Jan 2009 EDI reports and rejections -...

EDI Reports and Rejections – January 2009

Taz Taylor

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Agenda

• Introduction and Administrative Notes

• McKesson/RelayHealth Reports • McKesson/RelayHealth Reports

• Claim Status Codes

• Washington Publishing Company website

• Working a Claim Status Code rejection• Working a Claim Status Code rejection

• Common EDI support questions

• www.HealthSystems.net/support• www.HealthSystems.net/support

• Questions

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Introduction – Administrative Notes

• DO NOT put your phone on HOLD - Very Important!

• If you have a lot of background noise in your office, please

mute your speakerphone or microphone.mute your speakerphone or microphone.

• Feel free to ask questions, but limit them to the current

topic. Hold other questions until the end of the presentation.

• This presentation will be available on the HealthSystems • This presentation will be available on the HealthSystems

website – www.HealthSystems.net

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McKesson/RelayHealth reports

• There are four main reports for McKesson EDI filing.

• CA – Claims Acknowledgement• CA – Claims Acknowledgement

• EC – Exclusion Claims

• CR – Carrier Report• CR – Carrier Report

• SR – Standardized Report

• Another useful report is the SE – Standardized Exclusions

• Remember: CR=SR and SE=SR (rejections only)

• **McKesson reports/messages update the Transaction tab

of the visit.of the visit.

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McKesson Exclusion and Claims Acknowledgement reportsCLAIMS ACKNOWLEDGEMENT REPORTCLAIMS ACKNOWLEDGEMENT REPORT

CPI651.01 CLAIMS ACKNOWLEDGMENT REPORT 12/02/2004

PROCESSING DATE: 12/02/2004 09:10:53

*******************************************************************************

009999-TEST CLINIC CLAIM BILLING DATE: 11/30/2004

999999=TEST CLINIC, INC. 999999=TEST CLINIC, INC.

*******************************************************************************

PATIENT / CLAIM PATIENT NAME CLAIM CLAIM D E S

ID NUMBER LAST FIRST MI FROM DATE AMOUNT C F C

*************** ******************** ********** * ********** ******** * * *

ANTHEM BLUE CROSS BLUE SHIELD CPID: 1549CO

A = Electronic to Payor

Claims forwarded

electronically to payor

B = Carrier – Direct Claims ANTHEM BLUE CROSS BLUE SHIELD CPID: 1549CO

12345678910111 TESTA TEST 11/20/2004 438.00 E E

TSH CLAIM ID: 9999930000001999775 CLAIM ID: N/A

TOTALS FOR CPID 1549CO: 1 438.00 0

MEDICAID CPID: 5510WI

1110987654321 TESTB TEST 11/20/2004 750.00 E E


B = Carrier – Direct Claims

forwarded to payor on paper

C = Patient –Direct Claims

forwarded to patient on

paperTSH CLAIM ID: 9999930000002999775 CLAIM ID: N/A

TOTALS FOR CPID 5510WI: 1 750.00 0

MEDICARE CPID: 1509

14131211100908 TESTC TEST 11/20/2004 11,450.00 E E


paper

E = Paper Claim –Mailbox

paper Claim forwarded to

customer via EMF

F = Paper Claim – Hardcopy 1122334455667 TESTD TEST 11/20/2004 155.00 A


TOTALS FOR CPID 1509 2 11,605.00 0

*******************************************************************************

CPID 1549CO: ACCEPTED 0 0.00 0

F = Paper Claim – Hardcopy

Paper claim forwarded via

mail to customer

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CPID 1549CO: ACCEPTED 0 0.00 0

EXCLUDED 1 438.00 0

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McKesson Exclusion and Claims Acknowledgement reports

EXCLUSION CLAIMS REPORT

EXCLUSION CLAIMS REPORT PAGE: 1EXCLUSION CLAIMS REPORT PAGE: 1

CPI652.01 12/02/2004

PROCESSING DATE: 12/02/2004 09:11:08 *******************************************************************************

009999-TEST CLINIC CLAIM BILLING DATE: 11/30/2004

999999-TEST CLINIC, INC.*******************************************************************************

A = Electronic to Payor

Claims forwarded

electronically to payor

B = Carrier – Direct *******************************************************************************

PATIENT / CLAIM PATIENT NAME CLAIM CLAIM D E S

ID NUMBER LAST FIRST MI FROM DATE AMOUNT C F C

*************** ******************** ********** * ********** ******** * * *

*** MEDICAID CPID: 5510WI

1110987654321 TESTB TEST 11/20/2004 750.00 E E

B = Carrier – Direct

Claims forwarded to payor

on paper

C = Patient – Direct

Claims forwarded to

patient on paper1110987654321 TESTB TEST 11/20/2004 750.00 E E


GJ MISSING OCCURRENCE CODE DATE UB

01 0050C: INVALID INSURED ID Z637738 UB

TOTALS FOR CPID 5510WI: 1 750.00 0

*** Blue Cross Blue Shield CPID: 1509

14131211100908 TESTC TEST 11/20/2004 11,450.00 E E

patient on paper

E = Paper Claim –

Mailbox Paper Claim

forwarded to customer via

EMF

F = Paper Claim –14131211100908 TESTC TEST 11/20/2004 11,450.00 E E


Error 01 INVALID Policy Number

TOTALS FOR CPID 1509: 1 11,450.00

*******************************************************************************

CPID 1549CO: EXCLUDED 0 0.00 0

Hardcopy Paper claim

forwarded via mail to

customer

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CPID 1549CO: EXCLUDED 0 0.00 0

ACCEPTED 1 438.00 0

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CR/SR/SE reports and Status code rejection

messagesmessages

• McKesson/RelayHealth has changed claim routing for some carriers. This means that claims that

formerly went through EMDEON-WebMD are now going directly to the insurance company.

• For many of these claims, the status of the claim (rejected vs. accepted) and the rejection reason as • For many of these claims, the status of the claim (rejected vs. accepted) and the rejection reason as

shown on the CR report is now a numeric code instead of a plain text explanation.

• Use the WPC-EDI website to translate these new status messages and rejections

• Example:

TRACEY DAWN 09/01/1946 M 254568663

TRACE NUMBER:

CLAIM CLAIM PAYORS CLAIM NUMBER: EA34A8DSH00

PERIOD BEG PERIOD END MEDICAL RECORD NUMBER:

12/05/2007 12/05/2007 BILLING TYPE:

EFFECTIVE ADJUDICATION PAYMENT CHARGE PAYMENT CHECK EFFECTIVE ADJUDICATION PAYMENT CHARGE PAYMENT CHECK

STATUS DATE PAYMENT DATE METHOD AMOUNT AMOUNT CHECK DATE NUMBER

12/06/2007 12/07/2007 300.00 0.00 12/10/2007

CLAIM LEVEL STATUS CATEGORY: F1 STATUS: 69 MODIFIER:

JAMES BEECHAM 11/15/1945 M 422637701

TRACE NUMBER: TRACE NUMBER:

CLAIM CLAIM PAYORS CLAIM NUMBER: EG34BQ1H800

PERIOD BEG PERIOD END MEDICAL RECORD NUMBER:

01/24/2008 01/24/2008 BILLING TYPE:

EFFECTIVE ADJUDICATION PAYMENT CHARGE PAYMENT CHECK

STATUS DATE PAYMENT DATE METHOD AMOUNT AMOUNT CHECK DATE NUMBER

01/30/2008 170.00 0.00 01/30/2008 170.00 0.00

CLAIM LEVEL STATUS CATEGORY: A2 STATUS: 19 MODIFIER: IN

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Washington Publishing Co. website

www.wpc-edi.com

Click here - then click here.

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Click here - then click here.

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Claim status categories

Click the category matching the first

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Click the category matching the first

letter of rejection codeWill expand category here

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Claim status codes

Look for

numeric numeric

code here

Scroll

through through

list here

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Description of status/rejection here

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How to Work a Claim Status Code Rejection

• Below are two rejection examples as they would appear on the CR report or on the Transaction tab of the visit.report or on the Transaction tab of the visit.

• Error message: Payer claim control number EPJKC4ET500. Pay claim status code A3:54 TCH claim status code rejected. ACK Returned unprocessable claim. Claim encounter has been rejected claim status code A3:54 TCH claim status code rejected. ACK Returned unprocessable claim. Claim encounter has been rejected and not entered into adjudication.

• Error Message: Payor Claim Control Number: ENYZC2CLV00; Payor• Error Message: Payor Claim Control Number: ENYZC2CLV00; PayorClaim Status Code: A7:109:DO; TSH Claim Status Code: R -REJECTED; Payor Reject/Message/Remark Code: A3:109:DO; PayorMessage: ACK, unprocessable claim - CLM,ENCNTER BEEN REJECTD AND NOT ENTERD INTO ADJUREJECTD AND NOT ENTERD INTO ADJU

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How to work a Claim Status Code rejection

Select “HIPAA Code List” from the list of available options at the left of the screen.

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How to work a Claim Status Code rejection How to work a Claim Status Code rejection

From the HIPAA-Related Code List:

•Select Claims Status Code or Claim Status Category Code

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From the Claim Status Category:From the Claim Status Category:

•Select Acknowledgments


From the Claim Status Category From the Claim Status Category Code Message:

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How to work a Claim Status Code

rejection rejection

From the Claim Status Category Code Message:

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How to work a Claim Status Code How to work a Claim Status Code

rejection

Claim Status Code Message:

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Frequent EDI support questions

(batching)

– Procedure Code Qualifier Missing

(batching)

– Other Payer ID is Missing from the Identification Tab

– Either no Plug-in is available or the clearinghouse is inactive for ticket number

– Either no Plug-in is available or the clearinghouse is inactive for ticket number

– Other Insurance Policy Type is Missing

– Referring Provider Federal Tax ID/SSN or Secondary ID is Missing

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“Procedure Code Qualifier Missing”

This rejection occurs

when the qualifier is when the qualifier is

missing from the

procedure code within

a visita visit

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“Procedure Code Qualifier Missing”

To correct this

•Go into the Charges and •Go into the Charges and

select the Charge1 tab of

the rejected visit

•Modify each procedure

and verify that the drop

down next to the CPT down next to the CPT

Code is not set to none

•As a standard it should

be set to HealthCare be set to HealthCare

Financing

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“Procedure Code Qualifier Missing”To establish the qualifier To establish the qualifier

as a default

•Go into Administration, •Go into Administration,

Edit, Procedures

•Select the Procedure that

is missing the Qualifieris missing the Qualifier

•Verify that the default

qualifier is set toqualifier is set to

Health Care Financing

•This will only correct the

procedure for any future procedure for any future

visits any old visits will

have to be updated

manuallymanually

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Other Payer ID is Missing From the Identification TabIdentification Tab

This rejection is

caused by missing

information on the

Identification tab of

the Secondary the Secondary

Insurance Carrier

associated with the

visitvisit

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Other Payer ID is Missing From the Identification TabIdentification Tab

Go to AdministrationGo to Administration

Edit

Insurance Carriers

Modify the insurance carrier

Click on the Identification Tab

Click NewClick New

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Other Payer ID is Missing From the Identification Tab Continued

Enter the carrier’s Payer ID

required for your clearinghouse

in the ID Number Field

Identification Tab Continued

in the ID Number Field

If the Carrier does not go

electronically enter the word electronically enter the word

unknown

Always select “All Insurance

Carrier”Carrier”

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“Either no Plug-in is available or the

clearinghouse is inactive for ticket number”clearinghouse is inactive for ticket number”

•This rejection is caused by 2 things

•The clearinghouse •The clearinghouse is not selected on the carrier’s EDI settings

•The clearinghouse has been set to inactive (rarely)inactive (rarely)

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“Either no Plug-in is available or the

clearinghouse is inactive for ticket number”clearinghouse is inactive for ticket number”

If the If the Clearinghouse does not have the Creator Plug-in Creator Plug-in Selected it will cause this rejectionrejection

This rejection usually occurs when the when the insurance carrier has not been setup completely.

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“Other Insurance Policy Type is Missing”

This rejection is

caused by missing

policy type on the policy type on the

Secondary

Insurance Carrier

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“Other Insurance Policy Type is Missing”

• Administration/Edit/Insurance Carrier

• Check the affected carrier to see • Check the affected carrier to see that the policy type is selected

• If it is not selected, select the appropriate Policy Type

• Save the Carrier then re-approve and re-batch the claim

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“Referring provider's FederalTaxId/SSN or Secondary Ids is missing”Secondary Ids is missing”

This rejection is caused

when the Referring

Physician on the visit is

missing Provider ID

information

Specifically - the referring

doctor’s NPI is missing

츰ء

“Referring provider's FederalTaxId/SSN or Secondary Ids is missing”Secondary Ids is missing”

•Go to Admin/ Edit/ Physicians•Go to Admin/ Edit/ Physicians

•Modify the affected Physician

•Go to the Identification Tab

•To Send the NPI as the referring ID

for all electronic claims enter it in for all electronic claims enter it in

the NPI field

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“Referring provider's FederalTaxId/SSN or Secondary Ids is missing”

• Create a new Identification row and set default to all Carriers

•Leave the Referring # blank and

Secondary Ids is missing”

•Leave the Referring # blank and select ‘None’ as the qualifier

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Other recent EDI support questions

• Filing a Claim to the Wrong Payer as Primary (also • Filing a Claim to the Wrong Payer as Primary (also refiling to primary after secondary crossover has paid)

* new and important *

• Populating Box 19 Electronically

• Medicare Secondary Insurance Type Code• Medicare Secondary Insurance Type Code

• Referring provider ID missing or invalid• Referring provider ID missing or invalid

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Filing a Claim to the Wrong Payer as Primary

(or re-filing to primary after other payment posted)(or re-filing to primary after other payment posted)

• Situation: A claim has been filed to one payer and a remittance (ERA) file has been returned stating they are not the primary or the patient is not covered. A been returned stating they are not the primary or the patient is not covered. A transaction line is created for the denial. The claim now needs to be filed to the correct primary payer.

Anytime a transaction is created for a payer, secondary loops and segments Anytime a transaction is created for a payer, secondary loops and segments are created when the claim is batched again. A primary claim should not contain payment records.

The payer will send back error messages stating why they are rejecting the claims:

The payer will send back error messages stating why they are rejecting the claims:

• Service line paid amount is missing though marked `Required`. (Error Code: X12P-101) (Centricity EDI)

• REJECTED: Element CAS01 is a coded list element. Code HE is not allowed. Segment CAS is defined in the guideline at position 545 (McKesson)

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Filing a Claim to the Wrong Payer as Primary(How to correct)(How to correct)

• From Administration

•Select Edit

•Choose Insurance Carriers

•Search for the appropriate payer•Search for the appropriate payer

•Select the secondary payer

•Click “modify”•Click “modify”

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• From the Insurance Carrier Information Tab

•Select EDI Tab

•Press the Modify Button in the Middle of the Screen

•Press the Settings Button Located Next to the Claim •Press the Settings Button Located Next to the Claim

Creator Plug-in

•Select the All Payers 2 Tab at the Top of this Window•Select the All Payers 2 Tab at the Top of this Window

•Click Okay to save settings changes

•Rebatch the claim to the correct primary carrier.

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Insurance Carrier Setups – EDI SettingsFiling a Claim to the Wrong Payer as Primary

Do Not Send Other

Payer Payment

Information Information

When Filing Primary

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How to Transmit Box 19 Electronically

• The local use box (Box 19) is what you use if you • The local use box (Box 19) is what you use if you print a claim to paper.

• Electronically, “box 19” information is transmitted in an NTE record. There are two options to choose from – claim level and line level.from – claim level and line level.

• Contact the carrier to see which option they prefer. • Contact the carrier to see which option they prefer.

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• Claim Level• Claim Level

• Populates Loop 2300 NTE 01 and 2300 NTE 01 and NTE 02

• In the Visit, on the Notes tab, select a Claim Header Note Type and enter youtType and enter youttext in the Claim Header

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• Line or Procedure LevelLevel

• Populates Loop 2400 NTE 01 and NTE 02 NTE 02

• In the visit, on the Charge Entry 1 Charge Entry 1 tab, select the Note Type as indicated and enter your text in the field.in the field.

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Medicare Secondary Insurance Type Code

• When filing Medicare as a secondary, the reason for • When filing Medicare as a secondary, the reason for Medicare being secondary is required.

• Payers will reject the claims if the incorrect reason is submitted.

• Select the appropriate Medicare Secondary reason in patient insurance information.

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• Common Rejection Messages for Medicare Secondary

(Type Code Missing or Invalid) (Type Code Missing or Invalid)

•Insurance type code values of 12 13 14 15 16 41 42 43

or 47 are only valid if Medicare is the billed insurance or 47 are only valid if Medicare is the billed insurance

and the billed insurance is secondary or tertiary. (Error

Code: X12-212.1)

•Missing Subscriber Insurance Type Code

•ERROR: FK INVALID SUBSCR INSURANCE TYPE

CODE 47

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• In Patient Information, highlight the Medicare secondary carrier.

• Click the ‘Details’ button

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In the Additional Policy Information Window, select the

appropriate Medicare Secondary reason from the pull down appropriate Medicare Secondary reason from the pull down

list.

Remember: Anytime MedicareRemember: Anytime Medicare

is in the secondary position a

reason must be populated.reason must be populated.

The next slide shows the ANSI

(EDI) code with the corresponding(EDI) code with the corresponding

Secondary reason. - Do not change

these codes without consulting HS

Support.Support.

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Physicians / Referring Providers

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Rejection for referring provider

• Rejection:

“Referring provider ID “Referring provider ID

missing or invalid

qualifier”

The referring or PCP

physician does not have

the NPI field populated!the NPI field populated!

Every referring physician

must have an NPI must have an NPI

number entered.

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NPI – *Reminder*

• Obtain an NPI number for each provider – this includes your

company or practice if enrolled as a ‘group’.

• Enter NPI numbers in correct locations in Centricity• Enter NPI numbers in correct locations in Centricity

• ** Register your NPI number(s) with your insurance

carriers**carriers**

• Submit claims with NPI numbers

• REVIEW your claim submissions for rejections• REVIEW your claim submissions for rejections

• **It is YOUR responsibility to confirm that the insurance

carrier has your NPI numbers on file and associated with carrier has your NPI numbers on file and associated with

the correct doctors, company, etc.

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HealthSystems.net/Support page

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Questions and Answers

Thank you for attending! Thank you for attending!

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Jan 2009 EDI reports and rejections -...

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