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SOFTWARE REQUIREMENTS FOR CONTRACT SET UP

 

 

Capitated (Pre-Paid) Contract Set Up

 

The following software requirements must be met PRIOR TO POSTING CHARGES:

 

/Utility/Category*                                    A category for each capitated contract whose Type is pre-paid.

 

/Utility/Insurance*                                   An insurance for each capitated contract.

 

/Utility/Insurance/Pay Plan Menu           Pay Plan* set up for each capitated contract.

Procedure entries, per contract, when applicable.

Diagnosis entries, per contract, when applicable.

 

/Utility/Procedure                                     Each /Utility/Procedure <HMO Adjust> field set appropriately.

 

/New Patient <Category>*                      The appropriate capitated contract Category Code entered.

 

/New Patient 2nd Screen

<Insurance Company Code>*                 The appropriate capitated contract Insurance Co. Code entered.

 

/New Patient 2nd Screen

<Pay Plan>*                                             The appropriate Plan Code entered.

 

*    To simplify patient data entry, it is recommended to use the same code for each.  For example, when setting up a contract with Huntington Provider Group, Category, Insurance Co. and Plan Code could each be HPG.

 

Setting up your Capitated (Pre-Paid) Contracts correctly will allow you to:

 

a)     Use the Auto Payment feature.  The Auto Payment feature will distribute your monthly cap check over all patients seen the previous month, printing a report noting the patient, charge, payment and adjustment.  In this way, you will be able to track month to month, per contract, your charges and payments thus giving you the tool to determine if you should want to continue with this contract or re-negotiate.

b)     Send statements for unpaid co-payments.

 

 

UTILITY/CATEGORY

 

Set up a category for each individual contract.  The Category Code will be entered on the Main Menu/New Patient <Category> field for those patients who are part of this Pre-Paid Contract.  Having a category for each contract will be advantageous in follow up and management reports.  Fill in each field appropriately, making sure to set Type (C/P/W/O/F/G) = P.  See the following example:

 

 

Category Code                         : PGC  

Description                               : PHYSICIANS OF GREATER CITY

Statement                                 : O

Message (Y/N)                        : Y

Billing Message                         : CP

Group 2 Message                     : 3

Group 3 Message                     : 4

Group 4 Message                     : 5

Billing (D/C/N)                         : C

Type (C/P/W/O/F/G)               : P       

Payment Method (A/S/I/P)       : I        

Birth Date Message                  :

Follow Up (P/A/I/N)                : A                                               Aging Method           : O

Payment Remark (DEF)           : POP                                             Default Form          : C

Adjustment Remark (DEF)       : WOP         Include Cost on Statement (Y/N)  : N

Number of Statement                :                                             On Going Diagnosis        : N

Default Plan                              : 5                                       Responsibility (G/P/X)       : P

Aging            Group_1  : 31       Group_2   : 61      Group_3   : 91      Group_4   : 121

Finance Charge                        :                                        Finance Charge Aging          :

 

ADD NEW CATEGORY

 

 

UTILITY/INSURANCE

 

Add an insurance company for each Pre-Paid Contract Category using the Category Code as the Insurance Co. Code.  This insurance company will be entered on the Main Menu/New Patient primary insurance <Insurance Company Code> field for those patients that are part of this pre-paid contract.  See the following example:

 

 

Insurance Co. Code                 :  PGC

Name                                       :  PHYSICIANS OF GREATER CITY

Address                                   : 123 CITY DRIVE

Zip Code                                  :  90808                   City:  LOS ANGELES  State:  CA

Phone No.                                :  (800) 339-9928          Fax No.:  (800) 339-9929

Contact Person                         :  JULI                                           OCNA       :

Group No.                               :

Submitter Code                        :                                                        Ver          :

Pin Number                              :                                          Include Payment    :  N 

Code(R/C/E/U)                        :  C                                Form Type____          :  C

Payor & Office Code               :                                           Payment Source   :  PGCP

Message                                   : SIGNATURE ON FILE                    Adj       : PGCA

Insurance Type                         : I                                Selection (1/2/3)            :  1

Provider Name (Y/N/X/Z)        : Z                          Comment On Bill___          :  Y

Assignment (Y/N/C)                 :  Y                            Electronic Billing :

Print Name on HCFA               :  Y

CLIA                                       :  N                                               Who            :

Remark                                    : 

 

ADD NEW INSURANCE

 

 

UTILITY/PROCEDURE <HMO Adjust> FIELD

 

Example:

 

Panel Code      :  22                             Panel Description          :   OV, LEVEL 1

CMD

Description

CODE R

CODE C

CODE E

TOS

Charge

Code R                        :  99212                          Modifier R   :                 (Y/N)   : N                

Code C                        :  99212                          Modifier C   :                              

Code E                        :  99212                          Modifier E    :                              

Description                   :  PROC. DEFAULT SETUP             PROBLEM FOCUSED

Provider                       :  N                               Global (Y/N)  :  N               Form         :  

Base Unit 1                  :                                                    2    :                         3  :                              

Global Charge              :  50.00                           Unit Value    :                 (Y/N)   :  N                          

Professional                  :                                      Unit Value    :                              

Type Of Service           :  01                                  Category    :  100                        

Days & Units                :  0010                 Assignment(Y/N)    :  N                           

Withhold (Y/N)            :  N                               Hold(Y/N)     :  N                         

Billing(A/N/C/E/P/B) :  A                             Qty.(Y/N/X)       :  N                         

Med/Legal(Y/N/D)       :  D                                 Line(5/6/7)   :                            

Cost                             :                                         Quantity    :

HMO Adjust              :  N                                UB92 Code  :

                                                                            

ADD NEW PANEL/PROCEDURE

 

HMO Adjust:  N        For all procedures whose payments will be made through the Main Menu/ Payment/Auto Payment feature, set the field HMO Adjust to N.

 

HMO Adjust:  X        For all procedures that will be paid as fee for service (thus payments will be made through Main Menu/Payment/Open Item, NOT Auto Payment) set the field HMO Adjust to X.  These are usually paid on a separate check by the carrier.

 

NOTE:  Leaving the HMO Adjust field blank defaults to N.

 

The procedure screen has only ONE HMO Adjust field and you may have several contracts which could vary on procedures considered as part of the cap check versus fee for service.  For example, one contract states injections will be paid as fee for service (HMO Adjust X) when another considers them as part of the cap check (HMO Adjust N).  You might consider setting all HMO Adjust fields to N, allowing you to carve out fee for service exceptions by use of the /Pay Plan Menu options.  Please refer to the documentation regarding the /Utility/Insurance/Pay Plan Menu for additional information.

 

 

CREATING A CO-PAYMENT CHARGE:

 

From time to time, patients do not pay their co-payment at the time of service.  Due to the nature of the program, you will need to add a Co-Payment procedure.

 

You may choose to create individual co-payment procedures for each of the various co-payment  amounts.  If this is the case, the Charge Global field would contain the appropriate co-payment amount (i.e., 5.00, 10.00, etc.) and the Y/N field to the right of Charge Global would be N as you have pre-determined the charge amount and do not need to modify it at the time of posting charges.

 

To create only one co-payment procedure, Charge Global  would be set to 0.00 and the Y/N field to the right of Charge Global would be set to Y.  This will cause the cursor to stop on the Charge field at the time of posting the charge and enable entry of the co-payment amount displayed in the Charges screen Co-Pay box.

 

Example:

Panel Code      :  CP                             Panel Description         :   CO-PAY CHARGE

CMD

Description

CODE R

CODE C

CODE E

TOS

Charge

Code R                        :  COPAY                      Modifier R    :                 (Y/N)   :  N               

Code C                        :  COPAY                      Modifier C    :                              

Code E                        :  COPAY                      Modifier E    :                              

Description                   :  UNPAID COPAY

Provider                       :   N                            Global (Y/N)    :  N              Form :  

Base Unit 1                  :                                                    2    :                         3  :                                Charge Global              :  0.00                             Unit Value    :                 (Y/N)   :  Y                           

Professional                  :                                      Unit Value    :                              

Type Of Service           :                                       Category     :                             

Days & Units                :                          Assignment(Y/N)     :  N                            

Withhold (Y/N)            :  N                                Hold(Y/N)    :  N                           

Billing(A/N/C/E/P/B) :  C                              Qty.(Y/N/X)    :  N                            

Med/Legal(Y/N/D)       :                                    Line(5/6/7)     :                            

Cost                             :                                        Quantity     :

HMO Adjust              :  X                               UB92 Code   :

 

 

ADD NEW PANEL/PROCEDURE

 

For all co-payment procedures set the following fields to the noted values:

 

HMO Adjust:  X        Since these charges will be paid through the Main Menu/Payment/Open Item (NOT Auto Payment) feature.

 

 

 

Billing:                        C bill patient ONLY.  Do NOT print on a HCFA 1500 claim form.  /Utility/Category <Responsibility (G/P/X)> field correctly set to P, pre-determines at the time of entering charges that the responsibility for payment for those charges is with the primary insurance of the patient.  This feature will automatically enter P in the W (Who) column.  We want to bill only the patient for the co-payment procedure and have the system automatically enter a G in the W (Who) column (since the patient IS responsible for the co-payment, NOT their primary insurance).  Setting the Billing field to C tells the program, when entering charges automatically default the W (Who) column to G (for guarantor/patient being responsible for payment), thus over-riding the /Utility/Category <Responsibility (G/P/X)> field setting of P.  The Billing field set to C will only allow this charge to appear on the patient's statement (if they did not make payment at the time of service).  It will not allow this procedure to be billed electronically or on paper.

 

 

 

 

For additional information see the documentation regarding the /Utility/Procedure and /Utility/Insurance/Pay Plan/Pay Plan, Diagnosis and Procedure screens.

 

 

FEE SCHEDULE CONTRACT SET UP

 

The following software requirements must be met PRIOR TO POSTING CHARGES:

 

/Utility/Procedure                                     The following fields are required for fee schedules:

 

                                                                        Type of Service

                                                                        Conversion

 

/Utility/Procedure/Fee Schedule              A fee schedule must be entered.

 

 

/Utility/Insurance/Pay Plan/Pay Plan      Complete a Pay Plan for each Fee Schedule based contract.  The following fields are required for Pay Plan set up:

 

                                                                        Percent fields

                                                                        Insurance Code

                                                                        Provider Code when sharing a fee schedule

 

 

/New Patient 2nd Screen

<Pay Plan>                                               Must contain the appropriate Plan Code.

 

 

Setting up your Fee Schedule based Contracts correctly will allow you to:

 

a)   Post an alternate charge amount (Charge Global, Professional or Technical dependent on/if modifier used) determined by the /Utility/Procedure/Fee Schedule entry.

b)     Allow the patient’s responsibility to display (what the patient will owe after primary insurance payment has been received) in the /Charges/Charge <Patient> box, thus allowing this amount to be collected at the time of posting charges. 

c)     Allow automatic calculation and posting of payment and adjustment by pressing A in the C (command) column of the /Payment/Open_Item screen.

d)     Allow the approved amount to display (your contracted approved amount for the procedure, Charge Global, Professional or Technical dependent on/if modifier used) in the /Payment/Open_Item <Approved> column, thus allowing you to tag a charge for underpayment at the time of posting.

e)     Allow the Remittance Report to display Charge Submitted, Net. Payment (contract approved amount), Actual Payment and Adjustment, thus being able to track if being paid according to contract rates.

 

For additional information, see Session II regarding the /Utility/Procedure and Fee Schedule screens and the /Utility/Insurance/Pay Plan/Pay Plan screen.

 

 

CONVERSION RATE/UNIT VALUE CONTRACT SET UP

 

The following software requirements must be met PRIOR TO POSTING CHARGES:

 

/Utility/Procedure                                     The following fields are required for fee schedules:

 

                                                                        Unit Value

Type of Service

                                                                        Conversion

 

/Utility/Procedure/Unit Value                  When applicable.

 

/Utility/Insurance/Pay Plan/Pay Plan      Complete a Pay Plan for each Conversion Rate/Unit Value based contract.  The following fields are required for Pay Plan set up:

 

                                                                        Conversion 0 through Conversion 4

                                                                        Percent fields

                                                                        Scale Code when applicable

                                                                        Unit Value Pointer when Scale Code is applicable

                                                                        Insurance Code and Provider Code only when specific procedures are negotiated at fee for service.

 

/New Patient 2nd Screen

<Pay Plan>                                               Must contain the appropriate Plan Code.

 

Setting up your Conversion Rate/Unit Value based Contracts correctly will allow you to:

 

a)   Post an alternate charge amount (Charge Global, Professional or Technical dependent on/if modifier used) determined by the /Utility/Procedure/Fee Schedule entry.

b)     Allow the patient’s responsibility to display (what the patient will owe after primary insurance payment has been received) in the /Charges/Charge <Patient> box, thus allowing this amount to be collected at the time of posting charges. 

c)     Allow automatic calculation and posting of payment and adjustment by pressing A in the C (command) column of the /Payment/Open_Item screen.

d)     Allow the approved amount to display (your contracted approved amount for the procedure, Charge Global, Professional or Technical dependent on/if modifier used) in the /Payment/Open_Item <Approved> column, thus allowing you to tag a charge for underpayment at the time of posting.

e)     Allow the Remittance Report to display Charge Submitted, Net. Payment (contract approved amount), Actual Payment and Adjustment, thus being able to track if being paid according to contract rates.

 

For additional information, see the documentation regarding the /Utility/Procedure and Unit Value screens and the /Utility/Insurance/Pay Plan/Pay Plan screen.

 

 

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