Release Notes - Billing

Version No: 2.0
Build No: 8

Table of Contents

1. Introduction

Numbers of new features related to PrognoCIS Billing have been released in Version 2.0 Build8.

2. Patient Registration

2.1 Contacts Tab: Allows association of ‘Employer’ to Patient.

Patient Registration >> Contacts Tab: As PrognoCIS supports Employer Billing, there are few changes are introduced on ‘Contacts Tab’ layout to accommodate functionality. The field ‘Name’ will allow user to enter ‘Employer’ name just by typing name and if specific Employer is present in database then Employer Name will be completed using auto complete feature. That is how employer at Patient Registration level can be associated. If user selects it from this auto complete list or from search, the Employer will be considered as Valid and if the user continues to type the employer name and tab out, this entry will be considered as text and it will not be a valid employer for Employer billing. If the employer is not from Master, word ‘Unknown Employer’ is displayed next to Clear field in BOLD. Next to search Binocular, ‘+’ Icon allows adding a new Employer in the system without leaving Patient Registration screen.

 

Figure2.1 – Text field 'Name' added to associate Employer on Contacts Tab.

2.2 Other Info. Tab: Checkbox ‘Self Pay’ is moved to ‘Billing Info. Tab’.

Patient Registration >> Other Info Tab: Checkbox ‘Self Pay’ is removed from ‘Other Info. Tab’ and is now placed under ‘Billing Info. Tab’. Logically, checkbox ‘Self Pay’ is more relevant when used in context with Billing.

2.3 Billing Info. Tab: various fields renamed according to appropriate functionality.

Patient Registration >> Billing Info Tab: Billing Info tab pertains to features relevant to ‘Billing’. The labels and fields which are displayed on this tab should provide clear understanding about what these fields are referring to. In order to have user friendliness, few existing fields are renamed and a checkbox ‘Self Pay’ is added on ‘Billing Info. Tab’. Label ‘Responsible Person’ is now renamed to ‘Responsibility’ and label ‘Relation’ is renamed as ‘Guarantor’. The functionality associated to these fields remains affected. Checkbox ‘Self Pay’ is included under ‘Financial Class’ section on ‘Billing Info. Tab’.

The duration of outstanding receivable amounts towards the Patient and Insurance are arranged in periodic range in days. The duration of the period range (aging buckets) is now customizable with the introduction of property ‘billing.aging.slots’. Customize the slots by entering comma separated values (For ex.) 10,20,30,40 as per Patient and Insurance outstanding receivables to be displayed in aging table.

Figure2.3 –Billing Info. Tab on Patient Registration Screen.

3. Patient Account Screen

3.1 'Visit Id' is displayed in Bold for Denied/Rebill claim.

Patient Account Screen: 'Visit Id' of the claim is displayed in bold letters under claims table when claim of the selected patient is either 'Denied/Rebill'.

Figure3.1 – 'Visit Id' in bold and black color for 'Denied/Rebill' claims on Patient Account.

3.2 Now 'Carrier' is displayed under Remittance Table.

Patient Account Screen: Remittances table now displays only carrier. Then it is followed by ‘Hold’ in case of remittances on ‘Hold’ as a result of change of Secondary / Tertiary. Earlier Insurance name was followed by carrier in bracket.

3.3Insurance name is prefixed with word 'CAP' for capitation claims.

Patient Account screen: Word 'Cap' in bold and red color is displayed before Insurance name under section 'claims' in column 'Billed To' to notify that specific claim is 'Capitation' type claim. EOB/ERA for such Capitation Type Claims displays Capitation Insurance name in column 'Pri Ins' with word 'Cap' as prefix in bold and red color font.

Figure3.3 – Insurance name prefixed with ‘CAP’ for capitation claims on Patient Account.

3.4 Now 'Deductible' is hyperlinked to show patient deductible details.

Patient Account screen: Now hyperlinked 'Deductible' displays pop up ‘Patient Deductible’ having columns ‘Subscriber Id ’, ‘Year’, ‘Ins.’, ‘Yearly Deductible’ (Deductible amount allowed as per Eligibility on Patient Insurance screen), ‘ClaimId’, ‘Visit Date’, ‘Collected Ded Amt’(on Copay Collected pop up). This pop up enables user to quickly compare the ‘Deductible amount allowed as per Eligibility’ and actual deductible amount collected from the patient.

Note: ‘Yearly Deductible’ amount displayed in pop up which is invoked by clicking hyperlink ‘Deductible’ always displays current year’s ‘Deductible’ amount.

Figure3.4 – Hyperlinked ‘Deductible’ displays deductible details of patient on Patient Account.

4. Patient Insurance Screen

4.1 Insurance Eligibility Format improved for better readability.

Insurance Eligibility Message (271) format is restructured to have better readability of these messages. Basically, formatting is about presentation of the messages, better organization of sections for better understanding and readability etc.

Figure4.1 – Improved Layout for Insurance Eligibility

5. ‘Rendering Doc’ selection at Encounter level is now supported by PrognoCIS.

In multi – provider/ multi NPs setups, there is no one-to-one association possible for NPs (non-Billing providers) and providers (Rendering Docs allowed for Billing). This decision is based on which provider is on location on the day of encounter and if there is more than one provider on location and some are Billable and eligible as rendering provider and some are non billable and can be Attending Docs but cannot be Rendering Docs. With this new feature, more flexibility to choose any applicable Rendering Doc on each Encounter level is provided. When patient walks in NP/provider will make decision on who will be the Rendering provider from the eligible billing providers on duty on that day. An option to select/change the Rendering Doc at the Encounter level on Encounter >> Start/Edit screen is provided. The Rendering Doc List will display list of doctors with checkbox ‘Non Billing’ not checked and BLANK as an option present. On Encounter close, if the field ‘Rendering Doc’ is Blank, alert message is displayed to the user and selection is forced to select from List box on Start/Edit Encounter screen. This field ‘Rendering Doc’ is grayed out on close of Encounter i.e. it will not be allowed to be changed and saved. Rendering Doc selected on Encounter is displayed on Claims >> Edit screen on ‘I’ button when claim is created from Encounter close.

6. Billing Home Page

5.1 Now Employer Outstanding is displayed on Home Page.

Now employer outstanding is also displayed on Billing Home page even if there is single Employer Billing claim under column ‘Employer’. Outstanding of other type of claims are still displayed under column ‘Total’ as it was displayed earlier.

7. ‘Employer Billing’ is now supported by PrognoCIS.

Local employers send their employees to the practice for drug testing or health screening (new hires, for instance).  The patient does not pay nor does it go to insurance.  So on one hand it’s a “self pay” but actually, it is a “3^rd party” that is neither the patient/guarantor nor the insurance company but rather the employer in this case not Worker’s Comp. The Billing to Employer is Invoice based and hence a separate workflow has been supported by PrognoCIS. Please refer separate document on ‘Employer Billing’ for more details and other various relevant functionalities are described in relevant section.

8. PrognoCIS allows creating ‘Capitation Type Claims’.

Capitation means that the doctor needs to take care of X patients at a determined $ rate per month. For example e.g.; $10 per registered Patient per month. Number of Patient who visited in a month and the number of visits does not matter. However the Providers would like to analyze this data as a % of amount they would have received from Medicare, if Medicare was paying for it instead of the capitation Insurance. The claim is a normal claim. It is send to Insurance in the normal way.

Insurance sends typically a Paper EOB. It is likely that Insurance EOB refers to some claims with a normal payment plan, and some claim with a Capitated plan. If the plan was capitated, the EOB will specify the Allowed amount is auto written off to $0. The system smartly differentiates capitation claims and word ‘CAPITATION’ is displayed in red and bold color on Claims >> Edit screen. Please refer separate document on ‘Capitation’ to learn more details and other various relevant functionalities are described in relevant section.

9. Now Complete Tertiary workflow is supported by PrognoCIS.

PrognoCIS now supports complete Tertiary functionality to cater the needs of users. Tertiary functionality is supported for claims as well as for EOB/ERA screen. The Tertiary insurance can be assigned if the patient has valid Tertiary Insurance. Typically Tertiary comes into action after Patient complains and mentions that he also has a tertiary. Please refer separate document on ‘Tertiary’ to learn more details and other various relevant functionalities are described in relevant section.

10. Now changing /assigning ‘Secondary/Tertiary Insurance’ are supported by PrognoCIS.

Now Tertiary Insurance is allowed to assign when a patient has valid ‘Tertiary Ins’. Drop down ‘Tertiary Ins’ would be enabled on Claims >> Edit screen conditionally when valid ‘Tertiary Ins’ exists for a patient. Similarly, claims selection on EOB screen now displays three tabs on ‘claims search’ list and Tertiary Insurance is allowed to select from ‘Ter’ tab. List of Tertiary Insurance will only be displayed when patient has valid third insurance. Please refer separate document on ‘Tertiary’ to learn more details and other various relevant functionalities are described in relevant section.

Note: ‘Tertiary Insurance’ is forcefully treated as ‘carrier’ as is the case with Primary and Secondary Insurance on EOB Screen.

11. Claims >> Edit

11.1 Claims >> Edit screen layout is modified to provide new features and better usability.

Claims >> Edit Screen: The layout of the Edit screen is modified to display the fields in more orderly and relevant manner according to usability and functionality. There are few fields which have been removed and some fields whose placement is changed on the screen. Layout and functionality related changes are listed down below:

Major Change

• Claims >> Edit screen is totally grayed out once claim is Billed except drop down ‘Secondary Ins.’ and ‘Tertiary Ins.’ to enable the changing/assigning the insurances.

UI related modification

Top Frame displays following fields:

Column1	Column2	Column3	Column4
Patient	Rendering Doc	Claim ID + Reopen	ICONS(left Aligned)
DOB	Primary Ins	DOS	Amt Paid
Chart #	Secondary Ins	Post Date	Pre Auth
A/C #	Tertiary Ins	Sent Date + Batch #+ Invoice no. (Employer billing)	Status + 4 Icons**

• ‘Resp. Person’ field is relocated from the main frame and is placed on ‘I’ button.
• ‘Rendering Doc’ is relocated to ‘Column2’.
• Checkbox ‘Paper Ins Form’ relocated from main frame to lower frame and renamed as checkbox ‘Paper’.

Middle Frame:

• Middle Frame: Drop down ‘Patient SOF’ and checkbox ‘Assign Benefit check Box’ is removed.
• Checkbox ‘Bill to Employer’ provided to indicate Employer billing.
• Word ‘CAPITATION’/ ‘EMPLOYER NAME’ is displayed in red and bold font.

Lower Frame:

• Button ‘CheatSheet’ is placed on top of lower frame.
• Cross Over: Moved button ‘Cross Over’ from lower frame to middle frame next to button ‘Copy Codes’. Using the Cross Over pop up, user can cross over CPT to HCPC and vice versa too.

Functionality related modification

• Functionality assign/change ‘Secondary/Tertiary Insurance’ introduced.
• If Sec / Ter Insurance are changed after Claim is ‘Billed’, an entry is created in Track Status.
• Button 'CheatSheet' to validate claim.
• Button 'Send' to process the 'Billed' claim.
• Button 'void' to mark claims as 'void'.

Figure 11.1 – ‘Rebill’ claim displayed in modified layout of Claims >> Edit screen.

Figure 11.1.1 – ‘Rebill and Reopen’ claim along with buttons ‘send’, ‘void’ and checkbox ‘Paper’ displayed in modified layout of Claims >> Edit screen.

11.2 Provision to assign/change ‘Tertiary Ins’ on Claims screen.

Dropdown ‘Tertiary Ins’ is enabled and displays all the insurances which are associated to the patient on Patient Insurance screen. Using drop down ‘Tertiary Ins.’, ‘Tertiary Ins.’ can be associated to a claim on Claims >> Edit screen. To retain the changes, click button ‘save’ and the appropriate actions are taken to update related screens. Tertiary Insurance can be changed when claim is billed and there is no transaction for Pat Receipt or Pat W/off.  On Tertiary change, ‘Copay/Ded’ adjustment is reversed if any. The responsibility is moved to Tertiary. But Tertiary Insurance cannot be changed after ‘reopen’ as these dropdowns (Pri/Sec/Ter Insurance) would be disabled. Please refer document 'rule book for claims' to learn more about rules applicable to Tertiary Insurance.

11.3 Provision to assign/change ‘Secondary Ins’ on Claims screen.

Now PrognoCIS allows change/assign Secondary insurance to the claims once claim is ‘Billed’ even after patient payment is posted. Please refer document 'rule book for claims' to learn more about rules applicable to Secondary Insurance.

11.4 ‘I’ button: Layout of pop up ‘Additional Claim Information is modified to accommodate more info and fields.

‘I’ button Layout is modified by addition of new fields, and labels displaying CMS Cell no. and EDI loops with respect to fields have been removed but displayed as tooltip. New fields such as ‘Rendering Provider’, ‘Resp. Person Name’, ‘Last Seen by Doc’, ‘Last Seen Date’, ‘Home Care Contract Date’ and ‘CLIA#’ are displayed on spacious layout of ‘I’ button. Fields like ‘Last Seen by Doc’ and ‘Last Seen Date’ are used in Specialty Template on EMR side and mapped with testcodes. These are displayed on ‘I’ button.

Figure11.4 – ‘I’ button with modified layout and new fields.

11.5 PreAuth and CLIA related changes are implemented.

PreAuth number and CLIA number is separately displayed in separate field on ‘I’ button. Now PreAuth number is displayed in field ‘PreAuthorised Visits’ and CLIA number in field ‘CLIA#’. Earlier PreAuth number and CLIA number was displayed in same field ‘PreAuthorised Visits’.

Figure 11.5 – Separate fields for PreAuth and CLIA number on ‘I’ button.

11.6 For Capitation type claim, word ‘CAPITATION’ in bold and red font is displayed.

Capitation type claims are those claims to which Primary Insurance Type is ‘Capitation’ and in such cases, Secondary insurance is not allowed to associate to the claim. Such claims when displayed on the Claims >> Edit screen, word ‘CAPITATION’ is displayed in bold and red font. It distinctly identifies Capitation Type claim from other claim at a glance. Copay amount is allowed to enter as charge rows remains enabled in non-posted EOB. The responsibility is appropriately and accordingly created and 'Bal' amount is written off in EOB. Capitation claim is created if Ins Type code is ‘Ins. Capitation’ for selected insurance. The Name of the Ins Type is ‘Ins Capitation’. This Ins Type is added in GroupTypes : Ins Type automatically during upgrade. Users can go and customize the Name field of this entry but the code has to be fixed: ‘CAP’. Capitation claim write-off is done with specific write-off reason which has code CAP. This write-off reason is added in GroupTypes : Writeoff Reason automatically during upgrade. Users can go and customize the Name field of this entry but the code has to be fixed: ‘CAP. On Patient Account screen, word 'Cap' in bold and red color is displayed before Insurance name under section 'claims' in column 'Billed To' to notify that specific claim is 'Capitation' type claim. EOB/ERA for such Capitation Type Claims displays Capitation Insurance name in column 'Pri Ins' .

Figure11.6 – ‘Capitation’ type claim displayed on Claims >> Edit screen.

11.7 New checkbox ‘Bill to Employer’ added to support Employer Billing.

A new checkbox ‘Bill to Employer’ is added on Claims >> Edit screen. When a claim is created from encounter Assessment where ‘Enc Type’ is set as ‘Employer’ then newly created claim is used for Billing to Employer. Whenever such claims are displayed on Claims >> Edit screen, checkbox ‘Bill to Employer’ gets automatically checked and ‘Name of the Employer’ is displayed in bold and red color font to easily identify these claims. Such claims are not raised to insurance companies but invoices are raised to Employer for specified period. PrognoCIS has provided interface to raise Employer invoices and generates reports to determine Employer Outstanding Responsibility.

As soon as Employer Invoice is generated, the status of Employer Billing claim changes to ‘Billed’ from ‘Ready to Send’. Employer Billing claim would be ‘Billed’ only when Employer invoice is generated for that employer from Claims >> Emp. Invoice. Emp. Invoice no. is displayed right after 'Sent Date' field on claim in bold and black font.

For Employer Billing Claims, following checks are implemented on ‘Ready to Send’:

• Copay Amt must be zero for Bill to Employer Claim.
• Deductible Amt must be zero for Bill to Employer Claim.
• Visit Amt must be zero for Bill to Employer Claim.
• ‘I’ button: Discount Amt and % fields are disabled.
• Only Advance can be collected on Co-pay screen pop-up.
  Warning:  Even if Advance is allowed to be collected for Employer claims, it should not be collected. This Advance if collected will continue to be lying in Advance bucket till it is moved to other record of this patient for Non-Employer visits using feature: Xfer PatCredit.

 

Figure11.7 –Employer Billing claim displayed on Claims >> Edit screen.

Note: User cannot Reopen and Delete an Employer Billing Claim. A non Employer Billing claim which is billed to patient/ insurance cannot be converted to Employer’s claims once processed.

11.8 CMS Flag: Change related to ‘NDC’ code implemented.

New edit fields 'unit' and 'Admin. Qty' are added on CMS flag, CMS flag is present for charge row. For specific NDC charge codes, 'unit' and 'Admin. Qty' can be specified. These fields are also allowed to set from following screens:

• Prescription screen on EMR side in 'Dosage' field.
• From CPT/HCPC Master - New edit fields 'unit' and 'Admin. Qty' are added.
• From CMS flag for a charge code - New edit fields 'unit' and 'Admin. Qty' are added.

Values in fields like 'unit' and 'Admin. Qty' are fetched from above mentioned screen and is sent with claims to Insurance companies but according to preference set for specific screen.

Consider a scenario; the fields 'unit' and 'Admin. Qty' are set on ‘Prescription screen’, CPT/HCPC master and ‘CMS’ flag. When claim is posted along with NDC charge code, the values which were set on ‘Prescription screen’ are pulled and sent with claim whereas the values coming from CPT/HCPC master and ‘CMS’ flag are ignored. Similarly, values from CPT/HCPC master override the values set in ‘CMS’ flag when claims are posted with NDC code if there are no values entered for these fields on 'Prescription screen'.

11.9 Additional filter criteria added on button ‘Filter’.

Button ‘Filter’ invokes pop up ‘Edit Claims Filter’ which displays list of filter criteria. Depending up on filter conditions set in pop up, search list displays the claims on Claims >> Edit screen. As new features are introduced in this version, more filter criteria are added to pop up. These filter criteria are related to ‘Employer Billing’ and ‘Tertiary Responsibility’ feature. If filter condition 'Selected Ins. Responsibility' is set to 'Y' then records related to insurance selected on claims screen is retrieved.

Figure11.9 –More filter criteria on button ‘Filter’.

11.10 Button ‘CheatSheet’ implemented to carry out mentioned validations.

‘CheatSheet’ is basically cheat sheet for customized validations maintained by Clinic for various Insurances. Cheat Sheet has descriptions only. There are no validations done for these entries. Here Built in Validations checkbox is not checked. Hence they are shown as display only points so that users can look at them and make corrections manually and then process the claims. The cheat sheet points are not read by the system and no alert message is given for them. Biller can implement various validations according to the distinct requirement so that claims are not rejected by Insurance companies for stringent requirement specific to Insurance Company. Whereas ‘scrubber checks’ with Validation marked as ‘1’ and checkbox ‘Built In Validation’ checked, actual validations done by program and conditions are fulfilled, then it gives alert. Basically, ‘scrubber checks’ takes off the worries of the biller to care about claims not being rejected as the required and critical validations are carried out automatically before posting claims to the insurance companies. If validation condition becomes valid then alert message is displayed so that proper action can be taken. The ‘cheat sheet’ and ‘scrubber checks’ are readily available to any internal user of the system at any point of time from any location. Therefore, it becomes very handy for Biller to refer to the customized validations.
 The validations for ‘scrubber checks’ can be customized from Settings >> Config >> Scrubber checks. 'Scrubber checks' interface provides option to add validation conditions and display the customized error message while validations are carried out before claim is posted on ‘Ready to Send’. The sequence of execution of validations is allowed to define in Settings >> Config. >> Scrubberchecks screen in field ‘sequence’.  Similarly, the description for ‘CheatSheet’ can be added from Settings >> Config >> Scrubber checks having checkbox ‘Built In Validation’ unchecked.

Note: Scrubber checks feature is implemented for Insurance Claims only, not for 'Employer' and 'Self Pay' claims.

Figure 11.10 – Button ‘CheatSheet’ displaying cheat sheet with customized validation.

11.11 Rules laid for allowing changes to Primary / Secondary Ins and Charge row changes / Delete.

PrognoCIS now allows assigning Secondary/Tertiary Insurance even after Claim is in ‘Billed’ state. The Secondary/Tertiary Insurance List box remains enabled even when the Claim Status is ‘Billed’. All other fields are disabled. If the Secondary/Tertiary Insurance is changed, button ‘Save’ will be enabled. On button ‘Save’ click, the Secondary/Tertiary Insurance will be changed. There will be validation on ‘Save’ for all changes related to assigning and changing Sec and Tertiary Insurance as AssignSec and Change Sec feature’s fusion has been created. An alert message is displayed - ‘You are about to change the Insurance. This change cannot be reverted back. Do you want to proceed?’ with buttons ’Yes’ and ‘Cancel’. This makes it a fusion of two earlier functionalities, the Assign Secondary/Tertiary Insurance and Change Secondary/Tertiary Insurance.

11.12 New constraints implemented when claim is edited after ‘reopen’.

After Receipt / post of EOB, some users go and change the claim and mess it. The new constraints on save of a reopened claim are implemented:

• All the insurance related dropdowns are disabled and insurance change is not allowed. This ensures that user do not change Primary to Self Pay and vice versa. If that is the objective, mark the current Claim as Void.
• If there is any ‘Denied / Pending / Receipt / Write Off’ transaction against the charge row from Primary or Secondary then that charge row can’t be deleted. However the Unit, Fees, Modifiers, ICDs, DO NOT SEND flag etc can be edited except ‘Discount’ field on CMS flag. If a wrong charge code was used, it can be marked as DO NOT SEND and a new charge code can be added.
• Once Primary EOB for the charge row had made any payment then responsibility no longer remains with Primary, it moves to Secondary or Patient. So the rule is ‘If responsibility is not with Primary, charge rows Billed to Insurance cannot be edited’.
• Charge rows billed to patient is allowed to be deleted.
• Deletion of claim is not allowed.

Limitation: If claim was ‘Billed’ with Sec. Insurance. The Sec. Insurance was marked as ‘Non-Active’ and claim was reopened then it does not allow posting the claim with ‘Non-Active’ Sec. Insurance and also Insurance from reopened claim cannot be edited.

11.13 'Bill' the claims from 'Claims >> Edit' screen using new button 'send'.

Sometimes, user might want to post the claim already ‘Billed’ claim or new claim directly to insurances right from Claims >> Edit screen, a new button ‘send’ provides the similar functionality to achieve it. This button will also allow to send the Primary and Secondary EDI claims from Claims >> Edit screen along with functionality of button ‘resend’. The button ‘Send’ has replaced button ‘resend’ on claims screen which was visible once claim was ‘Billed’. All the functionality of button ‘resend’ has been incorporated along with added functionality in button ‘Send’. This button remains enabled when claim is either in ‘Ready to Send’ or ‘Billed’ state. Whenever claim either in ‘Ready to Send’ or ‘Billed’ state is sent using button ‘send’, all the validations including EDI checks are carried out on ‘save’ of the claim once it is marked as ‘Ready to Send’. For the first time, button ‘send’ simply posts the claim to EDI and thereafter pop up ‘Claims Resend Options’ is invoked which has listing related to post the claim either by printing CMS or post EDI ‘837 Professional’. According to association of Insurances with claim, options are appropriately listed on the pop up. Default option either for CMS print or EDI post depends on status of checkbox ‘Paper’. It is also possible to print CMS for EDI claims by just selecting the option from that pop up. Therefore, it now comes as an easy option to ‘Bill’ individual claim right from Claims >> Edit screen either by printing CMS or posting to EDI 837. Claims can be ‘billed’ even after these were in ‘Billed’ state.

Note: Unless secondary responsibility is created, the option to post to respective CMS/EDI is not displayed on pop up.

Figure 11.13 – New button ‘send’ on Claims >> Edit screen.

11.14 Now capability to mark ‘Billed’ claim as ‘void’.

Consider scenario, when incorrect primary insurance was associated to the claim when it was posted, Denial or may be claim needs to be ‘rebilled’ and user wishes to discard the earlier claim. To cater these scenarios, PrognoCIS has added a functionality ‘void’. The claim can be marked as ‘void’ under following conditions:

• Claim status is ‘Billed’.
• There is no EOB from Primary (except case of Denied with no further action taken.)

Button ‘void’ invokes pop up asking about confirmation for chosen option as stated below:

1. Make this claim as Void.
2. Make a copy of this claim, and make current claim void.

When claim is marked as ‘void’ then

• Balance of the claims will not be displayed on ‘AR with Insurance responsibility’ or write off should not be done.
• Entry about ‘void’ claim is however displayed on Patient Account with ‘Void’ flagged for claim and ‘Billed’ amount as zero so that it does not add to the ‘Totals’.
• The claim’s status changes to ‘void claim’ and is displayed in black and bold font.

Note: If there was an EOB with status Denied, make the subsequent action as Resolved. Then make a copy of claim if required. Button 'void' remains disabled for Employer Billing claims.

Warning: Create a copy of void claim is not allowed from claims >> New screen.

 

Figure 11.14 – Claim marked as 'void' displayed on Claims >> Edit screen.

11.15 Patient Alert is now displayed once when claim loads on claims screen.

Patient Alerts are allowed to be created /added from Appointment Scheduler, Encounter and Patient Account screens. Patient Alert is displayed on Appointment Scheduler, Encounter and Patient Account screens till now. The Patient Alert display on the mentioned screens is dependent on the parameter set in property ‘facesheet.showalert.fortypes’. When ‘PA’ is set in this property then would it display on Appointment Scheduler, Encounter and Patient Account screens. With this setting of the parameter in the property, now Patient Alert would also be displayed Claims screen in addition to earlier ones. The Patient Alert would be displayed on Claims Screen if patient has associated alert and it will be displayed only when claim loads for the first time on the screen and again when user revisits the same claim from any other screen than Claims >>Edit screen.  The icon ‘Patient Alert’ has red tick marked in case patient associated to claim has alert.

11.16 Ability to send Group NPI in Cell24J of CMS1500.

Sometimes, certain insurances require Group NPI instead of individual NPI sent along with Claims posted. As a work around to entertain this ability to send Group NPI, new checkbox ‘Organization’ on Provider Master (Settings>>Configuration>>Medics>>Provider) is added. In order to send Group NPI, create an additional provider on provider master. Enter the first and last name by dividing the name of the organization. Remember that last name is displayed first while provider is searched using search list. Mandatory details required on Provider screen for the organization are:

• Enter ‘Group NPI’ of the organization in field ‘NPI’.

• Enter other details like Tax Id, Taxonomy Code of the rendering provider.

On Claims>> Edit screen, for the specific insurance which needs Group NPI in Cell24J, ensure following details on ‘I’ button:

• Select ‘Rendering Provider’ as group’s name as entered in Provider Master.

• Choose ‘Billing Provider’ as ‘Business Unit’ otherwise claim will not be allowed to post. The proper error message is displayed – ‘Select Business Unit, if ‘Billing Provider’ = Organization’. Claim is not allowed to post till corrections are done.

After checking ‘Ready to Send’ and saving the claim, the claim gets ‘Billed’. The information about ‘Group NPI’ is sent to Cell24J of CMS1500. User can print CMS1500 form using button ‘print’.

Figure 11.16.1 – Group NPI in field ‘NPI’ and checkbox ‘organization’ checked on Provider Master.

Figure 11.16.2 – Field ‘Rendering Provider’ and drop down ‘Billing Provider’ on ‘I‘ button of Claims >> Edit screen.

Figure 11.16.3 – Group NPI printed on CMS1500 in Cell24J.

Note: Group NPI is sent in corresponding EDI loop for EDI claims

11.17 Generalized style tags introduced to print Paid and Balance Amount in Cell29 and Cell30.

With the introduction of Tertiary Insurance in PrognoCIS, CMS1500 templates are modified to print the ‘Paid’ and ‘Balance’ amount in Cell29 and Cell30. These tags are commonly used for printing amounts for Primary/Secondary/Tertiary Insurance. The Paid and Balance amount is printed appropriately for the option chosen to print the CMS1500 for specific insurance assigned to that claim. For example: When user selects to print CMS1500 for Tertiary Insurance once EOB is received for it then it will consider all relevant amounts to calculate the ‘Total Paid’ amount from Primary Insurance till Tertiary Insurance. Generation of output will differ when

• Claim is posted but EOB is not received.
• Claim is posted and EOB is received.

There are four style tags to cater these requirements:

• _CELL2930_STYLE_PA_ : This tag prints latest current amount for the insurance. ‘Adjust’ amount is also considered while calculating the total.
  • Pri Paid + Adj for PriCMS – CMS for Primary Insurance
  • Pri Paid + Adj + Sec Paid for Sec CMS – CMS for Secondary Insurance
  • Pri Paid + Adj + Sec Paid + Ter Paid for Ter CMS – CMS for Tertiary Insurance
• _CELL2930_STYLE_OA_: This tag does not consider ‘Paid’ amount of specific insurance for which would be printed CMS.
  • 0 for Pri CMS – CMS for Primary Insurance
  • Pri Paid + Adj for SecCMS – CMS for Secondary Insurance
  • Pri Paid + Adj + Sec Paid for TerCMS – CMS for Tertiary Insurance
• _CELL2930_STYLE_PN_: This tag does not consider ‘Adjust’ amount but prints latest amounts.
  • Pri Paid for PriCMS – CMS for Primary Insurance
  • Pri Paid + Sec Paid for Sec CMS – CMS for Secondary Insurance
  • Pri Paid + Sec Paid + Ter Paid for Ter CMS – CMS for Tertiary Insurance
• _CELL2930_STYLE_ON__: This tag does not consider ‘Adjust’ amount. It also ignores ‘Paid’ amount of insurance for which CMS would be printed.
  • 0 for Pri CMS – CMS for Primary Insurance
  • Pri Paid for SecCMS – CMS for Secondary Insurance
  • Pri Paid + Sec Paid for TerCMS – CMS for Tertiary Insurance

For better understanding about usage of above tags in Cell29 and Cell30 of CMS 1500, example is illustrated below:

Details about EOB received from Insurance

Insurance	Bill	Adjust	Allowed	Paid	Bal (Next Resp.)
Primary	100	10	90	60	30
Secondary	100		30	20	10
Tertiary	100		10	7	3

CMS 1500 Output using different tags in Cell29 and Cell30 for selected Insurance

Tag	Output For Primary – After EOB Received			Output For Secondary – After EOB Received		Output For Tertiary – After EOB Received
	Bill	Paid(Cell29)	Bal(Cell30)	Paid(Cell29)	Bal(Cell30)		Paid(Cell29)	Bal(Cell30)
_CELL2930_STYLE_PA_	100	60+10=70	30	10+60+20=90	10		97	3
_CELL2930_STYLE_OA_	100	0	100	70	30		90	10
_CELL2930_STYLE_PN_	100	60	40	80	10		87	3
_CELL2930_STYLE_ON_	100	0	100	60	30		80	10

The total of ‘Paid’ and ‘Balance’ amount displayed in Cell29 and Cell30 respectively are dependent on property ‘cms.page.totals’. When property is set to ‘Y’ then page wise total amount is displayed otherwise cumulative total is displayed on each page if there are number of pages in CMS1500.

11.18 Ability to pick up appropriate ICD codes for charge codes when numbers like 1,2,3 entered to associate ICD codes.

Claims >> Edit: Enter numbers like 1,2,3,4 for associating ICD codes to charge codes in a claim and system will pick up appropriate ICD codes from the ICD codes present at claims level on Claim >> Edit screen.

Figure 11.18 – Enter 1,2,3 for ICD codes and system picks up appropriate ICD codes for charge codes after save on  Claims >> Edit screen.

 

12. Claims >> Send Claims

12.1 New tab ‘Ter-CMS’ added to support Tertiary claims.

Tertiary claims are now supported in PrognoCIS. The status of posted Tertiary claims are visible on Claims >> Send Claims screen in ‘Ter-CMS’ tab. These Tertiary paper claims are posted to the Insurance Companies after button 'process' is clicked.

Figure12.1 –'Ter-CMS' tab on Send Claims screen.

12.2 More validations related to Claim EDI readiness implemented on ‘Send Claims’ screen.

Claims >> Send Claims: PrognoCIS has included more validations for checking the EDI readiness of the claims being posted to insurances. When posted claim does not pass the validation incorporated on Send Claims screen, the claim is not allowed to post. The corresponding EDI readiness status is displayed against such claims in appropriate Pri-EDI/Sec-EDI/Pri-CMS/Sec-CMS/Ter-CMS buckets. Newly added validations are ‘136’ to ‘144’. These validations are related to PO Address and Subscriber Address for Pri, Sec, Ter Insurances, and select ‘Business Unit’ when Billing Provider is Organization etc.  Refer the screen shot below which displays new validations included on the pop ‘EDI Readiness Status Legends’ invoked by clicking button ‘legends’.

Figure12.2 –More EDI Readiness Status Legends on Send Claims screen.

13. Claims >> Send UB04

13.1 Institutional EDI claims can now be sent electronically.

Now UB04 claims where EDI enabled Insurances are associated to claims are allowed to send as EDI 837I from Send UB04 claims screen. Therefore on Send UB04 Claims Screen>> Pri-EDI and Sec-EDI buckets are enabled which displays all institutional claims to be processed as EDI and on click of button ‘process’, are sent as EDI 837I claims. These are basic functionalities provided for UB04 institutional claims and enhancements related to it would be ongoing process.

14. Claims >> Returned

14.1 New status legend ‘51’ added to track status.

Many a times, it happens that Claims rejected/ returned in EOB received from Clearinghouse or Insurance Company remain unattended in Claims >> Returned screen as required attention is not given to such claims. Sometimes, Biller prefers to directly access website of respective Clearinghouse or Insurance Company to carry out corrections in the claims returned by Clearinghouse or Insurance Company. Therefore, stock of returned claims keep on increasing on Claims >> Returned screen at PrognoCIS level. PrognoCIS has now incorporated a new legend in the Track Status of Claims >> Returned screen where in system will track such EOB received which are returned by Clearinghouse or Insurance Company. When system finds that EOB is returned then it will automatically remove the claims from Claims >> Returned screen and track status will be updated with legend ‘51’ along with comments and name of the insurance company.

15. Claims >> Emp Invoice

15.1 New menu option ‘Emp Invoice’ introduced to support Employer Billing.

A new menu option ‘Claims >> Emp Invoice’ has been introduced to generate Employer Invoices. Generally, the Employer is billed not for individual claim for each employee but by generating an invoice every month. There can be various types of visits like Fire Fighter Physical, Audio, DOT, PPD for which multiple patients were seen. For each such type of visit for each employer, one Invoice has to be generated. For ex: If Employer A sends employees for 8 types of visits in a month, there have to be 8 Invoices generated for that employer. In PrognoCIS, these visit types are defined as Encounter types. Since each claim is associated to one Encounter type, as soon as Enc type based invoices are generated, all unprocessed claims which are marked as ‘Ready to Send’ are automatically considered for Invoice for that Enc Type, automatically get marked as ‘Billed’ and the Invoice Number gets automatically assigned to the claim. Each Invoice Number has a prefix of code of Enc Type for which it is created.

Note: Once a claim is marked ‘Billed’, and Invoice number is associated to it, that claim will never be considered again in any Invoice for the same employer for the same Enc Type for the qualified Date Range.

 

 

 

 

 

 

 

Figure 15.1– New menu option ‘Emp Invoice’ under Claims >> Edit.

Figure 15.1.1– Employer Invoice generated using Emp. Invoice menu option.

16. Claims >> Returned

16.1Claims Entry automatically gets removed when returned claim payment is received.

When the returned claim’s payment is received (and posted), that claim entry goes away from Claims>Returned screen’.

 

16. Claims >> Outstanding

16.1 Layout is modified with extra columns to display ‘Denied’ and ‘Last EOB Dt.’.

Claims >> Outstanding screen: It lists those unpaid claims against which remittance is not yet received. On this screen, two more columns are added. These columns are ‘Denied’ and ‘Last EOB date’. The column ‘Denied’ will show number of denied charge codes in EOB sent by Insurance Company for which is still unpaid and column ‘Last EOB Dt.’ will display last date of remittance received against such claims. Data under column ‘Denied’ i.e. no. of denied charge code is hyperlinked which displays details like ‘Claim Id’,  ‘Code’, ‘Status’ , ‘reason’, ‘Action’, ‘Amount’, and ‘Action Taken’ for denied charge code.

Figure 16.1 – New columns ‘Denied’ and ‘Last EOB Dt.’ added on ‘Outstanding’ screen.

16.2 Button ‘Claim Ledger’ added on screen ‘Outstanding’.

A new button ‘Claim Ledger’ is now provided on ‘Outstanding’ screen to show the details of the claim selected on the screen. When button ‘Claim Ledger’ is invoked for a selected claim on ‘Outstanding’ screen, pop up ‘Claim Ledger’ is displayed. Pop up ‘Claim Ledger’ displays the charge code wise outstanding ‘payment against claim’ in a tabular format. Therefore, biller can preview and analyze outstanding payment pending from Insurance Company against each charge code.User can even print claim details from this pop up. Button ‘print’ will open print dialog which shows list of printers attached to the computer to choose and after selecting the printer and clicking Ok, it would print the document on selected printer. It could be document writer option like One Note.Button ‘Patient Ledger’ has been removed from here as ‘Claim Ledger’ details are more relevant on this screen. Claim ledger plays important while AR calling feature is used by support to provide outstanding claims details.

Figure 16.2 – Button ‘Claim Ledger’ added on ‘Outstanding’ screen.

16.3 More filter criteria introduced in button ‘Filter’.

Few more filter conditions are added on pop up ‘Outstanding Filter’ to support the new features like ‘Employer Billing’ and ‘Tertiary Insurance’ in PrognoCIS.
Limitation:Field 'Denied' is not included as filter condition because data displayed is computed field at run time.

Figure 16.3 – New filter conditions added on pop up ‘Outstanding Filter’.

17. Remittance >> EOB/ERA

17.1 Multiple Feature and UI related changes on layout of ‘EOB’ screen.

Many changes have been incorporated on EOB screen which are as follows:

• Checkbox ‘Ready to Post’ on EOB screen has been relocated to match the placement with the ready to Send checkbox on claim screen. ‘Ready to Post’ moved to lower right of the lower frame.
• ‘AllocateAmt’ in Claims table is now hyperlinked and displays the pop-up which was shown when button ‘Claim Amt’ is clicked. Button ‘Claim Amt’ is now removed.
  • A pop-up ‘Allocation Summary’ for Allocated Amt hyperlink is displayed with following fields:
    * Edit field: ‘Check Amt’
    * Edit field: Ext Claims Payment(‘Paid Amt’ for Non PrognoCIS claims.)
    * Edit field: Ext Recoup(‘Recoup Amt’ for Non PrognoCIS Claims)

* Edit field: Recoup Amt(For PrognoCIS Recoup done in this EOB)* Edit field: Total Available Amt(Check Amt –Ext Paid+Ext Recoup+Prog Recoup)
* Edit field: Current Allocated Amt(For Allocation done to claims in this EOB)
* Edit field: Current Remaining Amt(Remaining Amt from Available Amt after Current Allocated Amt)

• Hyperlinked 'Remaining Amt' displays pop up 'For Remittance'. User can assign 'Location', 'Business Unit', 'Rendering Doc', 'Attending Doc' and 'Insurance' to specify particular details about insurance in the claims as 'Payor' field treats 'Payor' as 'carrier' only.
• Name of Capitation Claims in EOB is displayed under 'Pri. Ins' column in bold and black color to distinguish from rest of the claims in the EOB. Text 'CAPITATION' is written in bold and red color on upper left side of middle frame.
• In Charge details table, the header displays next responsible appropriately as per Insurance selected in ‘Paid As’ drop down.
• Write Off reason for capitation claim is displayed appropriately as 'CAPITATION Write off' for capitation type claim in EOB as 'Bal' is automatically written Off.
• Patient tooltip now displays ‘DOB’ and ‘Financial Class’ of the patient on mouse move over.
• Hyperlink ‘Allocate Amt’ renamed as ‘Allocated’.
• The recouped claims are displayed completely in bold and red color in EOB.
• ‘Pending’ reason is removed from ‘Status’ list box displayed in lower frame.
• Status ‘Approve’ reason is changed to ‘Approved’ ‘Status’ list box.
• Status ‘Reason’ reason is changed to ‘Denied’ ‘Status’ list box.
• Button ‘PatIns’ and ‘SecIns’ are now hidden.
• Single Claim Edit feature is not supported in Build V2B8.

Figure 17.1 – Modified layout of EOB/ERA screen.

17.2 Label ‘Insurance’ renamed as ‘Payor’ as soon as EOB is saved.

Label ‘insurance’ on screen ‘EOB/ERA’ is renamed as ‘Payor’ as this term is more relevant and obvious for EOB/ERA screen. ‘EOB/ERA’ is created to prepare the remittances against payment received from Insurances for claims. The Insurance Companies are ‘Payor’ in actual terms and hence the renaming of the label ‘Insurance’ to ‘Payor’. In a newly created EOB, now button ‘save’ remains enabled even without filling ‘Payor’ field. As soon as user tabs out of the field ‘Claim’ after entering claim Id, the claim is populated in the middle frame and along with appropriate ‘Paid As’ according to current responsibility in the claim. In such cases when claim is selected prior to ‘Payor’ then ‘Payor’ field displays the name of the Payor which has current responsibility. Now newly created EOB can be saved even without 'Payor' name.
Earlier it was mandatory to select ‘Payor’ before saving the record otherwise button ‘save’ used to remain disabled. Also when user used to tab out from Claim Id, ‘Primary Duplicate’ was created as it used to consider that current responsibility was with Primary. Now, to create ‘Primary Duplicate’, user has to explicitly change ‘Paid As’ to ‘Pri’.

Note:Selected ‘Payor’ is forcefully treated as ‘carrier’ only. All relevant screens label ‘insurance’ has been renamed as ‘Payor’ and are treated as ‘carrier’ only.

Figure 17.2 – Label ‘Insurance’ renamed to ‘Payor’.

17.3 ‘Payor’ is always treated as ‘carrier’.

Now ‘Payor’ is always treated as ‘carrier’ on EOB screen. Although the Auto Complete edit control works as earlier, user can select an Insurance name or type in any other. On tab out no questions are asked, and even if an existing Insurance name was selected it is treated as a Carrier.

17.4 Balance is automatically written off when Capitation type claim is selected in EOB.

When the Selected Claim in EOB is a ‘Capitation Claim’, ‘Bal’ is automatically written off by the system smartly against charge codes. The ‘Bal’ amount is displayed in the red color and strikethrough indicating that amount has been written off. When ‘Copay’ is collected for the claim, then it is assigned to ‘Copay’ bucket on charge line and only ‘Bal’ is ‘written Off’. The charge row remains enabled till EOB is posted to allow editing of charge row. Sometimes, it might so happen that in EOB received from Insurance Companies amounts in ‘Copay’ ‘Deduct’ etc. columns need to be modified.

Figure 17.4 – ‘Bal’ amount is smartly written off for Capitation type claims in EOB.

17.5 New icon ‘Patient Detail’ added to access patient registration screen from EOB screen.

A new icon 'Patient Detail' is now provided on 'EOB/ERA' screen. When icon 'Patient Detail' is invoked, the details of the patient associated to selected claim on EOB/ERA screen is displayed in the pop up ‘Patient Registration Information’. From ‘EOB/RA’ screen, user can edit the details of the patient and save the edited information about patient without leaving the screen.

Figure 17.5 – ‘Patient Registration Detail’ on ‘EOB/ERA’ screen displaying details of the patient.

17.6 Button ‘Claim Ledger’ is added to display claim details on EOB screen.

A new button ‘Claim Ledger’ is now provided on ‘EOB/ERA ‘screen to show the details of the claim selected on the screen. When button ‘Claim Ledger’ is invoked on ‘EOB/ERA’ screen, pop up ‘Claim Ledger’ is displayed. Pop up ‘Claim Ledger’ displays payments for all the charge code(s) wise for all claims included in EOB. It is displayed in a tabular format. Therefore, biller can preview individual payment received against each charge code in an EOB from Insurance Company. User can even print claim details from this pop up. Button ‘print’ will open print dialog which shows list of printers attached to the computer to choose and after selecting the printer and clicking Ok, it would print the document on selected printer. It could be document writer option like One Note.

Figure 17.6 – Pop up ‘Claim Ledger’ displaying charge code wise payment details on ‘EOB/ERA’ screen.

17.7 Pop up ‘Claim Search’ has new tab for searching Tertiary Claims.

On EOB/ERA screen, ‘claim’ search binocular displays list of Outstanding Claims pertaining to the selected Insurance. Now this ‘claims search’ has new tab ‘Ter’ in addition to ‘Pri’ and ‘Sec’ tabs. ‘Ter’ tab will display list of claims having Tertiary Insurance responsibility.

Figure 17.7 – ‘Ter’ tab on pop up ‘claims search’ in EOB/ERA’ screen.

17.8 Text in label ‘Recoup Claims’ changed to ‘Recoup’.

Label ‘Recoup Claims’ is now renamed as ‘Recoup’ to accommodate more actions related to remittance and obviously making way for provision to more functionality.

Figure 17.8 – Label ‘Recoup Claims’ renamed to ‘Recoup’ in EOB/ERA’ screen.

17.9 Now hyperlinked ‘Allocated Amt’ will display ‘Paid Amt $’ and ‘Recoup Amt $’ for ‘Non PrognoCIS amounts’.

'Allocated Amt' is now hyperlinked. It is used to display ‘Paid Amt (paid)’ and ‘Recouped Amt’ of Non-PrognoCIS Claims. Non-PrognoCIS Claims means the claims which were earlier posted by end user by other software but has now received remittances for such claims when end user started using PrognoCIS. To keep track of such amounts received for Non-PrognoCIS Claims in a remittance, ‘Allocated Amt’ is now hyperlinked. Hyperlinked ‘Allocated Amt’ invokes pop up ‘Allocation Summary’ where end user can enter the amounts like ‘Ext. Claims Payment $’ and ‘Ext. Recoup Amt $’ for such claims. List of ‘Allocated Amt’ Non-PrognoCIS Claims can be seen from hyperlink ‘Instrument#’. The hyperlink ‘Instrument#’ will display list of claims posted from PrognoCIS and posted by other software along with ‘Allocated Amt. Therefore, hyperlink ‘Instrument#’ gives clear picture whether claims received in ERA were posted from PrognoCIS or other software. There are various fields on pop up ‘Allocation Summary’ which are used to calculate ‘Total Available Amt $’ and ‘Remaining Amt $’. These amounts are calculated as follows:
‘Total Available Amt $’ = Check Amt $ + Ext. Recoup Amt $ + Recoup Amt $ - Ext Claims Payment $
‘Current Remaining Amt $’ = ‘Total Available Amt $’ – Current Allocated $

Figure 17.9 – Hyperlinked 'Allocated Amt’ in EOB/ERA’ screen.

17.10 Now hyperlinked ‘Remaining Amt’ used for ‘Move to / Used from Advance’.

As field ‘Payor’ accepts carrier only, in order to use ‘Move to/ Used from Advance’ feature, name of the specific insurance is must so that amount can be used / moved to ‘Advance’ bucket of the insurance associated to claim in EOB. A provision has been made to specify precise details about claims to use this feature using hyperlinked ‘Remaining Amt’. The details like ‘Location’, ‘Business Unit’, ‘Rendering Provider’, ‘Attending Provider’ and ‘Insurance’ are essentially required to be filled in. These details are later used for generating reports as well. According to value set in property ‘era.remittance.useadvance’, the ‘Remaining Amt’ is moved ‘to/from’ in the advance bucket of the insurance depending up on positive/negative ‘Remaining Amt’.

Figure 17.10 – Pop up ‘Remaining Amt’ on EOB/ERA screen.

17.11 Column ‘Del’ is now renamed to ‘Act’ in middle frame.

Column ‘Del’ is now renamed as ‘Act’. Column ‘Act’ is displayed in the table which shows number of claims in the middle frame associated to remittance. When a claim is selected, icon is displayed. Depending up on status of remittance, the action of this icon is decided. When remittance is in ‘Entered’ state, user can delete the selected claim in the remittance. When remittance(s) is in ‘Posted’ state, same icon is used for ‘Single Claim Edit’ functionality.

Figure 17.11 – Column ‘Act’ in EOB/ERA’ screen.

17.12 New column ‘Ter Ins’ introduced in middle frame.

New column ‘Ter Ins’ has been introduced in table in the middle frame. This column will display the name of the Tertiary Insurance if Tertiary Insurance is associated the claim.

Figure 17.12 – Column ‘Ter Ins’ included showing tertiary detail in EOB/ERA’ screen.

17.13 Checkbox under column ‘Sec’ is now replaced by dropdown list for ‘EOB from Sec Ins.’.

The checkbox 'Sec' is now replaced by drop down 'EOB from Sec Ins.' which shows who has paid for the EOB with the help of 'Paid As' dropdown selection and appropriately the corresponding Insurance is highlighted and allowed amts are brought over.

Figure 17.13 – ‘Paid As’ drop down in EOB/ERA’ screen.

17.14 New columns ‘Cur. Bal’ and ‘Cur. Resp.’ for charge row details introduced.

New columns are added under charge line description table which adds to user friendliness. Those columns are ‘Cur Bal’ and ‘Cur Resp.’. These columns will provide additional information like current responsibility assigned to for the charge code and amount which has to be paid by responsible party.

Figure 17.14 – New columns like ‘Cur. Bal’ and ‘Cur. Resp.’ added in Charge line on EOB screen.

17.15 New feature ‘Partial Recoup’ implemented in the system.

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’ partially of a single line item, allow recouping partial ‘paid amount’ + Excess Amount of a single line item from multiple charge lines of a claim now. There is no way to recoup only ‘Paid Amount (Without Excess).

Note: Partially recouped claims in EOB are displayed completely in bold and red color in middle frame of EOB.Limitation: '$0' recoup will not be supported because of Partial Recoup Support.

Figure 17.15 – Partial Recoup feature displayed on EOB screen.

17.16Now pop up for ‘Approved’ and ‘Denied’ reasons are separated.

Pop up for ‘Approved’ and ‘Denied’ reasons are now separated which is invoked on click according to the reason selected in the status list box. This has resulted in proper and logical grouping of the functionality supporting ‘Approved’ / ‘Denied’ reasons. Thereby, now its usage is much simplified and factors adding to confusion are almost removed. Option ‘pending’ is removed from the dropdown ‘Status’.

Figure 17.16 – Different pop up ‘Payment Status’ for ‘Approved’ and ‘Denied’ reasons.

17.17 Hyperlinked ‘Allocate’ invokes pop up ‘Claims in Eob’, appropriately displays Pri/Sec/Ter Ins in column ‘Paid As’.

Hyperlinked ‘Allocate’ invokes pop up ‘Claims in Eob’. This pop up displays details of claims which are present in an EOB received. Column ‘Paid As’ now displays PRI/SEC/TER appropriately for the EOB paid by insurance. For example, if EOB is paid by Primary Insurance then ‘PRI’ is displayed under ‘Paid As’. Column ‘Recoup’ displays ‘YES’ for recouped claim otherwise it displays ‘Blank’. Earlier it used to display ‘0/1’ which was confusing for user to conclude the status of it.

Figure 17.17 – Pop up ‘Claims in Eob’ displayed on clicking hyperlink ‘Allocated’.

17.18 Format of ELE received from clearinghouse is changed for better readability.

Electronic remittances (ELE) received from some of the clearinghouses (Gateway) are not readable and understood by human. Normally single ELE contains the details of three claims and to parse out details of each claim was very difficult. Now PrognoCIS has changed the format of ELE received. The format of the ELE is changed while ELE are being processed by PrognoCIS and it can be downloaded using button ‘View_Attachment’.

Figure 16.18 – More readable ELE format for the received ELE from clearinghouse.

17.19 ERA reason codes interpreted for each charge code and appropriate action is taken.

Till now, ELE status change was done at Claim Level. At charge code level there was no ‘Status’ change done even if ELE was sent with appropriate ‘Reason codes’. For Ex: In a Claim if one charge code status came from Insurance as ‘Denied’ and one was ‘Approved’, our system did not mark the ‘Denied’ charge code as ‘Denied’. If all the charge codes from that Claim were ‘Denied’, only then were the individual charge codes marked as ‘Denied’.Same way, there are 1000’s of reason codes valid for each charge code. Our system was reading only CO-45 and considering it as Acceptance and considering the unallocated amt as Adjustment instead of dumping it as ‘Unapplied’ amt. Now, out of these 1000’s of reason codes, there are 60 to 70 relevant reason codes selected which are critical and they will be read and interpreted and appropriately the data will be populated, actions will be taken for each charge code.For Ex: Code CO-A2, PR-B13, P1-B22 will be appropriately parsed as ‘Approved’ and unallocated amt will be properly put as ‘Ins Adjustment’ amount instead of ‘Not Covered’.Ex2: Code…. If associated to a charge code, it means bill patient ‘Directly’, so the amounts will be appropriately added as ‘Not Covered’ and ‘BPD’ will be marked on that charge row so that even if there is secondary ins, the amount will be billed to patient directly.Ex3: If the reason code is for Status Denied, the charge code will be marked as ‘Denied’ and appropriate Denial Reason will also be populated.

17.20 Property ‘era.validate.conditions' will now have one more parameter ‘V’ appended for ‘void’ claims in EOB.

Property  ’era.validate.conditions’ will now have one more parameter 'V' appended. This parameter if set and If there is a claim whose Primary EOB is in entered status(not posted), and that claim is now marked Void,  and then EOB is posted, an appropriate message will be given on post of EOB not allowing to post the EOB till that claim is removed from the EOB. At the same time, header of the EOB displays message ‘Cannot Post with Void Claims’ in red font.

Figure 17.20 – Error message displayed EOB screen when ‘era.validate.condition’= ‘V’ turns valid.

18. Remittance >> Denied

18.1 Menu name changed to ‘Denied’ from ‘Denied/Pending’.

Remittance >> Denied/Pending: The menu name under ‘Remittance’ tab is now changed to ‘Denied’ so that it becomes pretty obvious to users by reading menu name that what screen is all about.

19. Remittance >> Pat Receipts

19.1 New drop down list ‘Received From’ to ascertain ‘Patient/Guarantor/Other’.

Patient receipts are payment received either from Patient/Guarantor/ Other. A new drop down list is added on Patient Receipt screen which has three options to choose from. These are–

• Patient
• Guarantor
• Other

Enter the name for the option selected in text field ‘Name’ either using auto complete feature or search binocular. If there is a claim in the detail row of the patient receipt then user cannot change options in ‘Received From’ list box and ‘Name’ text box as these are grayed out.
User can create patient receipts which can be paid or received from any option chosen from drop down list. It has now added flexibility to receive amount from ‘Resp. Person/Other’ in addition to patients themselves.
If Remaining Amt is non zero on ‘Post’, ‘Move to Advance / Use from Advance’ is applicable for only Patient but for ‘Guarantor / Other’ an error is raised.Name of the label ‘Patient Balance’ and ‘Advance’ is changed according to selection in ‘Received from’ :

Option in List box ‘Received From’	Current/Renamed label name – Patient Balance	Current/Renamed to label name - Advance
Patient	Patient Balance/ Patient Balance	Advance/Advance
Guarantor	Patient Balance/ Resp. Person Balance	Advance/ NA
Other	Patient Balance/NA	Advance/ NA

Note1: Patient Receipt does note allow moved to/ used from Advance for other/Guarantor.

Note2: When Remaining Amount for Guarantor/Other in Patient Receipt is zero then error message is displayed. Error message - 'Remaining Amount cannot be 'zero for Guarantor/Other'.

Note3: Patient Balance must be greater than zero for claims search.

Figure 19.1 – Newly added ‘Received From’ drop down list.

19.2 New edit field ‘Name’ added with auto complete and search feature.

New edit field ‘Name’ has been provided to enter the name of the person from whom amount is being ‘Received From’. This edit field has auto complete feature as well as search binocular option. The ‘Name’ field will display list of persons according to the selection in drop down list ‘Received From’. For example, if ‘Resp. Person’ is selected in drop down ‘Received From’ then search list will populate only responsible persons available in the system.

Figure 19.2 – Newly added edit Field ‘Name’ on Patient Receipt screen.

20. Remittance >> Emp Receipts

20.1New menu option ‘Emp Receipts’ added.

Remittance >> Emp Receipts: Once the Invoices for a period are sent to an employer, the employer generally pays in full for that Invoice. Employer may or may not send the detailed split per claim per charge code. Hence, PrognoCIS takes care of automatically allocating the check amount to all charge codes of the paid invoice. There is a new menu option added in PrognoCIS to process Employer receipts or payments called ‘Remittance>Emp Receipt’. Please refer separate document on ‘Employer Billing’ for more details and other various relevant functionalities are described in relevant section.

Figure 20.1– New menu option ‘Emp Receipts’ under Remittance.

20.2 Search icon ‘Select Invoices’ added to select invoices from search list.

Binocular search icon is added on screen ‘Emp. Receipts’ which allows selection of invoices which was raised against Employer to receive amount receivable from Employer. The amounts are apportioned to selected claims and even if the amount available for assignment is exhausted, all the remaining claims / charge rows from selected invoices will be displayed with zero paid amount. If there is a claim in the detail row, user cannot change the ‘Received From’ list box and text box options. Since the billing to each employer is Invoice based, the payments are received from Employer per Invoice. Button ‘save’ must be clicked to enable the binocular ‘Select Invoice’.  The Select Invoice search shows all the Invoices for which the payment is still outstanding. Even if the partial payment has been received for some claims and some charge codes of an Invoice, it will still be listed. The details shown are Invoice number, Invoice Date, Enc Type, Billed Amount and Balance Amount. As soon as an Invoice is selected, all the claims from that Invoice are displayed in ascending order and the check amount is automatically allocated to each claim equal to the Billed Amount. Please refer separate document on ‘Employer Billing’ for more details and other various relevant functionalities are described in relevant section.

Figure 20.2– Search binocular to select invoices for Emp. Receipts.

20.3 Auto allocation of claims in 'Emp Receipts' for selected Employer Invoice No.

When Employer invoices are selected using ‘Select Invoices’ binocular icon, the claims included in those invoices are automatically selected in Employer receipts for the employer which is selected in field 'Employer' .

21. Remittance >> Ins./Pat. Refund

21.1 Ins./Pat. Refund is not allowed to post when ‘Advance’ amount is less than Ins./Pat. Refund amount.

Remittance >> Ins. / Pat. Refund: Insurance or Patient Refund is not allowed to post if ‘Advance’ available amount is less than ‘Refund’ amount.

22. Reports

22.1 New ‘Pre-defined’ amounts fields added to generate detailed reports.

With the introduction of Tertiary insurance, the original Amounts is kept as it is and have added/squeezed in new Amount fields for Ex: for Tertiary.
The newly added pre-defined amounts are:

• 111- For Emp Billing
• 518 - No of Encounters
• 519 - No of Appointments
• 520 - No of Cancellations
• 521 - No of No Shows
• 208 – Ter Remittance
• 209 - Ter Duplicate Remittances
• 210 - Ter Excess Remittances ADD+EXCESS?
• 211 - Ter on Hold
• 257 - Ter Normal and Additional Recoup
• 258 - Ter Duplicate Recoup
• 259 - Ter Excess Recoup
• 277 - Ter Normal and Additional Recoup
• 278 -
• 279 -
• 357 -
• 414 - Moved to Advance
• 415 - Used from Advance
• 416 - Ins WO in Ter Remittance
• 417 - Ins WO in Ter Remittance Recoup
• 418 - Ins WO Vouchers Ter
• 430 - Employer WO Receipt

23. Reports >> Statement

23.1 Insurance name and plan type of ERA received is now prefixed to display on Patient Statement.

Now Patient Statement also prints prefix like ‘Pri/Sec/Ter’ from 'Paid As' field on EOB screen along with the name of Primary/Secondary or Tertiary insurance accordingly and appropriately. Therefore, now Patient Statement provides complete information about Patient details in terms of ERA received.

Figure 23.1– Primary/Secondary/Tertiary Insurance displayed for ERA received on Patient Statement.

23.2 Secondary/Tertiary Responsibility is displayed clearly on Patient Statement.

Changes have been incorporated to show the Secondary/Tertiary Responsibility on Patient Statement.

23.3 Statement for Resp. Person is allowed to print for ‘Charge code wise’ option as per workflow.

Statement for 'Resp. Person' can be generated for charge code wise option only according to PrognoCIS workflow. When option 'Resp. Person' is chosen, option for statement format is by default selected as 'Charge Code wise' and option 'Claim wise' is grayed out. The new template 'Resp. person statement type 3 - STRIB3' is added to print the statement for ‘Resp. Person' through upgrade process.

Note: Text label for Field ‘Outstanding amount more than’ changed to ‘Min. Outstanding Amt’

Figure 23.3– Pop up Statement for printing 'Charge Code wise' statement for Resp. Person.

23.4 Patient statement allows printing of Opening Bal. and related claim transactions in statement.

Reports >> Statement: Sometimes user wants to view the outstanding amount which could not be displayed in the bulk statement as Bulk statement is generated for 365 days only. In case, user wants to find out opening balance for the last month and all those claims involved in the transaction resulted in last month’s opening balance. Two new radio buttons ‘Print Ope Bal’ and ‘Ope Claim Details’ comes as rescue tool. User can generate patient statement to print opening balance of claims that are outstanding for a patient as on date selected. Radio button ‘Print Ope Bal’ will print opening outstanding balance as on date selected in single line. When radio button ‘Ope Claim Details’ is selected, statement will be generated having opening balance and also claims related to transactions for that opening balance. According to value defined in property 'statement2.donotuse.opening.balance', radio button ‘Print Ope Bal’/ ‘Ope Claim Details’ is by default selected. Default value is 'N' and radio button ‘Print Ope Bal'.

Figure 23.4– New radio button to print opening balance and claims involved in transactions.

24.Reports >> Tabular

24.1 Three new tabular reports related to ‘Capitation’ are added to the system.

PrognoCIS has added capability to generate tabular reports for ‘Capitation’ type claims as these ‘Capitation’ type claims are now supported by PrognoCIS. The ‘option name’ and ‘code’ used in the system for these three reports are as follows:

Figure 24.1– Options for Capitation reports in Tabular Reports search list.

1. CAP01 - Capitation Amt distribution per charge code –computed: It is the consolidated summary report for the capitation amount distribution for all capitation claims for selected date range for all providers and grouped by Insurance Company. This report computes the payment for each charge code of a capitation claim based on Medicare Allowed Amt and monthly capitation receipt.

Figure 24.1.1– Tabular Report for Capitation:  CAP01 - Capitation Amt distribution per charge code.

2. CAP02 - Capitation Amt distribution per Attending Doc- It computes the amount to be paid for each charge code of a capitation claim for an attending doctor based on the percentage of Medicare contracted with him. The attending doctor could be any internal doc or outside provider defined as referring doctor and associated to capitation claim. This report is grouped by claims for the selected Attending Doc.

Figure 24.1.2– Tabular Report for Capitation:  CAP02 - Capitation Amt distribution per Attending Doc.

3. CAP03 - Capitation Visit payments to Outside Provider - This report allows user to get list of all capitation visits done by outside providers and amount to be paid to them based on negotiated % of Medicare rate. The report allows selecting single outside provider or ALL outside providers associated as attending doctor on capitation claims from referring provider list.

Figure 24.1.3– Tabular Report for Capitation:  CAP03 - Capitation Visit payments to Outside Provider.

24.2 New tabular report ‘Copay Amount Moved to Advance’ added to the system.

Many transactions are done to move Copay, Deductible and Visit fee to Advance and then apply that advance to some other claim’s outstanding amount. While looking at the Patient Account, it is not clear why there is a patient responsibility outstanding if there was copay collected for that visit. This report will help users to quickly know that even though either Copay, Deductible or Visit fee was collected for a DOS, it was moved to Advance and once it goes to Advance bucket, it cannot be tracked to which specific claim’s responsibility was it applied. This report is named as ‘CP2AV’ under tabular report. This report shows the entries of Co-pay, Deductible and Visit Fees collected for a visit and later moved to Advance bucket explicitly using Remittance>Advance screen.
Here, the amounts moved from Co-pay, Deductible and Visit columns are shown with a negative sign and their sum total is shown in column Advance as positive amount.

Figure 24.2– ‘Copay Amounts Moved To Advance’ Tabular report.

24.3 Two new tabular report for Employer Billing added to the system.

Reports >> Tabular: There are two reports provided in context to Employer Aging. These reports are

• EMP01 - It is a report which displays itemized invoice List per Employer.

This report shows Itemized Invoice List per Employer. For a selected Date Range Employers selected, all Invoices billed, their date, Enc Type in Description and Amount Billed are shown. Generally, one Invoice per Encounter Type or Visit Type is generated for an Employer from Employer Invoice Screen. This is a detailed Charge code wise Invoice. There are several such Invoices generated. This report will show one entry per Invoice for all such Invoices generated per Employer in a period for quick reference along with amount billed.

Figure 24.3– EMP01: Employer Billing report with itemized invoice list per Employer .

• EMP02 -Employer Billing Report - Enc Type wise Charge Codes Billed and OS amounts.

This report allows filtering the Claims billed to Employer based on Enc Type for a date range. Enc Types represents the various visit types for which the patients from each employer are seen. When this report is run, it shows quick summary of all charge codes billed per Enc type per Employer and how much is paid and outstanding amount. This data will help clinics analyze how their business with various employers is progressing and what types of visits are more common and their revenues for the chosen period.
The other details like Invoice Number, Invoice Date, Claim ID, Claim Date, Patient Name, Code, etc. gives them in depth information for analysis purposes.

Figure 24.3.2– EMP02: Employer Billing report with Enc Type wise Charge Codes Billed and OS amounts.

25. Reports >> Pat Aging

25.1 New radio button options for ‘Normal’, ‘Collection’, ‘All patients’ introduced to calculate patient outstanding responsibility.

Patient Aging reports can be generated for ‘Normal’ claims / claims with ‘Collection Agency’ / collectively for all type of claims associated to patient using three new radio buttons ‘Normal’/’Collection’/’All’ respectively.

 

Figure 25.1– New radio buttons ‘Normal/Collections/All’ to generate Patient Aging report.

25.2 Now aging buckets can be customized at run time and printed in generated report.

Reports >> Pat. Aging: Any Patient Aging report displays outstanding receivable amount from the Patient over a period of duration. The duration might be divided in to various period ranges to provide clear picture about outstanding receivable during specific range. Pat. Aging report now has added capability which will allow user to define the Aging bucket range and also ability to hide and display the specific Aging bucket during runtime when Pat. Aging report is finally printed. This kind of flexibility has been incorporated with help of button ‘Layout’ on pop up of ‘Pat. Aging’. Button ‘Layout’ invokes ‘Aging Report Params’. User can define duration for each slot by entering slot duration under column ‘slot’. The next range for the slot starts from incremented value of the last slot value. Therefore, ‘Column Title’ for unapplied gets customized as per slot duration. Other features are that specific aging bucket can be hidden on generated report and also amounts like ‘121Plus, ‘Total OS’, ‘Net OS’ can be hidden if required.

Figure 25.2–Pat. Aging Report customized at run time using button ‘Layout’.

26. Reports >> Ins Aging

26.1Property based Insurance Outstanding receivables slots are now customizable.

Reports >> Ins. Aging: New property ‘billing.aging.slots’ has been introduced to customize the number of Insurance outstanding slots according to user preference. The default values are set to ‘30,60,90,120’. User can now define customized number of slots values using comma separated list. This property will allow users to set the slots according to urgency to get notified about outstanding receivables. It is also used on patient registration billing info, patient account, statement etc.

Note: If property value is changed, the Aging Templates also need to be changed.

26.2 Now aging buckets can be customized at run time and printed in generated report.

Reports >> Ins. Aging: Any Insurance Aging report displays outstanding receivable amount from the Insurance over a period of duration. The duration might be divided in to various period ranges to provide clear picture about outstanding receivable during specific range. Ins. Aging report now has added capability which will allow user to define the Aging bucket range and also ability to hide and display the specific Aging bucket at runtime when Ins. Aging report is finally printed. This kind of flexibility has been incorporated with help of button ‘Layout’ on pop up of ‘Ins. Aging’. Button ‘Layout’ invokes ‘Aging Report Params’. User can define duration for each slot by entering slot duration under column ‘slot’. The next range for the slot starts from incremented value of the last slot value. Therefore, ‘Column Title’ for unapplied gets customized as per slot duration. Other features are that specific aging bucket can be hidden on generated report and also amounts like ‘121Plus, ‘Total OS’, ‘Net OS’ can be hidden if required.

Figure 26.2–Ins Aging Report customized at run time using button ‘Layout’.

27. Reports >> Emp Aging

27.1New menu option ‘Emp Aging’ added to calculate employer outstanding responsibility.

A new menu option ‘EMP Aging’ has been introduced to generate outstanding amount receivable from Employer. This feature is introduced to support Employer Billing Claim in PrognoCIS.
The screen ‘Emp Aging’ allows searching the Employers for whom the aging report has to be generated. The Aging report can be generated based on either Responsibility date i.e when the responsibility of that employer was generated i.e Invoice Creation Date OR based on DOS i.e. Date of Service.

Figure 27.1– Pop up ‘Emp Aging’ to generate Aging reports for Employers.

There are 3 formats in which the Employer Aging report can be generated:

 1. Employer Aging Summary
This report displays each  Employer in one row and shows the total Billed amount so far, various aging buckets and their amounts and the Total Outstanding Amount from all displayed aging buckets.

Figure 27.1.1– Employer Aging Summary: One row per Employer

2.Employer Claim Wise Aging
This report displays one table for each employer and one claim per row with Claim ID, Invoice Date, Patient Name, Sent Date, Billed Amount, Aging columns and Total Outstanding amount. It also shows the Totals for each Amounts column per Employer.

Figure 27.1.2- Employer Claim Wise Aging: one table for each employer and one claim per row

3. Employer – Claim – Charge Details
This report displays Employer wise, Invoice wise, Clam Wise, Charge code wise details including Patient Name, Charge code, Billed Amount, Outstanding Amount and Number of Days since it is outstanding. Here Aging buckets are not shown but ‘Days’ column will show the number of days since that charge code is outstanding.

Figure 27.1.3- Employer – Claim – Charge Details: Employer wise, Invoice wise, Clam Wise, Charge code wise detail. No Outstanding Buckets but outstanding ‘Days’ .

Button ‘Layout’ in the list of parameters for generating Employer Invoice allows selecting the appropriate Aging buckets to be seen in output report.
For Example: If only two Aging Buckets 0-365 and 365+ are to be seen, the Layout will allow users to select only one bucket 0-365 and the bucket 365+ will be automatically shown in the output Aging report.

28. Reports >> Collection

28.1New checkbox ‘Employer’ added to view collection from Employer.

Collection Report feature capability now extended to analysis and view the collections from Employers. A new checkbox is added for transaction related to Employer Billing. When Checkbox ‘Employer’ is selected for collection reports ‘By Voucher’, report with all the collections received from the Employer receipts sent by Employers is generated. When Checkbox ‘Employer’ is selected for collection reports ‘By Claim’, report displays the amount raised in the Employer Billing Claim by the clinic. User has ability to generate the collection report for ‘Posted’/’Non Posted’ / ‘Both’ vouchers/claims related to Employer.

Figure 28.1- Collection Report for Employer transaction which are ‘posted’.

28.2 Collection report prints the Footer with filter details selected.

Now Collection reports print the Footer with the details of the filter criteria selected on pop up 'collection' report so that it gives quick access to the user to view those filters which were selected while report was being generated.

Figure 28.2- Collection Report for with Footer having Filter details.

29. Settings >> Diagnostics

29.1 Several new cases are added in Diagnostics Screen to list out and fix exceptional cases.

New diagnostics cases are added to list out problems in exceptional cases and fix to resolve the problems with listed exceptional cases. This tool is used by admin to resolve problems.New diagnostic cases are added as following:

1. Case: 082 : List of EOB with wrong ERD_FACTOR value.
2. Case: 083: Fix EOB with wrong ERD_FACTOR value.
3. Case: 084 : List of EOB with Write off Amount and without Write Off reasons.
4. Case: 085 : Fix EOB with Write off Amount and without Write Off reasons.
5. Case: 086 : List of EOB with Duplicate BLD Id.
6. Case: 087 : List of Mismatched Header and Details Amounts in Receipts.
7. Case: 088 : Fix Copay Not Applied.
8. Case: 089 : List of mismatched Pri Adjustment Amts
9. Case: 090 : List of Remittances with Charge Codes Billed to Patient.
10. Case: 091 : List of EOB with accidental INS WO amounts
11. Case: 092 : List Claims with EDI errors
12. Case: 093 : List EDI errors with claims
    

30. Settings >> Clinic >> Enc Types

30.1 New field ‘Bill To’ added along with layout change.

New field ‘Bill To’ is added on the layout of ‘Encounter Types’. Drop down list ‘Bill to’ determines the encounter type. With this, use of properties for defining encounter type has been forbidden. Properties which were used earlier to define the encounter types were

• encounters.visittype.auto.accident
• encounters.visittype.other.accident
• encounters.visittype.ub04
• encounters.visittype.workers.comp

Earlier Encounter type was decided by value defined in the property. As these properties are now forbidden, selection in ‘Bill To’ is used to decide the billing of claim generated from Encounter. There are various options in drop down and each option has distinctive meaning when used. These options are:

• Normal – On Encounter close, ‘Normal’ claim would be created.
• Worker Comp - On Encounter close, Worker Comp claim would be created if associated Primary Insurance has ‘WorkerComp’ status on Patient Insurance screen.
• Auto Accident - On Encounter close, Auto Accident claim would be created if associated Primary Insurance has ‘Motor Acc’ status on Patient Insurance screen.
• Other Accident - On Encounter close, ‘PersonalAcc’ claim would be created if associated Primary Insurance has Personal Accident status on Patient Insurance screen.
• UB04 - On Encounter close, ‘UB04’ claim would be created.
• Employer - On Encounter close, ‘Employer’ Billing claim would be created.
• Normal+ UB04 - On Encounter close, ‘Normal’ and ‘UB04’ claims would be created.
• Self - On Encounter close, ‘Self Pay’ claim would be created.
• No Claim – Only encounter would be generated but no claim. When Encounter is closed, checkbox ‘Create Claim’ remains disabled.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Figure 30.1– New field ‘Bill To’ added on ‘Encounter Type’ layout.

31. Settings >> Configuration >> Scheduled Process

31.1 Schedule Process can be executed explicitly using new option.

Self scheduled processes are executed during evening or night as per default settings. Consider a scenario where clinic is required to fetch all relevant information about claims that they had posted a day before, just 3-4 hrs before clinic starts in morning. That is, clinic would like to retrieve the latest info from Clearinghouse about ‘277’ message or ‘Insurance Eligibility’ for the claims which were posted a day before. In such scenarios, clinic can explicitly select the option to execute the self schedule process during morning at specific time, freq. etc. Two new radio buttons are added on the ‘Schedule Process’ screen for ‘evening’ and ‘morning’. Accordingly two Windows / Linux Scheduled Processes are scheduled to run in the evening with Parameter 1, and one more to run in the morning with Parameter 2. If the Parameters to the currently running process is NOT changed on a server, it will execute ALL self scheduled Processes. This Logic works for RunSelfScheduledProcess4AllPoolnames as well as RunSelfScheduledProcess4ThisPoolname.

32. Settings >> codes/drugs >> CPT/HCPC Master

32.1 New fields ‘Units’, ‘Quantity’ and button ‘CCI Codes..’ added on CPT/HCPC Master.

New fields 'unit' and 'Quantity' are added on CPT/HCPC Master. When 'unit' and ' Quantity' are specified for a code then these values are automatically populated on claims screen whenever that charge code is used in a claim. Button ‘CCI Codes..’ has also been included to accommodate ‘CCI’ functionality in the system. ‘CCI Codes..’ prevents improper payment of procedures that should not be submitted together for Medicare Part B and Medicaid claims. Button ‘crossOver’ now allows selection of both CPT / HCPC Codes in the search.

Figure 32.1– New fields ‘Unit’, Quantity’ and button ‘CCI COdes’ added on CPT/HCPC Master.

33. Fee Schedule

33.1 Fee Schedule implemented for Employer billing.

Specific ‘Billable’ fee schedule for an Employer is allowed to define from Fee Schedule. Defined Employer fee schedule must be assigned to employer on Employer in order to pull fee rate for charge code used in the claim.

34. Settings >> codes/drugs >> Scrubber Checks

34.1 New option ‘Scrubber Checks’ added to define rules for evaluation.

It allows defining ‘Scrubber Text ‘to be displayed in ‘Non modal’ window and allows defining rules for evaluation of claims. In a customizable window, name, description of the validation (which displays 'IF' conditions created by user), 'Built In Validations', sequence, Active fields can be entered. Button 'setup' is enabled only when checkbox 'Built In Validations' is checked and pop up 'Scrubber Checks is displayed. Using this simple interface, user can create various conditions using categories, conditions from drop down list. Interface provides flexibility to create various permutations and combinations of conditions. In text field 'Error Message', user can enter customized error message which will be validated on 'Ready to Send' of the claim. The claim is not allowed to post till claim is corrected for the reasons displayed in the error message when checkbox 'Built In Validation' is checked for that validation. Therefore, customized scrubbing criteria for claims can be created by clinic to meet the special requirements before posting claim to Insurance companies other than general validations done by the system.

Note: Scrubber checks feature is implemented for Insurance Claims only, not for 'Employer' and 'Self Pay' claims.

Figure 34.1 – Scrubber Checks interface to customize validations on claims screen.

35. Settings >> vendors >> Employer Master

35.1 New field added to assign Fee schedule to Employer.

New field 'Fee Schedule' is introduced to assign fee schedule dedicated to the Employer. When Employer Billing Claims are created, the Fee Schedule dedicated to the employer on this layout gets automatically associated on Claims >> Edit screen. Charge code on Employer Billing Claims pulls fee from fee schedule assigned to Employer on this layout.

Figure 35.1– New field 'Fee Schedule' to assign Fee Schedule to employer in the system.

 

New Properties Introduced

Property	Description
allow.directprint.ub04	If it is set to Y, a click on the printer Icon prints the document to the default printer. If it is set to N, a printer selection Dialog Box will be popped up, and the document is printed on the selected printer.
allow.directprint.cms1500	If it is set to Y, a click on the printer Icon prints the document to the default printer. If it is set to N, a printer selection Dialog Box will be popped up, and the document is printed on the selected printer.
Cms1500.default.printer	Property used for selecting default printer. Possible values1. DEFAULTPRINTER – The print will go to default printer configured in user’s machine.2. Printer name – The printer name should be the exact match with the printer installed in the user’s machine.3. blank – if it is set to blank then the printer selection dialogue box will be shown 4.RESETPRINTER - the printer selection dialogue box will be shown, on printer selection the property value set to blank.
ub04.default.printer	Property used for selecting default printer. Possible values 1. DEFAULTPRINTER – The print will go to default printer configured in user’s machine.2. Printer name – The printer name should be the exact match with the printer installed in the user’s machine.3. blank – if it is set to blank then the printer selection dialogue box will be shown4. RESETPRINTER - the printer selection dialogue box will be shown, on printer selection the property value set to blank.
claim.charges.max_rows	Max charges which can be selected at a time before save.
claim.charges.max_rows	Max claims which can be selected at a time on EOB/Receipts screen before save.
era.empinvno.prefix	Prefix to be Used for Employee invoice no
era.empinvno.length	Prefix to be Used for Employee invoice length
billing.capitation.outsideproviders	If this is Y, allow user to select Referring Docs too as Attending Docs.
billing.ter.cms1500.templatename	CMS 1500 form will be printed for tertiary insurance considering the above template name defined under Billing template.
billing.aging.slots	The number of slots for outstanding receivables according to user preference. Used on patient registration billing info, patient account, statement etc.
billing.insaging.extrafields.ter	In Insurance Aging template, Add a string of Tags to be printed after the Patient name and Claim date in case of Tertiary Insurance. Typically tags starting with PT_ or BLH_INS_ will be used.
billing.ter.ub04.templatename	UB04 form will be printed for tertiary insurance considering the above template name defined under Billing template.
billing.alledichecks.onready2send	If this is set to Y System make all Edi check Before making it ready to send.
billing.aging.slot	The number of slots for outstanding receivables according to user preference. Used on patient registration billing info, patient account, statement etc.
statement2.donotuse.opening.balance	On pop up statement, there are two radio buttons Print ope Bal and Ope Claims details for Claim wise statement format. When this property is set to N then opening balance is displayed on patient statement having radio button Print ope Bal selected by default on pop up statement. When this property is set to Y then Claim transaction details are displayed on patient statement having radio button Ope Claims details selected by default on pop up statement.

New Tags Introduced

BLH_CELL29CMSPAID  
BLH_CELL29CMSPAID_AMT
BLH_CELL29CMSPAID_USD
BLH_CELL29CMSPAID_CENT
BLH_CELL30CMSBAL                     
BLH_CELL30CMSBAL_AMT
BLH_CELL30CMSBAL_USD
BLH_CELL30CMSBAL_CENT

BLH_BATCH_NO
CL_OSSLOT$
BLH_EMPLOYER
BLH_EMPLOYER_NAME 
BLH_EMPLOYER_ADDRESS$
BLH_EMPLOYER_ENCTYPE

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