomy (speciality) code is.
  7. Ambulatory Chat - Stuck on something? After attempting to resolve the issue yourself, reach out to a Tech II/III through Ambulatory Chat. Mention what you've tried so far so that you don't end up repeating redundant information. Please don't reach out direct to someone unless you've already asked in Ambulatory Chat.
  8. Google - The last great hope of the Universe. When we're stuck on something a quick Google search can give us all that we're looking for. Be wary, however, the information may be incorrect, out of date, or may be specific to a payer. Information gathered from a payer's website, CMS, or a MAC is more reliable than anything found on a random website.