Release Notes
Version No: 2.0

Build No: 1

The release notes describe the various new features and enhancements carried out in version 2.0 of PrognoCIS™

2. New Features

2.1 Insurance Eligibility

PrognoCIS Version 2.0 now supports Insurance Eligibility using Gateway Clearing House. As explained in the EMR release notes for Version 2.0, Insurance Eligibility check is to verify whether the patient has got the insurance or not and if yes then what are the benefits he/she is going to get.

Button is provided on Patient Registration > Insurance screen. On click of check button system checks the insurance eligibility of the patient.
Button is provided just near to check button which displays details of patient's insurance.

Note: At present PrognoCIS supports 4010 EDI version available in market. 5010 is not yet released and is planned for 2012.
Also note that there is a separate document explaining the set-up and functionality of Insurance Eligibility.

2.2 Fee Schedule Definition

•  In version 2.0 of PrognoCIS TM , the Fee Schedule Definition is more customizable. Variation in fees was observed based on Business Units, location of encounter, patient's insurance company and/or provider involved in the encounter.

•  In PrognoCIS version 2.0, it is possible to define multiple fee schedules in various permutations and combinations, but it is highly recommended that ONE (default) fee schedule of type Usual and Customary (U&C) be followed wherein all the parameters are SET as ‘ALL'.

•  Type: By default, the Fee Schedule Type should be U&C. For exceptional cases like Special Fee Schedule or a Group Fee Schedule to be applied to multiple Insurance companies, additional Types are required to be defined.

•  Fee Schedule set-up parameters:
It is possible to define Fee Schedule to read following parameters: The Default setting for all these parameters is “All”.

•  Business Unit Code: A drop-down to select a Business Unit Code from the defined Business Unit for the clinic for which the Fee schedule will be applicable.

•  Location Code: The location code for which the fee schedule will be applicable.

•  Insurance: the Insurance Company for which the Fee Schedule is applicable; if the same fee schedule has to be associated with multiple insurances then it is possible to define a new Type, name it appropriately for the group, keep the Insurance option to ALL, Save and then associate this new Fee Schedule to multiple Insurance companies.

•  Provider: If a clinic is a Multi-provider clinic then it is possible to define different fee schedules for different providers.

•  Special Billing Fee Schedules, Allowed Schedules and Out of Network Fee Schedules:
There is an additional concept of defining Special Billing Fee Schedules and Allowed Schedules and Out of Network Fee Schedules.

•  Special Billing Fee Schedule: Special billing fee schedule can be defined only in case of following examples: Self Pay Fee Schedule, Economically Poor Fee Schedule, etc. For marking a schedule as special, there is checkbox given on Fee Schedule screen named “Special”. These Special Billing Fee Schedules can be applied by selecting them from Claim screen's “Fee Schedule” dropdown.

•  Allowed Schedule: Allowed Schedules are the Fee Schedules which are used to automatically populate the “Allowable Amounts” for each line item on the Remittance Screen. Most Insurance companies have a fixed amount for each CPT/HCPC code called “Allowable Amount”. If these allowable amounts are pre-defined, then the users won't have to manually enter them while entering the Remittances. The radio button ‘Allowed Schedule' has to be selected to mark a Fee Schedule as ‘Allowed Amount Fee Schedule'. By default, this radio button is on “Billing”. Fees from “Billing” Fee schedules are applied to charges on claim screen.

•  Out of Network Fee Schedule: Consider a scenario wherein a clinic provider is IN a certain Insurance plan networks and OUT of other Plan networks. In such a case, if a patient has an insurance plan where the clinic provider is IN network, then that patient is generally charged less as compared to a patient who has insurance plan for which the provider seeing him is OUT of network. Based on these criteria it is now possible to define fee schedule as ‘In Network Fee Schedule' and ‘Out of Network Fee Schedule'. By default a Fee Schedule is ‘In Network'. For out of network fee schedule, ‘Out of Network' checkbox has to be checked.

•  Custom CPT and HCPC Codes :
It is possible to include Custom CPT and HCPC Codes in the Fee Schedule. Custom CPT and HCPC codes are the codes which are not from the standard CPT or HCPC list but they are still used for billing the Insurance Company in some special circumstances like Worker's Comp or Auto Accidents or Personal Accidents. This feature is property based.

•  Property : feeschedule.allow.nonstd.codes: N (Default), Y

•  Please Note: When such a Custom CPT and HCPC code is added in any Fee Schedule, it will be applicable only when the Status on Patient/Insurance screen is chosen either as MotorAcc; PersonalAcc; WorkerComp

2.3 Claims

Currently, there are 3 new buttons on Claims Screen:

•  Track Status: Track Status screen captures every event that changed the status of a claim.
For ex: Printing of CMS1500 changed the status of the claim from Ready to Send to Billed or Reopening a claim changed the status from Billed to Ready to Bill.

•  List of Reopened Claims: Shows every entry when the claim was reopened, the name of the user who reopened it, the Date Time stamp, Amount billed when it was reopened, the status of the claim as ‘A' indicating that it is archived. After clicking on the entry, the archived instance of that claim is opened. To go back to the current claim, the button “List of Reopened Claims” has to be clicked on and the claim has to be selected.

•  Resend Button: At the Right-bottom corner, now there is a “Resend” button (a blue anti-clockwise arrow symbol) which will allow resending the selected claim to the insurance company.

•  ‘I' button: Provision to set the Original / Corrected / Replacement flag for a Claim

•  Generally, if a claim is reopened and some changes are made to it and the claim is resent, it should go as a Corrected claim else it is marked by Insurance company as duplicate claim. Sometimes major changes are made to the claim that the biller wants the Insurance to treat this resent claim as a Replacement to the Original claim. In such a case, when an EDI is sent, there is a flag which can be set to :
1) Original

2) Corrected
3) Replacement
For setting this flag, there is a provision given on claim screen under “i” button to mark that claim as Corrected or Replacement. By default it will get sent as “Original Claim”.

•  Claims Creation and ReCalc now considers the new Fee Schedule Parameters. The old rules/properties are discarded.
•  The Fee Schedule List now displays Only Default and Special Fee Schedules. The other customized fee schedules where either Business unit or Location or Provider or Insurance is set other than “All”, such a fee schedule will not be displayed on the Claim/Fee Schedule drop down. This fee schedule will automatically be read and applied when the criteria for that fee schedule are met.
•  Attachment on Claim screen: When claims are created from PrognoCIS EMR, this feature is not required. Only when any claim is created from Billing module, associated superbill or progress note can be attached to that claim using the Attach button on claim screen (next to Claim ID). You can Browse to a local file on your computer or network and attach it. Once attached, it can be viewed using the View button next to the Attach Button.
•  Batch: Provision to Define a Batch for Entering Claims and assigning a Batch to a Claim. This feature is useful for non-EMR using billing services. Generally, all the claims created by a biller if assigned a batch, it later becomes easy for the biller to track claims billed in a batch referring to the batch number and batch date, etc.

•  Properties:
Claims.use.entry.batch: N (Default), Y.

User can assign a number for batch in Entry of claims. If set to N, the Entry Batch No option is disabled.

billing.entrybatch.prefix: EB

2.4 Send Claims

Now there is a Radio Button provided to be able to send New Claims or to Resend Claims for which there is NO EOB received in specified Days. If the option to Resend claims is chosen, it will enable putting a Date. All claims sent before this X date and for which there is no EOB received even once will be automatically resent with this Resend claims feature.

2.5 Claims Center

•  Claims Center shows the list of claims that are billed.

•  Select Filter: The ‘Select Filter' Button provides a UI to select one or more of up to 23 parameters like Patient Name, Insurance, Dates, etc. to filter the list.

•  Track Status: Same as on the Claims page, the status of the highlighted claim can be checked by clicking on the Track Status button.

•  Assign To: The Claims Center has blue hand icon which is called Assign To. The selected claim can be assigned to a specific biller to work on or follow-up on. The Status and Date can also be entered. Once the claim is assigned to a user, the name, status and date can be seen in the Tool tip on mouse over on Location field for that entry.

•  Statement for DOS: Highlight a claim and print the statement only for the highlighted claim for a patient by clicking the button Statement for DOS.

•  Resend Claim: An individual claim can be resent to Insurance Company by highlighting it and then clicking on the “Resend Claim” button.

2.6 Charges Center

•  Charges Center is a good place to keep track of individual charges. It displays each Charge line of a billed claim.

•  There is a Claim ID with a hyperlink for each charge code to quickly display the claim from which the charge code was billed.

2.7 Remittance Order Set

•  Insurance EOB – Recoup
The Recoup functionality has been now extended to allow Partial Recoup, Recoup of Excess Amount and Recoup of Paid + Excess Amount. Earlier, only Recoup of full Paid Amt for a claim was supported.
Partial Recoup: If a claim has multiple line items remitted and if Insurance Company instructs to recoup the paid amount of a single line item, we allow recouping paid amount of a single line item from multiple charge lines of a claim now.
Recoup Excess Amount: For a claim, if a line item has excess amount associated while entering a remittance, that excess amount can now be selected when that claim is selected from Recoup binoculars. The Recouped Excess amount can then be applied to pay for another claim.
Recoup Paid + Excess Amount: When a claim is selected for Recoup, all the line items in that claim are displayed on a pop-up to be selected. Once a line item is selected, if there is a paid amount and excess amount associated to that line item, both Paid amounts and Excess Amount check boxes can be selected for both the amounts to be recouped.

2.8 Denied

There are 2 new options under action button on Remittance-Denied screen making the total options as 6.

2.9 Insurance Credit

•  Insurance Credit screen allows transferring certain amount paid in excess by the Insurance Company to INSURANCE ADVANCE. Insurance Credit entry is created by selecting “Recoup Claim” binocular and selecting the appropriate claim whose line item(s) amount is to be transferred to Insurance Advance. Two types of amounts can be transferred to Insurance Credit:

•  Amount under “Paid Amt” by the Insurance Remittance Screen.

•  Excess amt posted on Remittance Screen.

Property: era.remittance.useadvance: N

When the above property is set to N, Insurance Credit cannot be posted.

Note : Other than Insurance Credit screen, following scenario will allow certain amount to be transferred to Insurance Advance:
When the property is era.remittance.useadvance: Y and on Remittance Entry/Edit screen, if the Check Amt is more than the Advance Amount, the Remaining Amount gets automatically transferred to Insurance Advance/Credit.

2.10 Patient Returns

Patient Returns screen is used in case of any item return. If the amount is to be credited back to the patient, it has to be first moved to Patient advance.

For achieving this, a new Patient Returns entry has to be created from Remittance>Patient Returns>Add New option.

Then select the proper patient>Save.

Pay Mode and Received Amt fields will be disabled on Patient Credit screen.

On Save, the Select Claims button will get enabled and Patient Balance and Advance amt will be displayed in Red color.

Select the proper claim. All charge line items will be displayed if (3 dotted buttons) is clicked.

In the Credited field for appropriate line item, add appropriate amount to be transferred to patient advance and save. The field “Credited Amt” in green color will show the total Credited amount. The field “Remaining Amt” in Orange color will show the same amount as Credited amount but with negative sign.

On Ready to Post and Save, the amount under Credited Amt field in green background will be moved to Patient “ADVANCE”.

The Patient A/C will appropriately adjust the Patient Balances and show the re-calculated amounts.
The Statement and Ledger will also show the entry for Patient Credit.

2.11 Transfer Patient Credit (Xfer Patcredit)

This allows user to transfer the Credit balance with one Patient to the Advance amount for another Patient. (typically in the same family). The patient from whom the amount needs to be transferred should have outstanding advance amount(OS Advance) same or more than the amount to be transferred.
Once the patient is selected and transfer amount is entered, select the patient to whom the amount needs to be transferred and save. Once the amount is transferred, the Patient A/C, Statement and Ledger of both the patients get updated appropriately.

2.12 Returned Payments

•  Sometimes, payments made by patients like check payments are returned may be because of non-availability of funds in patient's bank account. Remittance/Returned Payments is a new screen to track such returned payments. User can create a new Returned Payment entry by clicking on “Add New” button, select the payments received from a patient (Both Co-Pay as well as Receipts) and mark them as Returned. A new claim is automatically created by the system for the patient with 2 line items, one for Returned Payment Amount (Ex: Charge code: bchk_amt) and the other for Returned Payment Penalty Charges – as per the clinic (Ex: Charge code: bchk_chrg). This new claim for the patient can be processed and payment can be demanded from the patient again. The Patient Statement, Ledger and Patient A/C screen shows the appropriate entries for this Returned Payments transaction.
Settings: For this functionality to work, following settings should be done:

a)  Group Types: Special Billing Codes should have 2 entries as follows:

• i. Name: Returned Payments Amount

Code: BCHK_AMT
Amt: The amount should be kept zero

• ii. Name: Returned Payment Penalty Charge

Code: BCHK_CHRG
Amt: $(penalty amt as per clinic)

b)  Properties: Billing Parameters:

• i. billing.splcode.bouncedamt: BCHK_AMT

2.13 Statement

•  User interface and some parameters for generating statements are now changed. You can now choose from “Claim wise” or “Charge wise” Statements for a Patient (Flavor 2 and Flavor 3). The Statement Flavor 1 is now obsolete.
Claim wise Statement Format: As the name suggests, Claim wise Statement Format prints the statement, claim wise. While generating Claim wise Statement Format there are 3 options:

i)   Hide Diagnosis Codes: When this option is checked, Diagnosis codes will not be printed on the statement generated.
ii)  Hide fully balanced claims: Details of claims which are fully paid off will not be printed on statement when this option is checked.
iii) Hide Charge Description: The Full name of the charge code will not be printed on the Statement if this option is selected.

Charge Code Wise Statement Format: Charge Code wise Statement format prints the statement per charge code. There are 2 options for generating Charge Code Wise Statement Format:
i)  Hide Diagnosis Codes: When this option is checked, Diagnosis codes will not be printed on the statement generated.

2.14 Patient Account

Additional hyperlinks are now provided on Patient Account Screen for Insurance Write Off, Patient Write Off, Adjustments, and Refunds.

2.15 Miscellaneous

•  Print Button: There is a Print Button on Claims/Unprocessed, Outstanding, and many more screens now….

•  Property: billing.sync.with.emr: NYL :
   Supports three values:

   N: never,

   Y: changes to ICD/CPT/HCPC/ITEM and their modifiers made in Billing Charge Entry will get reflected in EMR even if the encounter is    closed.

2.16 ERA 835 – Electronic

Electronic Remittances are now supported for Availity clearing house and Gateway clearing house. It will be eventually extended to other clearing houses and Insurances like Medicare.

2.17 Patient Balances calculations now considers the Advance amount only for calculating the Net Due amount