Release Notes - Billing

Version No: 2.0
Build No: 9

Table of Contents

1. Introduction

Numbers of new features related to PrognoCIS Billing have been released in Version 2.0 Build9.

2. UB04 - Rural Health Billing Workflows are now supported.

Many clinics, these days are moving from regular professional practice to Rural Heath practice. These practices sign up with Government Insurances like Medicaid and Medicare to be approved for seeing Rural Health patients. Government gives such practices some additional incentives against each Rural Heath Claim, for which clinics have to send UB04 i.e Institutional claim.

This feature is intended to support various Rural Health Billing scenarios by creating appropriate claims and appropriate procedure codes, their amounts depending on value set in the property and for appropriate Insurances provided the Bill Type on Enc Type is selected as ‘Rural Health’. The pre-requisite to create claims for Rural Health are:

• Property ‘billing.ub04.rural.health.support’ is set to ‘Y’. When this property is set to ‘Y’ then only ‘Bill To’ drop down is populated with ‘Rural Health’ option.
• On Encounter Master for an Encounter, field ‘Type’ set to ‘RV’ and field ‘Bill To’ must be set to ‘Rural Health’.
• At least single property mentioned below should be set in order to create UB04 Rural Health Claims’



• ‘ub04.rh1.revprocamts’ – for Primary Ins with Rural Heath Checkbox checked
• ‘ub04.rh2.revprocamts’ – for Secondary Ins with Rural Heath Checkbox checked
• ‘ub04.managedcare.revprocamts’ – for Primary Ins with Rural Heath Checkbox checked and Main Ins Associated and Secondary Ins with Rural Health Checkbox checked but no Main Ins associated.
• Insurance selected on Patient Insurance must have checkbox ‘Rural Health’ as marked.

Note:  When none of the property is set then UB04 Rural Health Billing claim is created without Revenue Code, Procedure Code and Amount.

Note: When the property is set to only Revenue Code, then UB04 Rural Health claim is created with only Revenue Code but Procedure Code and Amount are not present.

For UB04 Rural Health Claims, Place of Service is set as '72' on Claims >> Edit screen.

The ‘Rural Health’ Claims are necessarily created from ‘Encounter Close’ of the patient with above conditions fulfilled.
There are four scenarios for which UB04 Rural Health claims would be created by the system. In some scenarios, a professional claim (CMS1500) as well as a UB04 claim will get created. For UB04 Rural Health Claims, Place of Service is automatically set as '72' on Claims >> Edit screen.

Scenario1: Patient having only Primary Rural Health Insurance (Proc Code: 01)
Create an Encounter of patient who has single primary insurance with no ‘Main Ins.’ on Insurance master associated on patient insurance screen and where all the three criteria defined above are satisfied. On Encounter Assessment screen, charge codes can be associated but are not included in the UB04 Rural Health claims. When patient Encounter is closed, claim is created. 
UB04 Rural Health claim is created with Revenue Code, Procedure Code and Amount as set in property ‘ub04.rh1.revprocamts’. The value of Revenue Code, Procedure Code and Amount is property driven. Therefore, it is important to set the values in the property stated above. For example if property ‘ub04.rh1.revprocamts = 451:01$100’ then Revenue Code = 451, Procedure Code = 01 and Amount = $100 for charge row on Rural Health Claim.
UB04 Form >> Box 50 will print name of Primary Insurance.

Scenario2: Patient having Non Rural Health Primary Insurance and Rural Health Secondary Insurance (Proc Code: 02)

Create an Encounter of patient with two insurances having Primary Insurance as Non Rural Health Primary Insurance and Rural Health Secondary Insurance. User can added CPT/HCPC codes on Assessment. On Encounter Close, two claims are created. These are:

• Professional Claim for Primary Insurance – This claim will include CPT/HCPC charge codes included in Encounter Assessment and CMS 1500 will print the name of Primary Insurance only.
• UB04 Rural Health for Secondary Insurance – This claim ignore CPT/HCPC charge codes included in Encounter Assessment and charge rows on this claim would be populated appropriately with values set in property ‘ub04.rh2.revprocamts’. UB04 Form >> Box 50 will print name of both Primary and Secondary Insurance.

Limitation: Generally, in this scenario, box 50 should print primary ‘Non-Rural’ insurance first and  Sec ‘Rural’ Insurance later but as per current logic, whatever is the sequence of Insurances on claim, the same sequence will be maintained while printing payers in box 50. Hence, in this case, Secondary Insurance will be printed first and then the Primary Insurance name.

Scenario3: Primary Managed Care Insurance and Seconadry Rural Health Insurance (Proc Code: 18)
Managed Care Program is for Low Income group individuals with multiple family members.
A Managed Care qualifying patient will have two Insurances defined:

• Primary Insurance- Checkbox ‘Rural Health’ is checked and  ‘Main Ins.’ is necessarily selected for this Primary Insurance. It is treated as subsidiary insurance.
• Secondary Insurance- Rural Health Insurance with checkbox ‘Rural Health’ as checked.
• When procedure code is set to ‘18’in property ‘ub04.managedcare.revprocamts’ then system checks field ‘Managed Care Amt.’ on Insurance Master for amount to be populated in charge row for UB04 Rural Health Claim. The priority is given to amount in field ‘Managed Care Amt.’. If amount is found set in that field then amount on UB04 Rural Health Claim is populated from field ‘Managed Care Amt.’ otherwise amount is populated from the amount set in property ‘ub04.managedcare.revprocamts’.

For a ‘Managed Care’ workflow, on encounter close, two claims are created. These claims are:

1. Professional Claim for Primary Insurance –This claim will include CPT/HCPC charge codes included in Encounter Assessment and CMS 1500 will print the name of Primary Insurance only.

2. UB04 Rural Health for Secondary Insurance –This claim ignores CPT/HCPC charge codes included in Encounter Assessment and charge rows on this claim would be populated appropriately with values set in property ‘ub04.managedcare.revprocamts’. UB04 Form >> Box 50 will print name of only Secondary Insurance since the Primary Insurance is the subsidiary of this Secondary Insurance.

Scenario4: Patient having Non Rural Health Primary Insurance and ‘Bill To’ set to Rural Health
In this scenario, single professional claim would be created and CMS 1500 will print Primary Insurance name. No UB04 Claim will be created.

Note: For Rural Health, a new UB04 template ‘UB04_RuralHealth’ has been added. To use this template, please change the name of this template to ‘UB04’.

Insurance (Box 50) Tag Details available for UB04 Form

UB04 Tags	Remarks
BLH_INS_COMPANY	Prints the Primary insurance name in Box 50.
BLH_INS2_COMPANY	Prints the Secondary insurance name in Box 50.
BLH_INS3_COMPANY	Prints the Tertiary insurance name in Box 50.
BLH_UB04_50PRINAME	Prints the Main Insurance name if present in Box 50 – cannot be used in conjunction with above 3 tags.

3. Patient Payment Plan is now introduced in PrognoCIS.

Patient Payment Plan or Financial Plan is based on an individual patient’s Insurance, Self Pay treatments offered by clinic and financial condition of patient. The Copay, Deductible, Visit Fee and Co-Ins amount is considered when offering the payment plan. There are three likely plans which are allowed 'Weekly', 'Monthly' and 'Per Visit' by the system.

Note:  The Payment Plan is always finalized before the patient treatment starts. One Patient has only one Payment Plan Open at a given time.

Note:  Copay/ Deductible/ Visit Fee/Advance are allowed to collect and applied to Patient Payment Plan.

 If the patient pays after patient responsibility is created, then normal fees are charged to the patient. If the patient pre-pays i.e before responsibility is created or during visit then the patient is given appropriate discount and the payment plan is chalked out based on the discounted rate.

A tracking mechanism is incorporated for remind users about next payment due, amount due, last payment date, amount paid last, etc.

When a ‘Patient Payment Plan’ is associated to the patient, impacts are visible on following screen:

• Appointment>Schedule>Patient Receipt: Checkbox ‘Plan Payment’ in bold and red font is automatically checked for such patients. Tooltip over it displays 'Plan Name Plan Type amount $Installment amount Next Pay date:'.
• Claims >> Edit Screen:
  • Checkbox ‘Payment Plan’ is automatically checked when claim is created for such patients. Tooltip over it displays 'Plan Name Plan Type amount $Installment amount Next Pay date:'.
  • When claim with Patient Payment Plan is reopened, the payment plan balance is recalculated.
• Patient A/C screen:  Word ‘Pay Plan’ is printed with ‘Plan Name’ in red and bold font. ‘Plan Name’ is hyperlinked to show details about Payment Plan. Tooltip over it displays 'Plan Name Plan Type amount $Installment amount Next Pay date:'.
• Remittance>>Pat Receipts:
  • Checkbox ‘Plan Payment’ is automatically checked for patients having Patient Payment Plan. Tooltip over it displays 'Plan Name Plan Type amount $Installment amount Next Pay date:'.
  • When Patient Receipts with Patient Payment Plan is reopened, the payment plan balance is recalculated.
• Reports >> Letters: A letter to be printed for list of defaulter patients having Patient Payment Plan can be generated to follow up with them for payments. The letter would print ‘date’ for which payment was not received and the amount pending. Basically, it would act a s reminder to the patient.

Limitation:  Copay collected from Copay Screen in ‘No Claim’ scenario cannot be associated to Payment Plan. If it has to be applied to Payment plan, create a Patient Receipt for this payment instead of putting it on Copay screen.

Figure 3: Tooltip of checkbox ‘ Plan Payment’ displays ‘Tooltip displaying 'Plan Name Plan Type  amount$xxx Next PayDate:'.

4. HSA/HRA payment for patient responsibility is now supported on EOB screen.

HSA means ‘Health Savings Account’. When a patient has HSA account then HSA account can be used against particular visit of the patient. After receipt of Primary / Secondary EOB, when responsibility is with Patient, one more EOB (in paper / ELE) will be received from HSA. Although it is received as an Insurance EOB, it is treated like a Patient Receipt.  When a HSA or HRA pays for Patient responsibility, they send EOB/ELE. Hence a provision is made to accept such  HSA or HRA as Carrier on EOB/ERA screen which allow users to change ‘Paid As’ value from dropdown to ‘HSA’ only if patient has responsibility against that claim and when posted, it would affect the patient responsibility only and not insurance responsibility even if EOB is being posted.

Note:  The option ‘HSA’ in field ‘Paid As’ Pri/Sec/Ter drop down at Claim level will be enabled only if there is patient responsibility against any charge line and users need to explicitly select this option from dropdown.

When a claim on EOB screen is marked as ‘HSA’ from ‘Paid As’ dropdown:
Salient features are listed below:

• Middle Frame: Dropdown ‘A2’ and button ‘I’ in middle frame on EOB screen are disabled.
• Middle Frame: ‘Recoup’ for ‘HSA’ payment is not allowed.
• Lower Frame: It might so happen that claim also contains other charge rows having responsibility associated to Pri/Sec Insurances other than charge row with patient responsibility. In such a case, all the fields for those charge rows having responsibility with Primary/Secondary insurances would be disabled. But all the fields having patient responsibility with ‘Paid As’ selected as ‘HSA’ for this charge row would be disabled except field ‘Paid’ amount.
• It is likely that while the ‘Paid As’ was ‘PRI’, user entered some Paid Amount and then changed it to ‘HSA’. Ins such a case Paid Amount although disabled is Not Zero. This error will be trapped when voucher is marked as Read to Post. The property ‘era.validate.conditions’ now has an additional Character ‘H’ supported for this HSA check.
• Lower Frame: When Primary/Secondary EOB is already received for claim and a new EOB is created for the same claim having patient responsibility against some charge rows, then all the charge rows displayed on EOB screen is marked as ‘Duplicate’ payment with highlighted with red background.

 The red color for ‘Duplicate’ payment would be removed and Payment status would change from ‘Duplicate’ to ‘Normal’ as soon as ‘Paid As’ option is chosen as ‘HSA’ for charge rows having patient responsibility.

• Lower Frame: Button ‘Excess’, Button ‘Wo’, Status List Box, Button ‘Action’, checkbox ‘Bill Pat’ are disabled for HSA payment.
• Lower Frame: System will disable fields ‘CoIns’, ‘Copay’ , ‘Deduct’ and ‘NotCov’  amounts.
• Lower Frame: In case, charge row is selected where responsibility was with say Pri/Sec, not with patient even then ‘Paid’ Amount will be disabled.
• Patient Account Screen: Under remittance table on patient account screen, an entry is created for EOB received from ‘HSA’ account with prefix as ‘HSA’ under column ‘Payor Name’ with Pri/Sec/Ter insurance.
• Reports >> Statement and Ledger: An entry for ‘HSA’ transaction is created and would show ERA number but would reduce the Patient Responsibility. Hence next to the Carrier Name, word ‘HSA’ is printed for Patients to understand that it’s a ‘HSA’ payment which resulted in reduction of patient responsibility.
• Reports >> Summary: Predefined amount ‘212’ is added to display total of all ‘HSA’ payments received through EOBs on summary reports with hyperlink.
• Reports >> Tabular: A Tabular report for ‘HSA/HRA’ payments received displaying patient name, DOS, HSA/HRA name, Amount Paid, etc. is incorporated . ‘HSA HRA Receipts’ tabular report is added to the system having code: ‘HSA01’ and classification code: ‘HSA HRA Receipts’.
• Reports >> Pat. Aging: Pat. Aging report displays outstanding amount after appropriate reduction when HSA/HRA payment is received.

Note:  ‘HSA’ account is not applicable to Capitation Type Claims and Employer Billing claims.

Limitation:  After ‘HSA/HRA’ EOB is received, assign Secondary/Tertiary Insurance is not allowed.

Figure4: ‘HSA’ account used in EOB received for a claim having patient responsibility.




Figure4.1: Patient Account: Word ‘HSA’ prefixed with insurance name for EOB received having field ‘Paid As’ as ‘HSA’.

5. Claim Creation When Enc Starts

In a scenario where the Providers are taking a few more weeks to fully functional, the Clinic would like to start using the scheduler and mark patient appointments as ‘arrived’ so that they can enter co-pays, and get their Billing operation started. In such a case, the Biller should enter the assessment details and create claims in the EMR and then bill them from PrognoCIS. However, the Biller has to navigate through a number of screens to get one claim billed.
As a solution towards reducing the steps that the Biller has to take in this scenario, now there is a  provision for claim creation when the encounter starts for the patient. This feature can be turned on using a property ‘create.claims.condition’. This property will come into effect only if Billing is turned ON for the clinic. The ‘Claim Creation When Enc Starts’ works when this property is set to ‘R’. The checkbox ‘Create Claim’ on Enc Close screen will get automatically checked when the claim is created.

• User has gone to ‘Start/Edit’ encounter and start a new Encounter.

This will mean that biller can then just enter the claim details on the billing side and based on Sync property, the ICD and Charge codes can be synced back to EMR if required.


The Claim will get created when the Encounter starts if:

• Appointment is marked Arrived and
• The User has gone to Start/Edit encounter and started a new encounter.

The Claim should not get created when the Encounter starts if:

• Encounter Type of the Appointment has ‘Bill To’ marked as ‘No Claim’.

Limitations when property ‘create.claims.condition’ to ‘R’:

• When Appointment is scheduled for Attending Doc as ‘Resource’ then claim is not allowed to be created upon Encounter start. System displays alert message about it.
• If the claim was created when the Encounter started and the Biller entered the charge details on the claim but before processing the claim, if the provider made some additions to the Assessment screen and unchecked and checked the checkbox ‘Create Claim’ on Enc Close screen, the earlier created claim will be deleted and a new claim with details from Assessment will be created.

Note: Hence it is advisable for users to change the Create Claim property to 'C' as soon as Nurse or Doctor starts putting Assessment codes and closing encounters to avoid deletion of Claims in Ready to Bill status which were created when appointment is marked Arrived.

• Rendering Doc changed on Edit Enc screen will not get considered for claim as the claim will be created before that change. Only if the claim gets deleted and new claim from EMR gets created as mentioned above, will the Rendering Doc and Assessment Charge codes and ICD codes be considered as new claim will be created.
• Claim is not allowed to create when Attending Doc is ‘Resource’.

6. Changes to fields 'Adjuster' and 'Attorney' on Patient Insurance screen and Implementation of Patient Attorney, Case Manager, Address Book Contacts association to Registration screen.

Generally, each patient is added separately for each injury case because a case has to be maintained separately and cannot be mixed with any other case of the same patient or any other general visits of the patient.  These are cases related to Worker’s Comp insurances. In Worker’s Comp Insurances, numbers of agencies are involved to determine the facts about patient’s injury, status, visits related to Worker’s Comp. There could be multiple agencies or persons involved which are Providers, Attorneys (Lawyers), Patient, Employer of the Patient and Case Manager.  With the involvement of multiple agencies or persons, lots of communications take place amongst them. To meet these requirements, PrognoCIS has introduced and implemented multiple changes on Patient Registration Screen, Patient Insurance Screen and Patient >> Letter Out screen.

Modifications on Patient Insurance Screen:

There are two fields which were already present on Patient Insurance Screen but were not implemented.



 

Figure 6: Fields ‘Attorney’ and ‘Adjuster’ on Patient Insurance Screen.

These fields are:

1. Attorney:  Attorney is appointed by Insurance to deal with matters related to Insurance claims.

•   Currently Insurance Attorney can be associated to each Patient’s Insurance from Patient Insurance screen. Attorney is independent of Insurance. Each Attorney name is nothing but a Law Firm’s name. To each Law firm added, a contact person can be associated on Attorney master. What gets searched and associated as Attorney is the Law Firm name.
•   Use Button ‘+’ between Search and Clear of Attorney field to allow addition of new Attorney on the fly. Although new Attorney can be added from Settings >> Config >> Attorney screen as well.


Figure 6.1.b: Add new ‘Attorney’ in the system using either button ‘+’ on Patient Insurance or from Settings >> Config >> Attorney.

2. Adjuster:  The Adjuster is generally appointed by the Insurance Company. He need not necessarily be an adjuster tied up with one Insurance company.

•   Adjuster Master List is maintained by system:

PrognoCIS  maintains the list of Adjusters in Adjuster Master and list can be viewed either using search binocular after field ‘Adjuster’ on Patient Insurance screen or from search list invoked from Settings >> Config >> Ins. Adjuster. When new ‘Adjuster’ is added and saved in the system, the field ‘Insurance Name’ is not mandatory.

•   Ability to Copy Address of the associated Insurance to Adjuster and edit the Address:
  Some times it might so happen that address of Adjuster is same as the address of the  Insurance company with whom the Adjuster is associated. System provides capability to copy the Insurance Company’s address to the Adjuster’s Address fields.  When Insurance is associated to Adjuster on Settings >> Config >> Ins. Adjuster screen, the button ‘Copy Ins Add’ gets enabled. Click button ‘Copy Ins Add’ to copy Insurance’s address to address fields of Adjuster. Therefore, button ‘Copy Ins Add’ can be used to dump the Address once on the Adjuster screen. Once copied address is saved for selected Adjuster, address can be edited as per requirement.

Figure 6.2.b: Add new ‘Adjuster’ in the system using either button ‘+’ on Patient Insurance or from Settings >> Config >> Ins Adjuster. Use button ‘Copy Ins Add’ to copy Insurance Address to Adjuster’s Address fields.

• Ability to associate any Adjuster to Patient Insurance:
  Adjuster can be associated to Patient from Patient Insurance Screen using search binocular in front of field ‘Adjuster’. PrognoCIS allows association of any Adjuster to Patient Insurance as Adjuster search list displays all Adjusters present in the system. Thereby, it allows associating any Adjuster to Patient Insurance and hence association of Adjuster is not specific to Insurance Company.
•  Ability to add new Adjuster from Patient Insurance Screen:
  Using button ‘+’ present between search binocular and hyperlink ‘Clear’ in front of field ‘Adjuster’, new Adjuster can be added to Adjuster Master. It facilitates the user to add Adjuster easily without navigating to Ins. Adjuster Master Screen.
• Insurance Adjuster Search list:
  Adjuster Search to first displays the ‘Adjuster Name’ column followed by column ‘Insurance Name’ along with other columns. These two columns are hyperlinked to allow sorting.

Modifications on Patient Registration Screen:
A patient can hire Patient Attorney to represent his/her facts by appointing ‘Patient Attorney’. Similarly, a clinic might have ‘Case Managers’ who would supervise entire cases for the Clinic and Employer. To store information about all these placeholders on ‘Other Info.’ tab, button ‘Case Manager’ is implemented.


Figure 6.3: Button ‘Case Manager’ on ‘Other Info’ tab.

Details about fields on button ‘Case Manager’






3. Patient Attorney: A patient is entitled to hire his/her own attorney to present his injury/disability case against Employer or to present it to the Work Comp Carrier. Field ‘Patient Attorney’ allows association of Attorney to patient on Patient Registration screen. The search list for Patient Attorney is populated from Attorney Master List. Therefore, single attorney can be associated as Patient Attorney for one patient or Insurance attorney for the other patient. New ‘Patient Attorney’ can be added either using button ‘Add New’ or from Settings >> Config >> Attorney.

4. Case Manager: Case Manager manages entire case for Clinic and Employers.

In addition to the Adjuster, Ins Attorney and Patient Attorney, mostly one or two Case Mangers are associated to a case. These Case Managers are also included in communication related to case. Address Book is the place where Case Managers are stored and populated in the search list. There is a category field in Address Book where the category called ‘Case Manager’ is defined.  Adding a new Case manager from Case Management popup from contacts tag will have category mandatory.To associate the Case manager to patient, there are 3 Address Book entries allowed by adding 3 rows below the field ‘Patient Attorney’ on ‘the pop-up on Patient Registration screen. The label for all 3 fields is ‘Case Manager’. All entries from the Address Book search is seen and allowed to be selected.
As soon as any category entry is selected, the label changes to that Category name.
These 3 fields with changed Category name is available on Letters out to select the Case Managers in To and CC fields.



Figure: Case Manager and Patient Attorney on Patient Registration Screen under Other Info tab.

Note: These 3 ‘Case Manager’ fields can be used as general fields to associate any relevant Patient Contacts from Address Book on Patient Registration screen.

Letter Out
As lots of communication takes place regarding cases between Adjuster, Attorney, Pat. Attorney and Case Managers, these are included in ‘To’ and ‘CC’ field on Letter Out screen (Patient >> Letter-Out from EMR module). User can send out Progress Notes, Work status Report, Patient Visit details, Disability status etc using templates as attachment to the concerned party.



7. Insurance Master redesigned and new fields added to support Rural Health Billing and Capitation Reports.

Insurance Master Interface has been modified and fields are now placed in logical order of sequence in which the information is required while insurances are assigned to claims. Fields are now arranged in three columns, title of some fields are now modified according to relevance and feature and some fields are removed from Insurance Master and button ‘Extra Info’ pop up as these were not required as per 5010 specs.

When ‘Billing’ is turned ‘OFF’, only first two rows on Insurance Master is visible to the user apart from ‘Address’ related fields.
The first two rows contain details about Insurance Company like Name, Short name, Carrier, Company ID etc.

Note: Tooltip on Insurance name text field now displays complete name.

Next two rows provide information whether specific insurance is:

• Main Insurance - Parent Insurance of selected Insurance Company. It provides the functionality of Subsidiary insurance grouping against a parent and accepting payment from parent for the subsidiary insurances. Parent insurance ID is used to group the subsidiaries of an insurance company together.
• AR Group
• Eligibility Payor ID
• Rural Health – When checkbox ‘Rural Health’ is marked, it notifies that specific Insurance is UB04 Rural Health.
• Rural Health Billed Amt. - Rural health UB04 amount.
• UB04 Inst Payor ID- This field is removed from button ‘Extra Info’ pop up and is placed on Insurance Master Interface.

Next two rows facilitate information about EDI. The details are about

• Fee Schedule
• Claim Filing Code
• Clearing House
• Professional Payor ID.

Next two rows give details about provider type:

• Billing Provider Type
• Pay to Prov Type
• Submitter Type
• Option to select CMS template when Insurance is Paper Insurance type.
• Overdue after days- This field is renamed from ‘Av. Response Time’ to ‘Overdue after days’. It is renamed to ‘Overdue after days’ to bring uniformity and consistency in the system for similar fields which are also available on other screen. Field ‘Overdue after days’ is also present as checkbox on ‘Send Claims’ screen. Field ‘Overdue after days’ now supports number up to 3 digits.

Address related fields remain unchanged.



Figure7: Insurance Master: Modified and logically placed fields on Insurance Master.

Modifications on button ‘Extra Info’:

Button ‘Extra Info’ on Insurance Master invokes pop up ‘Insurance Extra Information’ pop up. This pop up displays the EDI related fields related to Insurance Company’s details.
Fields which are removed as these were not required by EDI as per 5010 specs from pop up ‘Insurance Extra Information’ are:

1. LOOP 2010AB Pay to Provider NMX
2. LOOP 2010AB REF Qualifiers like EI, SY, 1C, 1D, G2
3. Institutional Payer ID- It is relocated to Insurance Master Screen and is renamed as ‘UB04 Inst Payor ID’.

Now pop up ‘Insurance Extra Information’ has become compact and easy to locate the relevant fields which are required for EDI Insurances.




Figure7.1: Pop up ‘Insurance Extra Information’: With modified and logically placed fields.

Note: For user having access to EMR module, only fields ‘IE NPI Credentials PC (provider/Clinic) and ‘IE REF Qualifier like EI,SY,1C,1D,G2’ on button ‘Extra Info’ will be visible.

Impact of ‘Main Ins.’ concept on Insurance Master in Capitation Reports:

Capitation Logic was implemented in V2B8. With enhancements requests from client that their claims are billed to multiple sub branches of Insurances but the payment comes from the Insurance. Earlier all the reports for Capitation were based on the logic that Capitation Receipt would come from the same Insurances. So even if a Capitation Receipt is created for main Insurance, the distribution of amount per claim in Reports could not be made till it was known which the main Insurance was and which are its Subsidiaries or Sub-Insurances.

To achieve it on Insurance Master, there is a new field added called ‘Main Insurance’. This will connect all Sub-Insurances with this Main Insurance. Then the capitation Receipt received will be for Main Insurance. No change is done in this logic of creation and posting the Capitation Receipt.

Now, following changes implemented in the Reports Logic.

• If the Capitation receipt is received for a Insurance, check all Insurances in Insurance master to find if that Insurance has been marked as Main Insurance for one or more Insurances.
• If not, no change in the logic i.e. this capitation receipt will be applied to all claims billed last month with that Insurance. Do not consider any other claims.
• If there are one or more insurances found where this capitation receipt Insurance has been associated as Main Insurance, then while generating reports, consider all claims of all these insurances + the main Insurance claims as well and then show the allocation per claim for all these claims from Main as well as Sub-Insurances.

Note:Here the assumption is that there will never be any Capitation Receipt for the Sub Insurance separately. If there is a separate Capitation Receipt received for any Insurance which has some Main Insurance associated, then that Capitation Receipt will be dropped from Capitation Reports and that Capitation Payment will not be considered at all.


• Just like HAS/HRA Claims on EOB, disable all options for each written off charge code except Copay column. Disable ability to write off and Approved Checkbox.

8. Header and Footer for Reports and Ledger.

Many a times, When Reports are viewed and printed; the clinics have to send those reports to outside entities. Hence clinics want their Letterhead printed on the top. Sometimes clinics have to include some note at the bottom. To meet these demands, PrognoCIS has introduced mechanism to include the letterhead as Report Header and some Report footer. A letterhead when saved as a template then the template ID is saved in a property so that every time if any report is generated, the Letterhead gets included as Header while displaying the report and while printing it as well. Same way, a Footer Template with any text can be created and its template ID is included in a footer property. These properties are 'claimrep.header.template', 'claimrep.footer.template', 'chargerep.header.template', 'chargerep.footer.template','collectiondetails.header.template','collectiondetails.footer.template','collectionheader.header.template', 'collectionheader.footer.template'.

Note:  These Reports related Headers and Footers allows only Clinic Details and general text. Specific Patient Tags or Provider Tags will not work on them.

Similarly, a separate property for Ledger related Header is introduced. Since a ledger is Patient based, allows including Patient Tags, provider tags, etc. on it.These properties are ‘ledger2.header.template’, ‘ledger2.footer.template’.

9. Void functionality

9.1 More Enhancements added to 'Void Claims' functionality.

‘Void’ functionality was introduced in Version V2B8 with certain limitations. In V2B9, more features are implemented to overcome previous limitations. These newly implemented features in the ‘Void’ functionality are:
• Denied Actions allowed for ‘Void’ claims are

a.Resend without Reopen
b. Resolved
c. Ins Agreed to Pay

• ‘Void’ claim’s copy can be created with same visit Id. Claims search list for ‘Select Claim’ on pop up Claims >> New will now display list of ‘Void’ claims when option ‘Create a copy  of Existing Claim with same visit id’ is selected.
• ‘Void’ claim’s copy can be created with different visit Id
• Claims >> Edit screen: Button ‘Copy codes’ displays void claims also.
• ‘Void’ functionality is now based on role. The Role name is ‘VoidClaim’ and by default, assigned to admin.
• When claim is marked as ‘Void’, an entry in Track Status is created.
• On ‘Void’ claims, the Insurance names are retained and displayed as it was prior to being marked as ‘Void’.  Earlier Insurance names for Pri/Sec/Ter were replaced by ‘Self Pay’ and now it would show relevant Insurance names.
• ‘Self Pay’ claims are not allowed to mark as ‘Void’ if any amount is written off from Patient Receipts.

9.2 ‘Mark Void ’ (Do Not Send) functionality enhanced.

Void Charge Codes: On pop up CMS flag, label of the checkbox ‘Do Not Send’ and its functionality has been tweaked. The label is changed to ‘Mark Void’.
Checkbox ‘Mark Void’ is enabled/ disabled when:

• ‘Billed’ and ‘Balance’ amount are same, it means that there is no ‘Adj’, ‘w/o’, payment voucher posted against that charge code. When ‘Billed’ and ‘Balance’ amount are same then checkbox ‘Mark Void’ is enabled.
• A charge code is marked ‘Denied’ with any further action(action like No action, Resend, Reopen claim for resend, Resolved) taken then that charge code can be marked as ‘Void’ and checkbox ‘Mark Void’ is enabled.
• Payment is received against a charge row in a claim then ‘Mark Void’ is disabled.

10. More functionality added to Change Secondary/ Tertiray.

When the Secondary or Tertiary is changed and amount paid by old Secondary is required to be recouped using Insurance Credit, the claims search for Insurance credit displays correct paid claims depending on Insurance selected. The amount recouped is sent to correct Insurance Credit bucket for refund later.

11. Patient Account Screen

11.1 Direct Access to Clearing House Portal from PrognoCIS.

A new Icon ‘CH’ has been added on Patient Account to help users go to clearing house website directly. Currently this feature is available for Gateway clients. To connect to Gateway portal from PrognoCIS, client needs to give Bizmatics a valid user id and password. EDI Partner master will hold Gateway’s portal URL, User Id and Password. Based on these details, system will invoke that URL with its login and password. This will open a new windows browser and after login, the client’s home page with Gateway will be shown. The client can then navigate and do the needful in that website.  Once done, they can logout of the site and close the browser.

Note:  Icon ‘CH’ is also available on Claims >>Returned and Outstanding Screen.



Figure11.1- Direct Access to Clearing House Portal using icon ‘CH’.

11.2 Entries about Responsible Person / CSV printed under Statement section.

All the entries related to Responsible Person/ CSV statements for a patient are created under ‘Statement’ section of Patient Account for tracking purpose. These statements are generated either using Reports >> Statement for Patient or through Schedule Process for CSV and Responsible Person. Statement entries for Responsible Person is hyperlinked whereas CSV statement entry is not hyperlinked.The hyperlinked ‘Responsible Person Statement’ displays detailed statement. In case of a ‘CSV’ output, it will be listed on Patient A/c screen without the hyperlink to show the statement entry. The Id will be suffixed with ‘CSV’. Likewise in case of ‘Resp Person’ statement, Id will be hyperlinked to show the consolidated statement for the Resp Person (rather than the Patient). The Id will be suffixed with ‘Rp’.



Figure11.2- Patient Statement/ Responsible Person Statement and CSV statement entries under ‘Statement’ section on Patient Account.

12. Patient Insurance : PreAuth

12.1 Patient Insurance PreAuth can now support upto 25 entries.

User can enter same pre authorization number for 25 times now for various reasons.
Here instead of identifying the pre authorization no based on the numbers, the system looks at the sequence no. of all three of them and puts them accordingly on the screen. As per the current working feature, the system moves the closed PreAuth at the bottom, followed by rest on the top.

13. EDI

13.1 EDI 837: For Office Ally ClearingHouse, EDI 837 files are generated with Prefix 837P_ for Professional/ 837I_ for Institutional UB04.

EDI 837 files: When clams are processed, EDI files are generated for these claims. When ‘Office Ally’ is clearing house for the associated Insurance in the claim then EDI files are generated as ‘837P_’ for Professional claims and ‘837I_’ for Institutional Claim.

13.2 EDI 835: Payment received from Check Mode is marked as ‘By Check’.

EDI 835: EDI ‘835’, in case of CHK Mode Payment received is now marked as By Check instead of By 'Electronic'.

13.3 EDI 835: Compressed .RMT files received from clearinghouse and PrognoCIS unzips to process it further.

The EDI 835 files received from clearinghouse are in compressed format. This compressed file is stored in EDI835FTP folder; system unzips it, processes it and moves those files to EDI835 folder to process further as per functionality.

13.4 EDI 997: Compressed .997 files received from clearinghouse and PrognoCIS unzips to process it further.

The EDI 997 files received from clearinghouse are in compressed format. This compressed file contains multiple claim response in a single file. System unzips it and processes it further as per functionality.

14. Claims >> Edit

14.1 Tooltip under field ‘charges’ displays allowed amount.

Claims >> Edit screen:  Field ‘Charges’ for each charge row in the claim shows a tooltip with allowed amount for respective charge code as defined in matching allowed fee schedule if available. For example: ‘Allowed $100’ is displayed as tooltip.

Figure 14.1- Tooltip under field ‘Charges’ amount is displayed.

14.2 Checkbox ‘Sync Fee Schedule on Save’ is now removed.

Claims >> Edit screen:  Checkbox ‘Sync Fee Schedule on Save’ is now removed from Claims >> Edit screen and now checkbox ‘Plan Payment’ is displayed where applicable.

14.3 Insurance Attorney and Adjuster fields gets auto populated on button ‘Injury’ for Worker’s Comp/Other accident claims.

Claims >> Edit screen:  Fields like insurance ‘Attorney’ and ‘Adjuster’ on button ‘Injury’ for Worker’s Comp/Other accident claims are populated if these fields are populated on Patient Registration screen before claim was created.



Figure 14.3- Fields Insurance ‘Adjuster’ and ‘Attorney’ populated on button ‘Injury’.

14.4 Charge codes marked as ‘Mark Void’ displayed with text ‘Marked Void’ on Claim Ledger.

Single or multiple charge codes in a claim can be marked as ‘Mark Void’ from pop up ‘CMS Flag’. Claim ledger of the claim displays such charge code with text ‘Marked Void’ in bold and red font in front of charge code. It becomes visually apparent about a charge code on Claim ledger.



Figure 14.4 – Void charge code on Claim Ledger displayed with text ‘Marked Void’.

14.5 New filter criteria added to button ‘Filter’.

Claims >> Edit screen: There are four new filter criteria added to ‘Charge Report Filter’. These additional filter conditions are

• Claim Financial Class Code – To filter out claims having specified ‘Financial Class’ in filter text.
• POS code– To filter out claims having specified ‘POS code’ i.e ‘Place of Service’ in filter text.
• TOS code – To filter out claims having specified ‘TOS code’ i.e ‘Type of Service’ in filter text.
• Capitation Claim Y/N– To filter out Capitation type claims if set to ‘Y’.

When filter conditions are selected on pop up ‘Charge Report Filter’ then icon turns ‘Green’ indicating that filter is applicable.

Note: These additional filter criteria are also available on all those screens where this filter button is present. Like Reports >> By Claims/ By Charges/ Claims >> Outstanding/ Claims Center/ Charges Center screens.



Figure 14.5 – Claims >> Edit screen having new additional filter conditions.

14.6 Filter: All fields (criteria) having Y/N option have dropdown list box.

All fields on icon ‘Filter’ where Y/N is displayed, will have a list box with ‘N’ shown as Default and ‘Y’ is displayed as 2nd option in dropdown list. This change is applicable all screens where this icon ‘Filter’ is displayed like Claims >> Outstanding, Claims >> Claims Center, Claims >> Charges Center etc.



Figure 14.6: Filter criteria having Boolean option are now displayed in drop down list box.

14.7 PO Box Address validation for Patient and Subscriber’s address is now property based.

New property ‘billing.patient.address.pobox.ok’ has been added and according to value set in the property PO Box address validation in Patient and Subscriber’s address would be implemented. If property ‘billing.patient.address.pobox.ok’ is set to ‘Y’, system will allow use of PO Box in Patient and Subscriber’s address while submission of claim otherwise validations are implemented.



Figure 14.7 – PO Box validation when property ‘billing.patient.address.pobox.ok’ is set to 'N'.

15. Claims >> Unprocessed

15.1 Ability to filter out ‘reopened-not reopened’ unprocessed claims.

A new filter condition has been added to field ‘Filter’ as ‘Reopen Y/N’. When this filter condition is selected ‘Reopen =N’, it displays list of unprocessed claims which are not reopened. This will act as status tracking tool for RCM team.



Figure 15.1 – Newly implemented filter ‘Reopen Y/N’ on Claims >> Unprocessed.

16. Remittance >> EOB/ERA

16.1 Population of 'Allowed' amount field for capitation claims is now property driven.

Remittance >> EOB/ERA screen: A new property 'billing.capitation.allowed.schedule' is introduced and it accepts the name of the Fee Schedule Type.

This property is applicable for Capitation claims for which EOB/ERA is received. The field 'Allowed' is populated using the Fee schedule Type defined in the property and this is later used to generate the capitation report. Now on capitation claims, this allowed amount has been made independent of Insurance Master's checkbox 'Not Assigned' and 'Fee Schedule Type. The allowed amount is populated from fee schedule type assigned in property. By default, this property would be set to 'Medicare' as Fee Shcedule . If 'Allowed' fee schedule type is not found or property is kept blank then earlier logic of taking Ins. Master Fee Schedule Type as allowed fee schedule will be in action.

16.2 Hyperlink ‘Instrument#’ displays ‘void’ for charge code marked as void.

In EOB received has claim where charge code was marked as void using checkbox ‘Mark Void’ on Claims >> Edit screen, then hyperlink ‘Instrument#’ displays text ‘void’ for such charge codes.

16.3 Claims search displays Pri/Sec/Ter Ins. name under Pri/Sec/Ter Tab respectively under column ‘Insurance’.

On EOB screen to drop a claim in the EOB, search binocular for claims is used. This ‘Claims Search’ now displays appropriate insurance under column ‘Insurance’ under appropriate insurance tab. For example: On ‘Sec Tab’ of the Claims Search pop up under column ‘Insurance’, will show name of the Secondary insurances only. Similarly, it is applicable for Ter Tab.

16.4 Partial recoup of ‘Excess’ amount is now allowed.

The Recoup functionality has been now extended to allow Partial Recoup of ‘Excess’ Amount. Earlier, only Recoup of full Paid Amt for a claim was supported.
Partial Recoup with Excess Amount: If a claim has multiple line items remitted and if Insurance Company instructs to recoup the ‘Paid and Excess amount’ partially of a single line charge code, allow recouping partial ‘paid amount’ + Excess Amount of a single line charge code from multiple charge lines of a claim now. There was no way to recoup only ‘Paid Amount (Without Excess)’. But now ‘Paid Amount with Excess amount)’ is allowed.

Note: Now Zero Paid Amount Recoup is now allowed.



Figure 16.4 : Partial Recoup of ‘Excess’ amount is displayed.

16.5 Text ‘Claim4PayPlan’/ ‘PatientPayPlan’ displayed against claims selected in EOB according to Patient Payment Plan association.

When a claim has checkbox ‘Plan Payment’ checked and is selected in EOB then text ‘Claim4PayPlan’ is displayed at left corner of the Middle frame in red and bold font. In case where Patient has associated ‘Patient Payment Plan’ but checkbox ‘Plan Payment’ is not marked on the claim then text ‘PatientPayPlan’ is printed.



Figure 16.5.1 - Text 'PatientPayPlan' displayed in bold and red font on for selected claim in EOB.



Figure 16.5.2 - Text 'Claim4PayPlan' displayed in bold and red font on for selected claim in EOB.

16.6 Recoup Claims Search on EOB screen has a new column: ‘For’.

Remittance >> EOB screen: Recoup Claims Search on EOB and Ins Credit screen has a new column: ‘For’ to show PRI, SEC, TER i.e who has paid that claim Amt.

Note: On Remittance >> Ins. Credit screen as well , Recoup Claims Search on Ins Credit screen has a new column ‘For’.



Figure 16.6 – New column ‘For’ on Recoup Claim Search list.

17. Reports >> Statement

17.1 Provision incorporated to print Statement for Attorney.

Reports >> Statement: Now Insurance ‘Attorney’ can be assigned to the patient on Patient Insurance screen and to support this concept, statement for ‘Attorney’ can be generated using Reports >> Statement. New radio button ‘An Attorney’ is provided to generate the statement. A consolidated statement is generated. This consolidated statement contains individual statement of patients who are associated to selected ‘Attorney’. It is the quickest way to find out about patient related transactions under Attorney. There are two statement formats using which statement can be generated:

1. Claim wise
2. Charge code wise

‘Claims wise’ statement format supports ‘Attorney Statement_type2’ whereas ‘Charge Code wise’ supports ‘Attorney Statement_type3’.



Figure 17.1 – New radio button ‘An Attorney’ to generate statement for ‘Attorney’.



Figure 17.1.1 – Attorney Statement using radio button ‘An Attorney’ on pop up statement.

18. Reports >> Tabular

18.1 HSA/HRA tabular reports generation capability to support HSA account feature.

HSA HRA Report used to determine that how many claims were paid from a HSA/HRA account electronically. These are patient payments which come as ELE and hence are received on Remittance>EOB/ERA screen. When 'Paid As' is chosen as HSA manually, the payment is applied to patient responsibility. Hence where there is patient responsibility outstanding, an HSA/HRA EOB can be posted.

 



Figure 18.1–Tabular Reports search list displaying ‘HAS/HRA’ report.

 

Search list Option Name: HSA HRA Receipts

Code: HSA01

 

HSA01:  This report shows the following fields: DocNo, Date, From, Claim, Patient, Code, and Amount.

 



 

Figure 18.1.1– Tabular Report for HSA/HRA Receipts Report:  HSA01.

18.2 Details about Void claims in Tabular Reports are now displayed.

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

 



 

Figure 18.2–Tabular Reports search list displaying ‘Void’ report.

 

Search list Option Name: List of Claims marked Void.

Code: VOID01

 

VOID01: This report displays list of Claims marked as ‘Void’. The report displays following fields: Visit Date, Claim ID, Patient, CopyCreated, Bill Ins Amt, Bill Pat Amt, Bill Tot Amt.

 



Figure 18.2.1– Tabular Report for Void claims:  VOID01.

18.3 Now Tabular report for Patient Payment Plan ‘Defaulters’ generated.

PrognoCIS has added capability to generate tabular reports to display defaulters for patient payment plan as ‘Patient Payment Plan’ feature is now supported by PrognoCIS. The ‘option name’ and ‘code’ used in the system.When 'PAYPLAN01 is selected on tabular report pop up, field 'Type' accepts any of the four values mentioned below:

• All - Generates report having all plan type ie. Monthly, Weekly and Visit.
• M - Generates report having all plan type as 'Monthly'.
• W - Generates report having all plan type as 'Weekly'.
• V- Generates report having all plan type as 'Visit'.



Figure 18.3–Pop up for tabular reports where ‘PAYPLAN01’ is selected.

 

PAYPLAN01: Report ‘PAYPLAN01’ (Patient Payment Plan Defaulters) gives a list of patients who are under payment plan and have skipped their installment payment. As per plan, the patient should pay on a specific date or day or visit based on whether they have signed up for a Monthly, Weekly or Per Visit Payment Plan.

 

This report displays the list of such defaulters with their names, the payment plan name, the due date of the installment which was skipped and the Installment amount they were supposed to pay. The oldest Payment Date skipped entries are shown on the top and for each date, the patient entries are shown in ascending order.

 

Based on this list, the clinic can send the reminder letters to the patients to follow up on the collection of installments.

 



Figure 18.3.1 –List of defaulter patients displayed on ‘Patient Payment Plan’ tabular report.

 

18.4 Tabular report for Capitation Amt for Attending Doc per claim with Copay is added.

Another tabular report for Capitation Amt. for Attending Doc per claim with Copay is introduced. This report prints capitation amt received by outside provider for various claims with Copay collected from patient. It is grouped by Outside Provider.



Figure 18.4- Capition Reports 'CAP04' Tabular Report.

18.5 Program now remembers the last report executed throughout session.

Reports >> Tabular now displays pop up 'Tabular Report' for the first time in the logged in session. Search will not pop-up now.For the first time by default, this pop up displays tabular report for the very first record in the search list. Once user selects and executes the report then the system remembers last executed report in that session. But in case, user logs out of the system then by default, first record in the 'Tabular Report' search list is displayed on the 'Tabular Report' interface. The last executed report is remembered for a session only.

18.6 New ‘Attending Provider Wise’ Daily Collection Tabular report added.

Tabular Report ‘Daily Collections (Co Pay Plus Ins and Pat) By Attending Provider’ is added to track the daily collections for Attending Doctors. The report is grouped by ‘Attending Doc’. User can track Cash Payment, Check Payment and Payment from Card etc using this report per Attending Doctor. The code for this report is ‘COL10’.



Figure 18.6: Daily Collection Report (Co Pay Plus Ins and Pat) By Attending Provider

19. Reports >> Letters

19.1 New layout format is introduced for Patient Ledger.

A new ledger format has been introduced. On Reports >> Ledger pop up, radio button ‘Layout 2’ is used for this newly introduced layout for Patient. As soon as radio button ‘Layout 2’ is invoked, fields ‘Group by’ and ‘Filter By’ gets enabled which allows grouping of fetched records and further narrowing down the transactions respectively.

The generated Ledger report will show all claims transactions on one page for a patient arranged in descending order of the claim’s DOS i.e the same sequence in which the claims are shown in Claims Table on Patient A/C. In Patient Ledger’s ‘Layout2’, lines are displayed after Header and Footer Templates to show proper demarcation and readability. The header and footer are governed by respective properties ‘Ledger2.header.template’ and ‘Ledger2.footer.template’. Various details on the ledger having ‘layout2’ format are printed:

• Insurance Details - Property ‘ledger.patins.fields’
• Patient Details - Property ‘ledger2.patient.tag’

When provider’s NPI is set in property ‘ledger2.exceptiondoc.npi’ and also CPT or HCPC codes are set in property ‘ledger2.exception.cpt’ / ledger2.exception.HCPC then ledger printed using ‘Layout2’ will be printed as following:

• If specified Charge codes(HCPC/CPT) in properties are found in claims  then the amounts under columns ‘Chrg, Ins Pmt, Pat Pmt, Adj, WO, Bal’ are displayed as zero.

The ‘Layout2’ prints charge code wise ledger for the selected patient displaying transactions about ‘ERA Voucher, Adj voucher, Patient Receipt voucher’.

Note:  Property ‘ledger.patient.default.layout’ has values ‘1’ or ‘2’. ‘1’ for current Layout, ‘2’ for new layout: Default value is ‘1’.



Figure 19 –Radio button ‘Layout 2’ used for new ledger layout.



Figure 19.1 – Patient Ledger Report using ‘Layout 2’.

20. Reports >> Letters

20.1 Now send outstanding reminder letter to ‘defaulter’ under Payment Plan Patient.

Reports >> Letters: PrognoCIS has extended the capability to send reminder letter for outstanding amount to defaulter patients under Patient Payment Plan. Radio button ‘Payment Plan Patients’ enables to send intimation/reminder by ‘Letter’ or ‘Email’. The letter is sent in the format which is provided by the system. User should select ‘Template’ using search binocular. The Template Name is ‘PaymentPlanReminder’. Please contact Bizmatics support if it is not found in search.

Note:  Payment Plan Letter is of type ‘BL’.




Figure 20.1 – Radio button ‘Payment Plan Patients’ used to send reminders to patient defaulter under ‘Patient Payment Plan'.

21. Reports >>By Claims/ By Charges/ Collection/ Fin Analysis

21.1 Printing of Header and Footer in reports is now property based.

With the introduction of header and footer templates for various reports and appropriate properties defined for the reports, now it is possible to set the ‘header’ and ‘footer’ template’s name in respective property. It provides customization ability to user to design and save the header and footer and use them as header and footer after being set in the respective property. It has become one time activity and can be used appropriately when required.
There are various properties for ‘By Claims’, ‘By Charges’, ‘Collection’ and ‘Fin Analysis’ report. Separate properties are defined header and detail for each report. These properties are are 'claimrep.header.template', ‘claimrep.footer.template’, 'chargerep.footer.template', 'chargerep.header.template',  'collectiondetails.header.template', 'collectiondetails.footer.template', 'collectionheader.header.template', 'collectionheader.footer.template'.  For example, user can set property ‘collectiondetails.header.template’ with template name as ‘Letterhead’, make sure that ‘Letterhead’ template already saved in the system. When collection report for detail is printed then that report will print the header having the format designed in template ‘collectiondetails.header.template’.



Figure 21.1 – Collection report displaying header printed as per designed in the header template.

22. Settings >> Config >> Clinic >> Enc Types

Two new options are introduced in the field 'Bill To' for the Encounter Type to be set. These options in the drop down 'Bill To' are:

• Normal + Ub04
• No Claim

Enc type >> Bill To: Normal + Ub04: When Enc Type having 'Bill To' as 'Normal + Ub04' is selected in an Encounter then two claims are created:

• Professional Claim: Professional Claim with CPT/HCPC codes if set in assessment.
• UB04 Claim: UB04 claim will be populated with Revenue Code, Procedure Code and Amount based on property 'rural.additional.ub04claim.ub04.codes'. The values set in the property are populated on UB04 Claims created.

Note:  For ‘Self Pay’ claims where Enc Type is ‘Normal+UB04’, single ‘professional’ claim gets created and ‘UB04’ claim does not get created.

Enc type >> Bill To: No Claim: With this Encounter Type, no claim would be created.

23. Settings >> Config >> Clinic >> Patient PayPlans

A new screen for creation of Patient Payment Plan and storing the payment details about the plan for patients is introduced. Screen ‘Patient PayPlans’ allows creation of the patient payment details and it also keeps history of the payments. Under a plan for patient, details like Patient, plan name, Total Amount To be Collected, Installment Amount, Plan Type, Payment Day, Pan Effective from Date, Closed on Date, Notes, Collected Amount, Balance Amount (Total Amount – Collected Amount), Next Payment, Active, Last Updated By can be stored and used for patient. There are three types of plans 'Weekly', Monthly' and 'Per Visit'.

Fields marked with '*' in front of field name are mandatory fields.

Details about fields on Patient Plan Interface:

Patient: It accepts the existing patient name either using search icon or auto complete feature.
Plan Name: The Payment Plan is always finalized before the patient treatment starts. One Patient has only one Payment Plan open at a given point of time.
Total Amount to be Collected: Total amount collected to be used for the created Patient Payment Plan.
Installment Amount: As per plan type, the fixed amount to be paid per month/week/per visit.
Plan Type: There are three Plan Types out which single can be selected. Drop down 'Plan Type' displays 'Monthly'/'Weekly'/'Visit'.
Payment Date: It is the day of the month on which installment should be be collected.
Plan Effective from Date: It is mandatory field. It is the Date when plan comes in to effect. It is standard date field with calendar and date format is mm-dd-yyyy. Appropriate date range is selected as per selection in drop down 'Plan Type'.
Closed on Date: It is mandatory field. Date when plan seizes to exist. It is standard date field with calendar and date format is mm-dd-yyyy.
Notes: The summary of the Payment Plan can be added by users.
Collected Amount: Actual amount collected from the patient. It is the addition of all installment amounts collected so far. It is grayed and is auto calculated by system. As soon as 'Collected Amount' is collected in the current month, the field 'Next Payment Date' is accordingly set to next with respect to the current date that was present before collection of 'Collected Amount'.
Balance Amount: It is remaining amount to be paid (Total Amount - Collected Amount). It is grayed and is auto calculated by system.
Next Payment Date: It is mandatory field. Date for next payment if balance amount is remaining. Consider a scenario, if payment was pending since last two months and payment is received in the current month. In this case, the 'Collected Amount' would change appropriately after collection of amount but user needs to manually change the 'Next Payment Date'.
Complete: It is a checkbox. At any point of time if checkbox is marked then the Plan becomes inactive. No further changes are entertained on the selected plan where checkbox 'Complete' is marked. It might so happen that when 'Plan' was active, there were some patient responsibility having 'Patient Payment Plan'. In such a case, user should simply writeoff patient responsibility in such claims. Once 'Plan' is complete, other 'Patient Payment Plan' for the patient can be defined.
Last Updated: It displays details about 'Last updated by user' with date and time stamp.

Note: Button 'delete' will delete the currently selected Patient Payment Plan provided that specific 'Patient Payment Plan' entry is not created for any Claim, Copay and Patient Receipt.

 



Figure 23 –Patient Payment Plan Master.

24. Settings >> Config >> Templates

24.1 . Various new templates added to support various features.

PrognoCIS has added various templates to support features. These templates are listed as follows:

Letter Template

1. Payment Plan Reminder Letters - 'PaymentPlanReminder'

Form Templates

1. Header Template for Billing Reports (Added new template under Forms and associated to properties)
2. Footer Template for Billing Reports (Added new template under Forms and associated to properties)

Billing Templates

1. UB04 (UB04)
2. CMS_1500_SEC_PDF_B9
3. RespPerson_Statement_Type2
4. RespPerson_Statement_Type3
5. Attorney_Statement_Type2
6. Attorney _Statement_Type3

24.2 .Modify UB04 template using button ‘Edit UB04’.

Settings >> Configuration>> Billing >> Templates; A new button ‘Edit UB04’ has been added on UB04 template screen to make editing of HTML tags associated with UB04 simple & easy. If template subtype selected is UB04 then ‘Edit Ub04’ button is visible on Template screen. On click of button ‘Edit UB04’, ‘Edit Template’ pop up is displayed which is in readable form. This pop up has ‘UB04 Cell Title’, ‘Default Tag’, ‘Tag Used’ as columns on pop up. User can edit the tag(s) on this pop up. These changes are reflected on the UB04 form once ‘Edit Template’ pop up closes.
Earlier it was tedious job to search a tag in the ‘HTML’ view and replace/ change the required tag.
But now with ‘Edit UB04’, UB04 form editing is made simple and easy with the help of user interface for tags used in UB04 form.

 Note: Fields in columns ‘Cell Title’ and ‘Default Tag’ are displayed as defined in file ‘ub04.csv’. It is saved in datafiles folder ‘blSummaryLayout’. The details of columns tag used are pulled from template currently displayed.

 



Figure 24.2 – Button ‘Edit UB04’ to edit UB04 templates from PrognoCIS.

25. Settings >> Diagnostics

25.1 . 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: 094: Set the Address for Patient Insurance where Address is blank or null.
2. Case: 095: List Claims with track status as rejected but EOB received for the same.
3. Case: 096: Fix Claims with track status as rejected but EOB received for the same.

26. Settings >> Vendors >> Ins Adjuster

26.1 .Ability to Copy Insurance Address to Adjuster Address and modify it.

Settings >> Config >> Adjuster Master: New button is added on Adjuster Master which allows copying of address of Insurance selected in field ‘Insurance’. This button is enabled once insurance is selected and saved. Click button ‘Copy Ins Add’ to copy the address of the Insurance Address. Once address is copied, user can modify it accordingly and save. It is very useful feature as data entry is reduced for the user.



Figure 26.1- Button ‘Copy Ins Add’ on Ins Adjuster.

27. Settings >> Clinics >> Scheduled Process

27.1 .New Scheduled Process ‘WRITE _OFF_CAPITATION’ is now introduced.

A new scheduled process 'WRITE_OFF_CAPITATION' is introduced by PrognoCIS which would automatically write off amounts in 'Capitation' type

claims. This scheduled process executes every evening. This would reduce the effort to write off amounts in Capitation claims when EOB is received for the same. Therefore, a biller does not have to wait till the EOB is received for Capitation type claims to write off amounts.

27.2 .Scheduled Process search list displays ‘Billing’ specific scheduled process only.

When hyperlink ‘Scheduled Process’ under Settings >> Config >> Scheduled Process is clicked, ‘Scheduled Process’ search list is displayed. This search list would now display those Scheduled Processes which are applicable to ‘Billing’ module. Definition is possible from EMR as well as Billing side. Only Search is restricted.

 

New Properties Introduced

Property	Description
billing.calc.allowed.onsave	If set to Y, computes Allowed amount for each Charge on every save of claim. If set to N, computes it on marking claim as Ready to Send.
billing.injury.exception.dxcodes	If ICD Codes 800 to 994 are used, as a rule Injury Date is mandatory. User can define a comma separated list of ICD Codes in this range which are an exception and do not follow this rule.
billing.ub04.rural.health.support	If Y is set, Encounter Type Master Bill to List Box has an extra option for Rural Health Visit.
billing.ub04.billtype.value	Enter the default 3 digit value of Bill Type for UB04 Claims.
billing.ub04.visittype.value	Valid values are Emergency/Urgent/Elective/New Born/Trauma Center/Other.
billing.ub04.cell76.qualifier.codes	Enter the priority sequence of comma separated Provider Qualifiers codes which will be considered for printing cell 76. Typical values are XX(NPI).
billing.ub04.cell77.qualifier.codes	Enter the priority sequence of comma separated Provider Qualifiers codes which will be considered for printing cell 77. Typical values are XX(NPI).
billing.ub04.cell78.qualifier.codes	Enter the priority sequence of comma separated Provider Qualifiers codes which will be considered for printing cell 78.Typical values are XX(NPI).
billing.ub04.cell79.qualifier.codes	Enter the priority sequence of comma separated Provider Qualifiers codes which will be considered for printing cell 79.Typical values are XX(NPI).
ub04.rh1.revprocamts	Enter the default comma separated sets of Revenue code, Procedure code and Bill Amount for UB04 Rural Health Claim for Primary Insurance. Note the two separator characters are : and $. Ex: 451:01$100, 452:02$200, 453$300.
ub04.managedcare.revprocamts	Enter the default comma separated sets of Revenue code, Procedure code and Bill Amount for UB04 Rural Health Claim for Managed Care type. Note the two separator characters are : and $. Ex: 451:01$100, 452:02$200, 453$300
ub04.rh2.revprocamts	Enter the default comma separated sets of Revenue code, Procedure code and Bill Amount for UB04 Rural Health Claim for Primary Insurance. Note the two separator characters are : and $. Ex: 451:01$100, 452:02$200, 453$300
claimrep.header.template	Enter a Form Template Name.
claimrep.footer.template	Enter a Form Template Name
claims.unprocessed.show.assigned	If set to Y, the Claims > Unprocessed screen displays the Assigned To / Date / Status fields as seen on Claims > Outstanding screen.
chargerep.header.template	Enter a Form Template Name
chargerep.footer.template	Enter a Form Template Name
collectiondetails.header.template	Enter a Form Template Name
collectiondetails.footer.template	Enter a Form Template Name
collectionheader.header.template	Enter a Form Template Name
collectionheader.footer.template	Enter a Form Template Name
billing.capitation.allowed.schedule	When any capitation claim is marked 'Ready to Send', the allowed amount is set to allowed amount in Fee Schedule that is set in property. This allowed amount is displayed on EOB >> Claims>> Allowed amt. field and is used for capitation reports.
ledger.patins.fields
billing.employer.invoice.patfields	Add any patient tag to print patient detail like Pat. SSN, chart no. on Employer Invoice.
ledger2.exceptiondoc.npis	Provider NPIs, if entered here are treated as exceptions and Charge Totals are not built for these providers on ledger printed.
ledger2.exception.cpt	CPT codes, if entered here are treated as exceptions. When these CPT codes are found in claim and ledger is printed for patient associated to that claim then Charge Totals are not built for these CPT codes and are displayed as zero in ledger. Various amounts under columns Chrg, Ins Pmt, Pat Pmt, Adj, WO, Bal are displayed with zero amount for CPT codes mentioned in the property.
ledger2.exception.hcpc	HCPC codes, if entered here are treated as exceptions. When these HCPC codes are found in claim and ledger is printed for patient associated to that claim then Charge Totals are not built for these HCPC codes and are displayed as zero in ledger. Various amounts under columns Chrg, Ins Pmt, Pat Pmt, Adj, WO, Bal are displayed with zero amount for HCPC codes mentioned in the property.
ledger2.patient.tag	Define Patient related tags which would be printed at the start of the Ledger below header. It will print customized patient details on ledger for the selected patient.
billing.disable.submit.claim	This property enables to process claims when set to Y otherwise claims are not allowed to process even though Billing is turned ON for user. This should be turned ON after complete EDI set up for user is ready and then property is turned ON so that claims are not rejected due incomplete EDI set up information by clearinghouse. Default value is set to N for existing clients. For new clients, this property is set to Y in library and frontend implementer should set it to N once EDI set up for new client is completed.
billing.patient.address.pobox.ok	If set to Y, system will allow the use of PO Box in address of Patient and Subscriber for submission of claims.





New Tags Introduced

ENC_FSS_NOTES_TITLE:
ENC_FSS_NOTES_TITLE_1:
ENC_FSS_NOTES_TITLE_2:
ENC_FSS_NOTES_TITLE_3:
ENC_FSS_NOTES_TITLE_4:
ENC_FSS_NOTES_TITLE_5:
ENC_FSS_NOTES_TEXT:
ENC_FSS_NOTES_TEXT_1:
ENC_FSS_NOTES_TEXT_2:
ENC_FSS_NOTES_TEXT_3:
ENC_FSS_NOTES_TEXT_4:
ENC_FSS_NOTES_TEXT_5:

ENC_SUPERVISOR$

PT_PPP
PT_PPP_CODE
PT_PPP_NAME
PT_PPP_AMOUNT
PT_PPP_INSTALMENTAMT
PT_PPP_COLLECTEDAMT
PT_PPP_BALANCEAMT
PT_PPP_DUEDATE

PT_ALERT
PT_ALERT_ALL
PT_ALERT_APPT
PT_ALERT_ENC
PT_ALERT_BILL
PT_BILLING_LEDGER

BLH_UB04_50PRINAME before BLH_SQL
BLH_UB04_4223COUNT

BLH_RESPBAL
BLH_RESPBAL_PRI
BLH_RESPBAL_SEC
BLH_RESPBAL_TER
BLH_RESPBAL_EMP
BLH_RESPBAL_PAT
BLH_RESPBAL_TOT

PT_ADJUSTER$
PT_ADDRESSBOOK1$
PT_ADDRESSBOOK2$
PT_ADDRESSBOOK3$
BLTag2String
DBAddressBook

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