The aim of this document is to give an overview of the new features related to PrognoCIS Billing released in Version 2.0 Build 3.

2. New Features

Following are the new features added in PrognoCIS version 2.0 Build 3:

2.1 CPT/HCPC Master changes

NDC codes can now be associated to HCPC codes on HCPC master for Non-Inhouse drugs.

User can now associate NDC codes directly to HCPC codes by going to Settings → Configuration → Codes/Drugs → HCPC.
The new field NDC Code will be enabled for those HCPC codes whose starting characters (Ex. J) are defined in the following property:
hcpc.assign.ndccodes.forstartchars

This NDC code will be sent alongwith the associated HCPC code for Billing when:
* That HCPC code is selected from Encounter → Assessment → HCPC Tab on EMR side
* Source of HCPC code to Assessment is Speciality Template or Test
* Source of HCPC code to Assessment is Vaccination administered
*HCPC code directly selected on Claim Screen

Note: For Inhouse Drugs selected on Setting → Configuration → Inhouse Drugs, and prescribed/administered in an encounter, the associated CPT and HCPC code will be sent to assessment as Source ‘Rx'. On creation of claim, the charge codes will be seen on Claim alongwith associated NDC code. The NDC code associated to that HCPC code on HCPC Master(if any) will not be considered in case of HCPC codes coming from Inhouse Drugs.

This is used for reporting purposes

Relative Value Units (RVU) is the numeric reimbursement value associated with the services a practice provides. Medicare publishes a list of RVU for charge codes.
RVU can now be associated to required HCPC codes in PrognoCIS by going to Settings → Configuration → Codes/Drugs → HCPC.

Figure 2: RVU associated to HCPC code Q0091

When HCPC codes(Ex:Q0091) with certain units(Ex:1) and associated RVU (Ex:0.37) are billed to Insurance through PrognoCIS, for the clinic to know the RVU production of that charge code and RVU production summary based on Charge Codes and Providers, there are 3 reports added on Billing side: Reports → Tabular, as shown in the figure below.

Figure 3: Three RVU Specific Reports added to the Standard Tabular Reports on Billing side

Following snapshot shows output of report ‘RVU Production Summary Provider wise”:

Figure 4: Report 3: Q0091 has one Unit Billed and RVU Associated as 0.37, resulting into RVU Total Qty as Units x RVU

If Anesthesia is Applicable for the Clinic (property prognocis.anesthesia.support), user can mark selected codes Applicable for Anesthesia and also define the Base Units. In such a case, if the Anesthesia Start and End Time and Duration is also entered, when the Code crosses over from Assessment to Billing, the system computes the Time Units (Time Duration / 15) adds Base Units and sets these as Units on the Claim generated.

Steps for using Anesthesia Billing functionality:

i.   For turning ON Anesthesia Billing, set the property, prognocis.anesthesia.support to Y.

ii.  During upgrade, a new Speciality Template named ‘Anesthesia' will automatically get added to: Settings>Configuration>Speciality
This template will have a System assigned: ‘ Anesthesia Time'

iii)  The 3 new elements displayed in table below with NUMERIC result type will be added to the above system:

Table 1: Elements Anesthesia Start Time, End Time and Duration

Figure 5: Anesthesia Template imported during Upgrade to Version 2, Build 3

iv.  Please make sure to associate the appropriate Charge code to the Anesthesia template, (alongwith modifier if required).
Ex: CPT code 00100 “Anesth Salivary Glands”

v.  The test codes for 3 elements have to be present in the 3 properties as shown in fig. below:

Figure 6: Properties with associated test codes for Anesthesia Duration, End Time and Start Time

vi. Check the checkbox “Applicable for Anesthesia” and Associate appropriate “Base Units” to the Charge Code associated to Anesthesia Template: Settings>Configuration>CPT Master.

Figure 7 : CPT Master with Anesthesia CPT code associated with Base Units(5)

vii.  When anesthesia is applied to any patient, go to Encounter → Speciality and select the template “Anesthesia” and fill the following:

Anesthesia Start time (Ex: 1200) as HHMM,
Anesthesia End time (Ex: 1245) as HHMM and
Duration (45) in minutes.

viii.  The associated CPT code will get transferred to Assessment on Save.

ix.  On creation of Claim, the system does following calculation for the Anesthesia Charge code Units:

Anesthesia Billable Units (8) = Time Units (3) + Base Units (5)
where,
Time Units = Anesthesia Duration / 15 (Ex: 45/15=3) and
Base Units = Units associated to Anesthesia Code on CPT/HCPC master (Ex: 5 for 00100).

Figure 8: Claim created with Anesthesia Charge Code with proper(Ex. 8 ) Billable units

Figure 9 : “i“ button on Claim Screen shows the Anesthesia Start Time, End Time and Duration

Note:

1. The Units added/transferred from Anesthesia template alongwith Anesthesia Code on Assessment screen in EMR will not be considered for Anesthesia Billing.
2. Note 2: If Anesthesia Duration is more than the multiples of 15, then Time Units considered are more by 1 unit.
   Ex: If Anesthesia Duration = 46 min, the Time Units = 46/15 = 3.06 (which is more than 3). Therefore instead of 3, the Time Units will be considered as (3 + 1) = 4.
3. This is how the Anesthesia Units and Minutes are displayed on CMS 1500 for associated Charge code (00100).
   Box 24G shows the Anesthesia Units for that charge code(8) and
   Gray Band of Charge code displays the Anesthesia Start Time and End Time in minutes.(Start Time 1200 End Time 1245)

Figure 10

x.  This is how the EDI Claims send the Anesthesia Time:

Figure 11

xi.  Settings → Configuration → Masters → Insurance → Extra Info Tab shows checkbox “Anesthesia Minutes on CMS” checked. This checkbox when checked, prints Minutes instead of Units in column 24G on a CMS 1500 form.

Figure 12: Anesthesia Minutes to be printed on CMS1500

xii.  Settings → Configuration → Masters → Insurance → Extra Info Tab shows checkbox “Anesthesia Minutes on CMS” checked .

Figure 13: 24G on CMS 1500 prints Anesthesia Minutes instead of Units when “Anesthesia Minutes On CMS” checkbox is checked on Insurance Master

Note: The above setting “Anesthesia Minutes On CMS” is applicable only for CMS1500 – paper Insurance form. The EDI Claim will still continue to send minutes as shown in EDI snapshot above.

2.4 CPT Master

To identify a CPT explicitly as a Procedure, a check Box is provided on Settings → Configuration → CPT screen. This way if required a tabular report can be generated for Procedure wise Claims made

2.5 CPT Master: The label ‘Follow up days’

i.  Settings → Configuration → CPT Screen is changed to “Free Procedure Follow up days”.

ii.  Cross Over CPT and Cross Ref ICD message Functionality:

For Cross Over functionality to work, please go to Settings → Configuration → Properties → Billing Parameters and turn ON the property:
Billing.use.crossover : Y

iii.  Then, go to Settings → Configuration → Group types → BD Insurance AR Codes

iv.  Click ‘BD' hyperlink and add/edit the AR Groups as shown in fig. below.

Figure 14: Group Type ‘Insurance AR Codes' with hyperlink on ‘BD' to add/edit AR codes

v.  On Insurance Master, Settings → Configuration → Insurance link, select the Insurance Company and associate AR group from drop-down list so that Cross Over functionality works for the selected Insurance.

Figure 15: Insurance Master Screen - AR Group Dropdown –Associate appropriate option

Note: One AR group (Ex: Commercial) can be associated to multiple Insurance companies (ex: Cigna, Aetna , etc.) where same Cross Over rules have to be applied.

vi.  Go to Settings → Configuration → Masters → CPT/HCPC and select a CPT/HCPC code for which a cross over code with Modifier for different AR groups has to be defined. The Fig. below shows CPT Code 99203 selected from CPT Master.

Figure 16: Cross Over Codes Pop-up shows INS Category, Cross Over Code and Modifiers 1,2 and 3

vii.  Click on ‘CO CPT' button as shown in Fig. above. The ‘Cross Over Codes' pop-up is displayed. All AR Groups are displayed as ‘INS Category'. For each AR group, a Cross Over code with modifier can be associated (Ex: For 99203 standard CPT code, 99213 with Mod 91 for AR Group ‘Medicare' has been associated).

viii.  Create a claim from Claims → New for Insurance : ‘Medicare FL First Coast Service J9' for which the AR group: ‘Medicare' is associated.

ix.  Select the CPT code: 99203 on the claim and click button ‘Save'.

x.  As soon as button ‘Save' becomes disabled, the button ‘Cross Over' becomes enabled. The reason the button ‘Cross Over' becomes enabled is because its finds a match for Cross over for CPT 99203. See Fig. below:

Figure 17 : On “Save”, “Cross Over” Button gets enabled if Insurance and CPT (for which Cross over code is defined) is present on the claim and when clicked, shows Original Code, New Code and Modifiers.

xi.  On clicking ‘Cross Over' button, “Cross Over Codes” pop-up will display with Original code, new code and Modifiers(if applicable) as shown in fig. above.

xii.  The standard CPT ‘99203' will get replaced by its Cross Over Code ‘99213' with modifier ‘91' as shown in fig. below. Fig:
Note: As soon as the Cross Over takes place, the “CrossOver” button becomes disabled again.

Figure 18: Charges Crossed Over after Ok button click on Cross Over pop-up

xiii. The claim will get processed with CPT Code ‘99213' and associated modifier ‘91'

2.6 Cross Over Message for Charge Code-ICD pair for a AR Group/INS Category

For the current CPT Code, and a range of ICD Codes, a cross over Message can be defined for each of the Insurance AR Group defined in the system. If a Charge code has Cross Over message stored for ICD ranges and one of the ICDs is associated to the charge code, on clicking of “Save” button on “Claim”, the Cross Over message pops up .

Examples of Cross Over Warnings:

• It is not recommended to use this CPT-ICD combination for the selected Insurance company.
• For getting paid more for this CPT-ICD combination, kindly use Modifier XX. Etc.

To invoke the Cross Over message functionality, please go to Settings → Configuration → Properties → Billing Parameters and turn ON the property: Billing.use.crossreficd : Y

i.  Then go to Settings → Configuration → Masters → CPT/HCPC and select a CPT/HCPC code for which Cross Over Message has to be associated for a specific ICD code range for a AR group/Ins Category. (Ex: CPT: 97124, ICD code: 847.1 for AR Group/INS Category: Commercial Pop-up message: “Medicare recommends ICD code 847.2 instead of ICD code 847.1 while billing CPT code 97124”).

ii.  Click on button ‘CO Msg'. For displayed AR group (Ex: Commercial) Select ICD code (Ex: 847.1). If 1 ICD is selected, the same ICD will display in both “From” and “Upto”. For selecting range of ICDs, select 2 ICDs : ICD From and ICDUpto from the same binocular.

iii.  Type the Cross Over message (Ex: “Recommendation to use ICD code 847.2 instead of ICD code 847.1 while billing CPT code 97124”) as shown in Fig. below.

Figure 19: CPT Master code with Cross Over Message details stored by clicking the “CO Msg” button

iv.  “Warn.”Checkbox Functionality:
If “Warn” checkbox is checked: Only Warning on Save. Allows Processing claim.
If “Warn” checkbox is unchecked: Users forced to change ICD-CPT combination.

v.  Based on the above functionality decide if the message should be only a warning or Biller should be forced to change the ICD-CPT combination before processing the claim.

vi.  Make sure that “INS Category” also referred to as AR Group (Ex: Commercial) is associated to appropriate Insurances in Settings → Configuration → Masters → Insurance (Ex: Aetna Health Plan)

vii.  When a Claim is created for the same combination of Insurance, ICD-Charge code, and checked/unchecked Checkbox “Warn.” , on click of button “Save “, the cross over message would pop-up as shown in Fig. below

Figure 20 : Claims: Cross Over Message for ICD-CPT-Insurance combination stored in CPT Master.
If “Warn” checkbox is checked: Only Warning on Save. Allows Processing claim.
If “Warn” checkbox is unchecked: Users forced to change ICD-CPT combination.

viii. Based on this message, the Billers are forced to take appropriate corrective actions based on whether Settings → Configuration → Masters → CPT/HCPC → Co Message → “WARN” checkbox is checked and then send the claim

2.7 Medics Master changes

1. Ability to mark a provider as ‘Non-Billing' Provider so that he is not available to be associated as Rendering Doc on a Claim

Figure 21: Provider marked as Non Billing so that claims cannot be billed on the provider's name even though the provider saw the patient

2. On the Claims → Edit → ‘i' button and on Claims → New screen, Rendering Provider Dropdown list does not show the Non Billing Provider. So the Non-Billing provider cannot be the Rendering Provider for a claim.

Note: If an encounter Attending Doc was the Provider marked as “Non Billing”, then the Rendering Doc of that claim will be as per following sequence:

• Rendering Doc associated to Non Billing Provider on Medics Master. If not associated…then
• Primary Provider of the Patient associated on Patient → Register screen.

2.8 Insurance Master changes

1. The button: EDI info on Insurance Master screen is now renamed as Extra Info.
   This button now has settings which are not necessarily related to EDI. See Figs. Below.
2. “Sec By Paper” checkbox on Extra Info screen of Ins Master.
   If this checkbox is checked, on posting Primary Remittance, if there is Secondary Insurance responsibility created, the claim for Secondary will get created under “Sec CMS” bucket on Claims → Send Screen.

Figure 22

3. For ERx and certain CPT combination: G8553 will be sent

4. Subscriber ID length can now be defined on Insurance Master.

a) Certain Insurances need fixed length Subscriber IDs to be sent. If they are not, then the claim gets rejected

b) For defining the Subscriber ID length, go to Settings → Configuration → Masters → Insurance. Select the Insurance company (Ex: AARP) for which the Subscriber ID length is to be defined. Click on Extra Info button. On the Extra Info button, there is a new field added: Subscriber ID Length. Enter the length (Ex: 8)

Figure 23: Subscriber ID Length can be defined on Insurance Master Screen

c) Now, consider a case where a patient has the same Insurance associated on screen Patient → Insurance.

d) When a claim is created for this patient, on clicking the button: “Save”, a pop-up message gets displayed as shown in the fig.

Figure 24: On “Save” on Claims /Edit Screen, the following pop-up comes if the Insurance associated to that patient claim does not have correct Subscriber ID Length as set on Insurance Master

e) To proceed further with the claim, go to Patient Insurance screen and change the Subscriber ID such that its length now matches the length defined on the Insurance Master.

5. Checkbox ‘Anesthesia Minutes on CMS' if checked, prints Minutes instead of Units in column 24G on a CMS 1500 - Paper Claim Form as seen during Anesthesia Functionality explanation above.

Figure 25: Settings → Configuration → Masters → Insurance → Extra Info Tab shows checkbox “Anesthesia Minutes on CMS” checked

6. The AR Group which was existing but not very important is now significant. As explained above in Cross Over Feature, the AR Group is used to define the entries on Settings → Configuration → CPT/HCPC Master → CrossOver Codes and CrossOver Message Screens and later on claim screen.

2.9 Home Page related changes (EMR and Billing)

1.  Insurance Eligibility button added to read Eligibility details on Home page. Click on the button: to read eligibility of the patient. If the eligibility is not previously checked, it will not be available and appropriate message is displayed on clicking the Eligibility button.

2. For display on Home Page of Billing module, Insurance Outstanding and Patient Outstanding Amount calculation has changed(Outstanding Claims → Insurance and Outstanding Claims → Patient columns). Earlier it would total only those claim amounts which were Not –ve. Now it totals them in either case.
Note: The Total Outstanding Amount under column Outstanding Claims((Outstanding Claims → Total) now match the total amount shown on Claims Center as well as Charges Center.

2.10 Patient Insurance Screen

1. System warns the user if Patient Insurance Subscriber Relation is ‘Self' for Minors -

If a patient is a minor and while adding the Insurance info for the patient, if Relation is “Self” then on click on “Update” button, the system pops the message “Subscriber Relation is SELF for minor”

Figure 27: Warning message displayed

2.  Additional Check for “Subscriber ID Length” and appropriate message display when Subscriber ID length defined on Insurance Master does not match with the Subscriber ID entered on patient Insurance screen as explained in section: Insurance Master Changes.

3.   If an Insurance company is marked as “Inactive” from screen: “Insurance Master” after that Insurance was associated to various patients, on press of button: “Update” on screen: “Patient Insurance” following message pops up indicating the users to mark the Insurance as Status: “Non-active”.
Message: “Insurance Company XXX is Inactive. Mark Status as Non Active”.
* After marking the Status as Non Active, the record gets updated successfully on click of button: “Update”. Earlier versions did not allow updating patient insurance record which was marked as Inactive on Insurance Master.

2.11 Co-Pay screen related changes

1. Co-pay after claim is already billed and EOB received

a)  Even after the Claim is processed, Co-pay screen will remain enabled to add/edit the Co-pay and Deductible amount. Once the patient responsibility is created, the Co-pay screen will be uneditable.

b)  This change will allow the Clinic to continue to add/edit the Co-pay and Deductible for a visit even from
* Remittance screen while doing Primary and Secondary remittance,
* from Claim Screen and
* from Home Page as well.
* In short, from wherever the button for Co-pay screen is available.

c)  In case there is only one insurance associated to a claim, on Ready to Post of Primary Remittance, the Co-pay and Deductible gets applied to Patient responsibility assigned by Insurance. Hence, on posting the Primary Remittance, the Co-pay screen will become non-editable.

d)  In case there are Primary and Secondary Insurances, on Ready to Post of Secondary Remittance, the Co-pay and Deductible gets applied to Patient responsibility assigned by Sec Insurance. Hence, on posting the Secondary Remittance, the Co-pay screen will become non-editable.

e)  This change will reduce the extra steps of creating Patient Responsibility for Co-pay received after visit and then applying those receipts to claim after patient responsibility is created (i.e. payments from Primary/Secondary Insurance is received and posted).

2. Batch Number linked to Co-pay.
Receipts Batch Number functionality has now been extended to Co-pay screen. Once a batch is opened and/or assigned to a Biller, the same batch number gets assigned to entries on 3 screens : Co-pay, Remittance>Receipts and Remittance>Entry/Edit screen.
The functionality is further elaborated under the topic of Receipt Batch Number .

3. Info button on Co-pay screen.
A new button has been introduced on Co-pay screen: “Info”.

Figure 29: On click of the button “Info” , a pop-up is displayed and it shows the names of Location, Business Unit and Rendering Provider associated to the claim

Note: The Info is “Display only” and hence the “ok” button remains disabled.

2.12 Claims > New Screen Changes

1. ‘Appointment Location' label changed to ‘ Claim Location ' since no appointment is generated on new claim creation from Billing side..
2. Lable ‘Reason' is changed to ‘ Reason for visit' while creating a new claim since this Reason is saved as Encounter Reason.
   Note: The “Reason for Visit” is not visible from frontend.

2.13 Claim screen changes

Following changes have been included in the Claim screen (GoTo tab: Claim à Edit):

Header Level changes on Claim Screen :

1.   ‘Self Pay' Insurance assignment to Claim if all Patient Insurances are marked “Non-Active”.

Figure 30: Both Insurances are Non Active and hence Insurance associated to Claim is “Self Pay”

2. If a Claim is created for a patient who has insurances associated, but they are marked as Status: Non-Active, the Insurance field on Claim will display “Self Pay” just like it shows for patients having no Insurance associated.

3. Earlier, even though the Insurance was non-active, the Insurance used to get associated to Claim and then the message used to display on Save of the claim that the Insurance is Non-active and users were required to change the insurance to “Self Pay” exclusively. Now this is no more required.

4. Inactive Insurance (From Insurance Master)when used on claim, gives a message “Primary Insurance Inactive”.
If Insurance company is marked as “Inactive” from screen: “Insurance Master” and has been already assigned as Patient Insurance before marking it as Inactive, then on creating a claim for such a patient for the inactive Insurance, on click of button: “Save” on Claim screen, a pop-up message displays: “Primary Insurance Inactive”.
Unless the Insurance is either marked as Active again from Insurance Master or other active Primary Insurance is associated to claim, the claim cannot be processed further.

5. Checkboxes -> Work Comp, Auto Accident and Personal Accident automatically checked based on Properties and appropriate Encounter Types.
System identifies the Accident type of Claims based on encounter type and properties and sets the appropriate check box on Claim screen automatically.
6. For Workers Comp case, following conditions have to be fulfilled for checkbox: “Work Comp Employment” to be checked on Screen: “Claims”:

I. First (Primary) Patient Insurances is of Status “WorkerComp”

•  Visit Type OR Encounter type is “WC”
                                   OR
Encounter Type code associated to appointment is as defined in property:
encounters.visittype.workers.comp :Comma separated list of Enc Types.
Note: When claim is created from Screen: Claims → New , there is no Enc Type and hence the property given above is not read, but for checkbox: “Work Comp Employment” to be checked on Screen: “Claims”, the first(primary) insurance associated on Screen: Patient Insurance has to be of status “WorkComp”.

II. For Auto Accident case, following conditions have to be fulfilled for checkbox: “Auto Accident” to be checked on Screen: “Claims”:

a) Atleast one of the Patient Insurances is of Status “MotorAcc”.

b) Visit Type OR Encounter type is “AA”
                                   OR
Encounter Type code associated to appointment is as defined in property:
encounters.visittype.auto.accident:Comma separated list of Enc Types to be used for Auto Accident.

Note: When claim is created from Screen: Claims → New , there is no Enc Type and hence the property given above is not read, but for checkbox: “Auto Accident” to be checked on Screen: “Claims”, the first(primary) insurance associated on Screen: Patient Insurance has to be of status “MotorAcc”.

III. For Personal Accident case , following conditions have to be fulfilled for checkbox: “Other Accidents” to be checked on Screen: “Claims”:
a. Atleast one of the Patient Insurances is of Status “PersonalAcc”.
b. Visit Type OR Encounter type is “OA”
                                   OR
Encounter Type code associated to appointment is as defined in property:
encounters.visittype.other.accident:Comma separated list of Enc Types to be used for Other Accident.
Note: When claim is created from Screen: Claims → New , there is no Enc Type and hence the property given above is not read, but for checkbox: “Other Accident” to be checked on Screen: “Claims”, the first(primary) insurance associated on Screen: Patient Insurance has to be of status “OtherAcc”.

IV. For claim created for Auto Accident and Personal Accident, Patient Insurance with corresponding status “MotorAcc” and “PersonalAcc” is chosen as Primary Insurance.

a) If it is an Auto Accident Type of Enc Type and
There are more than one Insurances associated to patient and
The Insurance with Status “MotorAcc” is not primary, i.e not first in sequence,
Then
It tries to assign the ID of Insurance with status as “MotorAcc” as Primary Insurance Id to the Claim. The Effective / Applicable Insurance Seqn is modified for the purpose.

b) Same is true for Personal Accident case.

c) Same is true for Workers Comp Case.
Note: There is NO Secondary Insurance for Worker Comp.
Hence, if there are 2 patient Insurances and 2 nd in sequence is of Status: “WorkerComp” for Ex. Then when for a encounter type WC or any type defined in property, the claim will get created for 2 nd ID or Second Sequence Insurance as Primary and there will not be any Secondary insurance associated to claim as shown in Fig. below.

6. Checkbox: “ Assign Benefits ”on screen: Claim is no more linked with Checkbox: “ Not Assigned ” on Master: Insurance – Fix.
Somehow when the Checkbox: “Not Assigned” used to be checked for any Insurance on Insurance Master, any claim created for that Insurance used to get created with Checkbox: “ Assign Benefits ” checked by default. This was not a correct functionality and hence it has been fixed now.

2.14 GUI (Graphical User Interface) changes in the Claims Screen - Header

1. New icon of Insurance Eligibility: has been added next to the link: Insurance in the GUI.
2. The icon, Track Status: is displayed next to the information text of Billing Status.
3. The icon, Patient A/c: has been added next to the option: Paper Ins Form. Thus the user is able to quickly go to the patient's account details while adding the Claims details in the Claim screen.
4. The icon, Claim ledger: has been shifted next to the icon, Patient A/c.
5. The icon, Resend Claim has been moved next to icon, Track Status.

Note: Refer to the following figures to compare the changes done.

Figure 32: Old GUI of the Claim screen - Header

Figure 33: New GUI of the Claim screen - Header

2.15 Support for Multiple Pre-Auth Nos. entered directly on Claims Screen

1. It is possible to enter more than one Pre-Auth numbers on the screen: “Claims → Edit” in the textbox titled “Pre Auth No”.
2. GoTo tab: Claims → Edit, the field: Pre-Auth No. now supports 30 characters to accommodate 'multiple' Pre-Auth Numbers.
3. Each Pre-Auth No. has to be entered as a comma separated value directly on the claim screen.
   
   It will not be automatically pulled from screen: “Patient Insurance” and neither will it be allowed to be selected from pop-up “Pre Auth” when clicked on hyperlink “Pre Auth No”.
4. Both Pre-auth numbers will be printed in Box 23 on CMS1500 form.

Figure 34: Pre-Auth numbers printed on CMS1500 form as typed in field “Pre Auth No” on Screen: Claim

5. In EDI currently both the Pre-auth numbers are sent as Comma separated.
30 2300 REF - PRE AUTH NUMBER

REF*G1*12345678901,98765432109~
Once specific claim is known to be sent with this requirement, the way both pre-auth numbers should be sent via EDI would be known and accordingly taken care of

6. The words ‘Rebill' and ‘Reopen' are now displayed in RED color after ‘Claim ID' if applicable.

7. The word ‘Reopen' is displayed in red color as shown in Fig. below, when the claim is Reopened.

Figure 35:

8. The claim can be reopened from : a. Reopen button on Claim screen, b. Denied → Action “Reopen Claim to Resend” on Remittance screen.

9. As soon as the claim is processed again, the word “Reopen” is displayed in black color.

10. The word ‘Reopened' also gets displayed on claim in Footer in black color.

Figure 36: Word ‘Reopen' displays in Black after the claim is reprocessed.
The word ‘Reopened' is displayed in Claim Footer once a claim is reopened.

11. The word ‘Rebill' is displayed on claim in red color quickly indicating that the claim has been Rebilled.

Figure 37:

12. The claim can be Rebilled by choosing Status: Denied with Action: ‘Rebill creating a new claim' while doing Remittance.

13. This new claim claim created with new Claim ID has the word “Rebill” in red color on it.

14. Once this claim is billed, the word Rebill is shown in black color.

Figure 38

15. Max ICDs allowed on a Claim are now 8. The ICD selection ‘+' button becomes disabled once 8 ICDs are selected.

Figure 39: As soon as 8 ICDs are assigned to a claim, the ‘+' button gets disabled

16. ‘ Pregnant' checkbox now editable from Claim screen irrespective of the details entered on EMR side. This is property based.

17. For enabling the “Pregnant” checkbox, kindly set the property:
billing.enable.pregnancy.cb : Y (Default value N)

18. If set to ‘Y', the “Pregnant” checkbox on claim screen will remain enabled to be checked. This will be helpful for claims created directly from Claims → New screen.

19. If set to ‘N', it will behave as per the earlier functionality:

• The ‘Pregnant checkbox will always remain disabled.
• The Test: “Pregnant? No/Yes in Speciality section on EMR side has to be answered as ‘Yes'.
• Also, its test code has to be mapped to property: rx.pregnancy.testcode.
  Only then will the ‘Pregnant' checkbox on claim will get automatically checked and remain disabled.

20. Statement for DOS generated from Preview, now appears in a proper window. FIXED.

21. ‘Post Date' – a new field editable by users has been added on Claims screen – used later for reporting.

• By default the System Date(Today's Date) is considered as Post Date. It can be edited to any date upto Today. Future Dates are not accepted in Post Date.
• Post Date is useful when the Users want to make a note of when actually the claim was posted if the Post Date is different than the Visit Date and Sent Date of Claim(When marked as Processed) in PrognoCIS.
• The Post Date can be used for Reporting purposes by generating reports based on Post Date.

22. Track Status' button now displays entries of claims processed as Patient EDI and Patient CMS from Print button of Claim, where Insurance is associated and amounts are billed to Patients.

2.16 Details Level changes on Claim Screen

1. Prescribed Dispensable Drug Name is populated in the Charge Row ‘Comments' field if the drug is Inhouse and has NDC code associated to it. It is property based.
2. Anesthesia Billing now supported. Anesthesia Time units considered while computing Actual units for applicable charge rows on claim. Anesthesia Billing Support is property based.
3. Pre-Authorization number selection and assignment to Claim now gets validated based on ‘ Date Range' in addition ‘Closed' checkbox - uncheck validation.
4. Post-Op CPT codes defined in a property will NOT get transferred to Claim from Assessment provided the Ins Type is IPA and there is no Secondary Insurance.
5. ‘Cross Over' button now available on Claim for charge codes billed to Insurance and for whom Cross Over is pre-defined. It is a property based functionality.
6. Bottom Line of Claim Screen displays following applicable Status when Claim is reopened.

• Reopened
• Reopened From Pri Eob Denied
• Reopened From Sec Eob Denied

1. ‘On Hold' - a new Claim Status has been added and can be set by checking the new checkbox “On Hold”. ‘On Hold' claims cannot be processed.
2. Duplicate charge rows are now allowed to be billed by default – property based.
3. NDC code gets added to the claim if HCPC code selected from Search has it associated on HCPC Master.
4. Ability to assign collected Copay to a specific charge code on the claim screen. With this association, the actual handling / allocation on receipt of EOB is not changed. This functionality can be turned ON using a property.
5. Tool tip now provided on the Flag Icon of charge row to quick display of changed info without opening the pop-up.
6. Button ‘Copy' now copies all charge codes including duplicates.
7. Binocular for ‘Modifier' when clicked continues to show the already selected modifiers as checked.

2.17 ‘i’ button screen on Claim

1. Rearrangement of fields now done on ‘i' button by logically grouping them, making them more readable.
2. Additional column now added on ‘i' button to map the fields with ‘ Cells/Boxes' on CMS1500 and ‘ loops and segments' on EDI claims.
3. ‘Rendering Doctor' search on ‘i' button screen will not show providers who have been marked as “NON BILLING” on the Provider master.
4. ‘Referral No' : A new field associated to Referring Provider is added on ‘i' button.
5. ‘Anesthesia Start Time', ‘End Time' and ‘Duration in minutes' are the 3 new fields added on ‘i' button for Anesthesia Billing. These fields get enabled only if the property related to Anesthesia Billing is turned ON.
6. ‘Cell 19 Local Use' field now support limited special characters, namely Dot, Forward Slash, Open and Close brackets.
7. The field ‘DCN ICN' on ‘i' button gets automatically populated on processing the Primary Insurance EOB when received Electronically as an EDI835 message.

1. ‘Inactive' Check of the Base CPT / HCPC Codes is done on saving the claim. This check is made for new Claims and is Not made if the Claim is Reopened.
2. ‘CrossOver Icd Message' if applicable during Claim>‘Ready to Send', it is displayed on the Claim screen.
3. On Ready to Send, if Nothing is Billed to Insurance and Insurance is selected (it's a case of Patient CMS) and Assign Benefits is checked, it gives a warning message.
4. A new hyperlink with word ‘CoIns' is displayed on the claim if claim is Billed AND there is a Secondary Insurance. The amount paid by Primary and amount marked as secondary responsibility as per Primary Insurance EOB are shown on the pop-up.
5. Even if the property related to ‘Sync EMR' is set, the Cross Over Codes, and Anesthesia Codes from Claim screen are Not added to Assessment on EMR side.
6. If there are Zero value Charge Rows in a claim, appropriate message is displayed on “Save”.
7. Batch No validity, and check if the Batch No in the Master is still Open is done only if the claim is getting processed for the first time. Reopened claims will not have this validation while reposting.
8. In case of Accident / Worker Comp Claims, the Date of Injury and Place of Accident are mandatory.
9. The CMS Flag>'Copay Assigned' checkbox will be unchecked, if the Claim was recreated for a Visit ID.
10. Additional validation will be now done for Inactive ICDs as defined in property billing.inactive.icds while saving the claim.
11. If the Primary Insurance Master does not have Submitter / Billing provider / Pay to Provider type set as default, then the defined type will match that in the claim on ‘i' button.

2.19 Send Claims Screen related change

1. Claims marked as ‘On Hold' on Claim screen are Not included on Send Claims Screen.
2. Claims reopened because of Sec EOB>Denied>Action “Reopen to resend” , on Post directly appear under Sec CMS / EDI with the claim status changing to Billed.
3. Select Filter button is provided to filter the Claims seen.
4. Button ‘chkReady' is renamed to ‘Validate' .

2.20 Remittance Related Changes

Remittance>Entry/Edit Screen

1. Status > Denied/Pending has a New Action > “Resend without Reopen”.
2. Status > Denied/Pending has a New Action > “Resolved”
   Remittance>Denied Screen.
3. Support for Secondary paid first while doing remittances.
4. Duplicate and additional payments / Payment received more than billed amount now supported. There are two new statuses added for each charge row: ‘Additional' and ‘Duplicate'.
5. If Copay is collected for a Claim, e ven if the copay value on EOB is Zero, it will invoke the action and move the amount on co-pay screen to Advance .

2.21 Remittance > Unallocated Screen

List Box ‘Voucher' has two more entries ‘Ins Credit' and ‘ Pat Return'.

2.22 Remittance > Processed Screen

List Box ‘Voucher' has two more entries ‘Ins Credit' and ‘ Pat Return'

2.23 Remittances > Denied Screen

Now, on post of an EOB, the system checks if there was an earlier EOB entry as Denied (and No subsequent Action)  for the same Charge Code. If such a case is found it Marks the Action taken as ‘Insurance Agreed to Pay', thus the original EOB entry will go out from the Remittances > Denied menu option .

‘Filter' List Box has three more entries:
•  Primary Insurance Y.

•  Secondary Insurance Y

Patient

2.24 Remittance > Ins w/off Screen

A New field ‘Post Date' added on this screen with functionality as on Remittance screen.

2.25 Remittance > Pat w/off screen

A New field ‘Post Date' added on this screen with functionality as on Remittance screen.

  2.26 Remittance > Pat Item Returns

The Lable ‘Pat Returns” has been changed to ‘Pat Item Returns' for clarity purposes.

2.27 Reports Tab options

Reports/Statement Screen

1. Claim wise Radio Button, template List Box, now does Not include the Template for Statement For DOS.
2. Earlier Statement was generated only for Active Patients. Now it is generated for all Patients even if their status is made Inactive.
3. Insurance Receipt column is renamed to “Settled”.
4. Now it will Not print the Amount Billed to Sec under Ins Bill column.
5. Statement now reflects Insurance IPA WriteOff transactions And Patient Return transactions too.
6. Prints the amounts moved to / from Advance from Patient Receipts.

Reports > Pat Aging Screen

1. Patient Aging Label changed from ‘Send Date' to ‘Responsibility Date' .
2. Aging by Send Date as well as by Date of Service is now supported.
3. Amounts Range is now considering Amount > Minimum Amount and Amount <= Max Amount.
4. Earlier Aging was generated only for Active Patients, Now it is generated for all Patients even if their status is made Inactive.

Reports > Ins Aging Screen

1. Group By is moved to the first line in the selection Pop up.
2. Amounts Range is now considering Amount > Minimum Amount and Amount <= Max Amount.
3. Aging by Send Date as well as by Date of Service is now supported.
4. Using ‘Group By created issues which are now Fixed.
5. Earlier only Claims for Sec Insurance were considered if they were sent. This constraint is removed.

Report > Tabular

1. If the Design of a Tabular report had the keyword BILLING_FILTER then a button to select the Billing Filter condition is available on the screen. The system saves the last selected Billing Filter conditions. The system already had a similar provision for PATIENT_FILTER.

Report > Ledger

Ledger now reflects Insurance IPA Write-Off transactions.

2.28 Settings>Configuration>Scheduled Processes > Statement

1. Bulk Billing Statement now supports an additional SQL condition for patients.
2. Bulk Billing Statement now supports associating Patient Statement template.
3. ‘Group By' Radio Button has a provision for Patient Location in case of Multi Location version.

2.29 Settings > Configuration > Business Unit

State Code and name in database discrepancy fixed.

Settings > Configuration > Receipts Batch No

2.30 Tabular Report Design related changes

Settings > Configuration > Tabular

Tabular Report Design allows Users to specify a Comma separated list of Report Codes. When the main report is run, each of the comma separated Report Codes specified are also executed and appended to the main report. Note that the parameters selected for main report are assumed to be applicable and sufficient for the appended reports.

2.31 Diagnostics related changes

Settings > Configuration > Diagnostics

Added options for

List of Minor Patients with Insurance relation as SELF.

List of Charge Rows with -ve Balance.

2.32 EDI and ERA Related Change

Electronic Claims: EDI837

1. The sequence of EDI message for 2410 loop and 2430 loop was swapped. This was a fix to address rejections.
2. If a claim has a referring provider present and the referral no is entered under ‘I' button, then system will send out this information by EDI under 2300 REF segment.
3. Anesthesia claims can be sent by EDI. System will send out the minutes instead of units in the SV1 segment. The start time and end time for anesthesia will be sent in NTE segment for EDI.
4. Earlier we were not sending the legacy IDs given to Business Units. Now it is supported.
5. In case a claim is directly created in Billing module, and Illness Date NOT entered on Claim I Button, then while sending it in 837, we were sending encounter date which is likely that this date was today, but the Charge level From and Upto Date were earlier, giving a rejection. Now in such a case system now sends the minimum date entered in the charge row as the Illness date.
6. While sending claims to secondary, system now considers the Submitter Type, Billing Provider Type & Pay to provider Type as set for Secondary Insurance. The secondary claim will go out as discussed above based on if the property 837.override.types.forsec is set to Y. This is will be handled for PAPER claims on a later date.
7. 106 Validation is changed.

Electronic Remittances: EDI835

1. On some instances we were receiving electronic remittances from secondary payer for claims for which there are no secondary insurance company selected in the claim. This will result in the electronic remittances process to abort. Now system updates the transaction log as invalid insurance and proceeds with processing remaining Claims. In such a case Note that Balance will Not tally, so User will need to manually reconcile and post.
2. Program had some debugging messages which used to display while the electronic remittance process was run. This has been removed.
3. The log file for electronic is enhanced to log the invalid charge code, invalid claim and invalid insurance for a claim.
4. ERA files have a DTM segment which will indicate the DOS from date and DOS to date. So if there are same charge codes repeated more than once in the claim which we send out with different DOS, then while processing ERA files we consider these dates.

2.33 Other Changes related to EDI and ERA

1. The clearing house acknowledgement file names from Office Ally have changed. System now considers files with extensions.997 .txt.997 and .txt.txt.997.
2. Previously we were processing the EBR files from Availity with a validation to check the equivalent ACK file exists to get the claim id. Now we ignore that part and directly take claim id from the EBR file itself.
3. Earlier we were getting one claim in an EBR, now Availity is sending multiple claims per EBR. System now supports that.