Product Tips & Answers
Tips for AVOIDING Common Electronic Claims Rejections
Prime Clinical Systems strongly recommends generating Intellect's Pre-Billing Report through Billing --► Insurance --► Group of Patients PRIOR to submitting electronic claims. The Pre-Billing Report allows you to verify the information associated with the claim (patient’s DOB and gender, insurance coverage, provider, facility, ICD10 diagnosis codes, CPT/HPCS procedure codes, modifiers, etc.) is complete and valid. See the online documentation for more details on requesting the Pre-Billing Report and a column review of the Sample Pre-Billing Report with how to update the information.
Reviewing your electronic billing reports DAILY allows you to identify and immediately correct any errors related to the Utility screens so those rejections are not recurring.
• DIAGNOSIS INVALID or NOT HIGHEST LEVEL SPECIFICITY: On the Utility --► Diagnosis --►Diagnosis --► Modify screen, set the <Retire Code> field to ‘R’ (retired/invalid) and/or the <Billable> field to ‘No’ (not the highest level of specificity) so a warning message appears when entered on the Charges --► Charge screen. NOTE: Warning messages also appear in PCM if a retired or not-billable code is selected by the provider.
• PROCEDURE CODE INVALID or NOT ACCEPTED: On the Utility --► Procedure --► Procedure --► Modify screen, set the <Parties to Bill> field to ‘R’ (for retired/obsolete) so a warning appears when entered on the Charges --►Charge screen.
• PROCEDURE CODE INVALID or NOT ACCEPTED: If a particular service requires different CPT or HCPCS codes based on the type of insurance (i.e., Medicare, Medicaid, PPO, etc.), then the <Code R>, <Code C>, <Code E>, and <Code O> fields on the Utility --► Procedure --► Procedure --► Modify screen may be set to different codes AND the <Code (R/C/E/U)> field on the Utility --► Insurance --► Insurance --► Modify screen determines the code used for billing. For example, Medicare insurance may be set to pull the HCPCS code in <Code E> while commercial insurances pull the CPT code entered in <Code C>.
SUBSCRIBER NOT ELIGIBLE or INVALID SUBCRIBER ID: Verify patient’s insurance eligibility to confirm the correct <Insurance Company Name> and <Subscriber No.> are populated on the Registration --► Regular --► Patient --► Modify (or Registration --► Worker --► Worker --► Modify) [Modify Insurance] screen. NOTE: Real-Time Eligibility Verification through the Appointment Schedule is available for supported clearinghouse vendors.
SUBSCRIBER NOT ELIGIBLE or COVERAGE TERMINATED: When posting charges, Intellect automatically associates the charge with primary, secondary, and tertiary insurances based on the <Coverage From> and <Coverage To> fields on the Patient Insurance screens. It is strongly recommended that all changes to the patient’s insurance screens are made PRIOR to posting charges.
• When insurance coverage has terminated, select the [Modify Insurance] button on the Registration --► Regular --► Patient --► Modify (or Registration --► Worker --► Worker --► Modify) screen and populate the <Coverage To> field with the termination date (or the last date of service covered by this insurance). Use the [Add Insurance] button on the Registration --► Regular --► Patient --► Modify (or Registration --► Worker --► Worker --► Modify) screen to add the new insurance and populate the <Coverage From> field with the effective date (or the first date of service covered by this insurance). For more details, see the online documentation for Modify Patient or Modify Worker.
• If the charge was posted before adding the insurance screen, then the insurance(s) associated with the charge must be updated on the Charges --► Modify screen. After entering the patient’s account and the applicable date of service range, select [Charge Information] to update the <Primary*>, <Secondary*>, and/or <Tertiary*> associated with the highlighted charge (or all displayed lines when ‘Apply To All*’ is checked) and then click [Save]. For more details, see the online documentation for Charges --►Modify.
DUPLICATE CLAIM:
• When working reports with unpaid claims, confirm if the claim was previously submitted. Select the [Ledger Remark] button on the Ledger --► Open Item --► Display screen to view the billing remarks for Paper Claims (<Flag> = I) and Electronic Claims (<Flag> = E). For more details, see the online documentation for Ledger Remark Screen on Open Item Ledger.
• If the Ledger Remarks indicates the claim was previously submitted, check the electronic billing reports and/or your clearinghouse portal to confirm the claim was received.
• If resubmitting a corrected or replacement claim, then the <Internal Control> and <Claim Frequency Code> fields must be populated on the Charges --► Encounter --► Generic screen AND the associated Encounter # must be populated in the <EN#> field on the Charges --► Modify screen. For more details, see the online documentation for Generic Encounter.