Claims Submission Process Map
Index of Guidelines
MAP / TASK / PAGEA__Electronic Claims Submission / A01__Import Electronic Claims Batch into MCMS and Scrub the Data / 2
A__Electronic Claims Submission / A02__Balance HQ Output Report with MCMS Input Report / 3
A__Electronic Claims Submission / A03__Correct Claim Level Errors / 4
A__Electronic Claims Submission / A05__Confirm Transmission / 5
A__Electronic Claims Submission / A06__ Review Payer Report / 6
A__Electronic Claims Submission / A07__Correct Balancing Errors / 7
A__Electronic Claims Submission / A08__Correct Account Level Errors / 8
A03__ Correct Claim Level Errors / A0301__Select Claim(s) to Review / 9
A03__ Correct Claim Level Errors / A0302__Correct Errors / 10
A03__ Correct Claim Level Errors / A0303__Re-Scrub the Claim / 11
A03__ Correct Claim Level Errors / A0304__Add Note to System / 12
A03__ Correct Claim Level Errors / A0305__Determine Transmission Method / 13
A03__ Correct Claim Level Errors / A0306__Enter and Transmit Claims / 14
A03__ Correct Claim Level Errors / A0307__Print and Mail Claim / 15
A03__ Correct Claim Level Errors / A0308__Add Note to System / 16
A03__ Correct Claim Level Errors / A0309__Delete Claim / 17
A03__ Correct Claim Level Errors / A0310__Add Note to System / 18
A04__Convert Claims to 837 Format and Send to Payer / A0401__Send 837 Claim Files / 19
A04__Convert Claims to 837 Format and Send to Payer / A0402__Copy Medicare 837 Files to the Network Drive / 20
A04__Convert Claims to 837 Format and Send to Payer / A0403__Document the Transmission in the Balancing Checklist / 21
A04__Convert Claims to 837 Format and Send to Payer / A0404__Correct 837 Format Error / 22
A08__ Correct Account Level Errors / A0802__Correct Errors / 23
A08__ Correct Account Level Errors / A0803__Re-Bill the Claim / 24
A08__ Correct Account Level Errors / A0804__Add Note to System / 25
A08__ Correct Account Level Errors / A0805__Re-Print the Claim / 26
B__Paper Claims Submission / B01__Distribute Printed Claims / 27
B__Paper Claims Submission / B02__Review Claims and Add Attachments / 28
B__Paper Claims Submission / B04__Add Note to System / 29
B__Paper Claims Submission / B05__Review and Resolve the Delayed Claim / 30
B__Paper Claims Submission / B06__Add Note to System / 31
C – Medicare Supplemental Claims / C01 – Import the 837 Claim File from the Network Drive to Emdeon DSS / 32
C – Medicare Supplemental Claims / C02__ Import the 835 Remittance File from the Network Drive to Emdeon DSS / 33
C – Medicare Supplemental Claims / C03__ Import the Supplemental Print Image File from the Network Drive to Emdeon DSS / 34
C – Medicare Supplemental Claims / C04__Compare the 837, 835 and Supplemental Print Image Data / 35
C – Medicare Supplemental Claims / C07__ Compare the 837 and 835 File Data / 36
C – Medicare Supplemental Claims / C08__Check Payment/Denial Status / 37
C – Medicare Supplemental Claims / C09__Create Supplemental Claim Using Payment Data / 38
C – Medicare Supplemental Claims / C11__Skip Unprocessed Claim – Claim Remains Open / 39
C05__ Crosswalk Provider Number to UPIN / C0501__Create the Crosswalk Text Files / 40
C06__Create Export File and Mark Crossover Claims / C0601__Create Export File / 41
C06__Create Export File and Mark Crossover Claims / C0602__Edit Crossover Claims / 42
C10__Transmit Print Image File to Print Vendor and Note HQ / C1001__ Move Print Image Claim Files to Outgoing Directory / 43
C10__Transmit Print Image File to Print Vendor and Note HQ / C1002__ Add a Transmission Note and Route Code / 44
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Patient Financial Services (PFS) Enterprise Process Map Guideline
(Last Updated: 08/21/06)
Enterprise Task
Subject: Claims Submission
Map: A__Electronic Claims Submission
Task: A01__Import Electronic Claims Batch into MCMS and Scrub the Data
Task Description:
This is an automated daily process through which ANSI 837 claim data is imported from HealthQuest (HQ) to the Misc Claims Management System (MCMS). Once the import has been completed, the ANSI 837 claim data is scrubbed within the Misc Claims Management System (MCMS). Any errors identified by the claim scrubbing software are worked and corrected within MCMS.
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Patient Financial Services (PFS) Enterprise Process Map Guideline
(Last Updated: 08/21/06)
Enterprise Task
Subject: Claims Submission
Map: A__Electronic Claims Submission
Task: A02__Balance HQ Output Report with MCMS Input Report
Task Description:
Balance the HealthQuest (HQ) output summary report with the Misc Claims Management System (MCMS) input summary report.
Additional Information:
When a batch file of ANSI 837 insurance claim data is produced by HQ and passed to MCMS, the ‘PACA01D1’ detail report and the ‘PACA01D2’ summary report are produced. These reports list the claims that have been output from HQ. In addition, the ‘IMPORT_HCFA_MCMS3_yyyy-mm-dd_hh-mm-ss.txt’ and ‘IMPORT_UB92_MCMS3_yyyy-mm-dd_hh-mm-ss.txt’ summary reports are produced. These reports list the claims that have been input into the claim scrubbing tool in MCMS.
Note: The HQ output reports sort the claim data by extract ID and plan code. The MCMS input reports sort the claim data by the claim scrubbing rule set to which they belong. In order to balance the input and output information, a Commercial Assistant Operations Specialist imports the summary report data into an Access database which will automatically calculate any variance between the output and input totals.
Generally, the output and input reports are in balance. On the rare occasions when the reports are out of balance, assistance may be requested from the Medicare, Medical Assistance & Other Government, and Commercial Assistant Operational Specialists to review the report data and identify the claim(s) causing the error. Once the source of the errors has been determined, claims may be manually corrected in the system or, if the errors are significant, a re-import of the claim data from HQ into MCMS may be necessary. Documentation of the actions taken to resolve balancing issues is archived for future reference.
Site Specific Notes:
Clinic A (CA):
§ While this task is performed at CA, no hand off occurs between Assistant Operations Specialist and Billing Representative. The Billing Representative handles the entire process.
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Patient Financial Services (PFS) Enterprise Process Map Guideline
(Last Updated: 8/21/06)
Enterprise Task
Subject: Claims Submission
Map: A__Electronic Claims Submission
Task: A03__Correct Claim Level Errors
Task Description:
When preparing claims for electronic transmission, any errors identified must be corrected prior to submission. Claim level errors refer to those where only one individual claim is affected while account level errors refer to an issue that would affect all current and future claims produced from the patient’s account. Claim level errors are corrected within the Misc Claims Management System (MCMS) claim system.
The claim level errors that need to be corrected generally fall into the following categories. Each error must be individually scrutinized and corrected before the claim can be transmitted.
§ Transmission Acknowledgement Errors:
An error in the Transmission Acknowledgement indicates that the payer has not loaded the claims in the transmitted batch into their system for adjudication.
§ Scrubber Errors:
Scrubber errors occur when a set of circumstances exists on a claim as defined in an MCMS edit. MCMS edits are written by EC Systems and Assistant Operations Specialists in response to HIPAA compliance, Operational procedures, or Payer relation issues.
§ Validator Errors:
Validator errors occur when a set of circumstances exists on a claim as defined by the Instream Validator tool. The Validator tool checks for HIPAA compliance issues and can validate values and check date dependencies.
§ Payer Report Errors:
Payer Claim Report errors occur when claims have been received into a payer’s adjudication system, reviewed, and found to have errors. These errors are returned on the payer or clearinghouse reports and must be corrected before claims can be re-submitted.
See Map A03 Level 2 for more information on correcting claim level errors.
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Patient Financial Services (PFS) Enterprise Process Map Guideline
(Last Updated: 08/21/06)
Enterprise Task
Subject: Claims Submission
Map: A__Electronic Claims Submission
Task: A05__Confirm Transmission
Task Description:
The 997 and Emdeon PGP transmission acknowledgement files are automatically distributed to the appropriate Assistant Operations Specialist(s) via e-mail. The Assistant Operations Specialist (AOS) responsible for each claim file transmission will document in the appropriate Balancing Checklist that the Transmission Acknowledgement was received and that the file was accepted. The acknowledgement reports are reviewed based on the following:
997 Acknowledgement Reports:
The Transaction Set Control Numbers (TSCN) in the 997 Acknowledgement reports are compared to the batch numbers on the EC Systems transmission stat file. This comparison is done to confirm that each file sent has also been received and acknowledged.
Emdeon PGP Acknowledgement Reports:
The transmission file name, {Payer Destination}.PGP, and the transmission date and time in the Emdeon PGP files are compared by an Assistant Operations Specialist. This comparison is done to confirm that each file sent has also been acknowledged.
Note: No transmission acknowledgement files are received from MMSI (payer).
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Patient Financial Services (PFS) Enterprise Process Map Guideline
(Last Updated: 08/21/06)
Enterprise Task
Subject: Claims Submission
Map: A__Claims Submission
Task: A06__ Review Payer Report
Task Description:
When Payer Claim Error Reports are received, they are automatically distributed the appropriate Assistant Operations Specialist (AOS) for review.
The appropriate Assistant Operations Specialist will enter data from the Payer Claim Error Report into the Balancing Checklist and distribute the claim errors to the Billing Representatives for correction and resubmission to the payer. The report is matched to the claim transmission by the transmission date, total number of claims or the total dollar amount of claims in the transmission.
Notes:
§ The Commercial Assistant Operations Specialist uses CIS ETaR to load payer reports. The Government and Other Government Assistant Operations Specialists do not.
§ The MMSI report is manually accessed through Document Direct and reviewed.
Site Specific Notes:
Clinic A (CA):
§ While this task is performed at CA, no hand off occurs between Assistant Operations Specialist and Billing Representative. The Billing Representative handles the entire process.
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Patient Financial Services (PFS) Enterprise Process Map Guideline
(Last Updated: 08/21/06)
Enterprise Task
Subject: Claims Submission
Map: A__Electronic Claims Submission
Task: A07__Correct Balancing Errors
Task Description:
On rare occasions following system or program changes, significant balancing errors may be identified during the import of claim data from HealthQuest (HQ) to the Misc Claims Management System (MCMS). When this occurs, an Assistant Operations Specialist will contact the appropriate staff to assist with identifying and correcting the source of the errors. Once the corrections have been made, the following steps are performed to re-import the claims from HQ to MCMS:
1. Instruct the effected MCMS users to exit claims and MCMS and wait to be notified that the re-import has been completed.
2. If necessary, coordinate with System Services personnel to recreate the HQ 837 files.
3. Coordinate with Electronic Commerce Systems to delete the claims previously imported into MCMS.
4. Coordinate with Electronic Commerce Systems to import the corrected HQ 837 file(s) into MCMS.
5. Notify the effected MCMS users that claims have been re-imported and the new claims can be worked.
Site Specific Notes:
Clinic A (CA) :
§ While this task is performed at CLINIC A, no hand off occurs between Assistant Operations Specialist and Billing Representative. The Billing Representative handles the entire process.
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Patient Financial Services (PFS) Enterprise Process Map Guideline
(Last Updated: 08/21/06)
Enterprise Task
Subject: Claims Submission
Map: A__Electronic Claims Submission
Task: A08__Correct Account Level Errors
Task Description:
When preparing claims for electronic transmission, any errors identified must be corrected prior to submission. Claim level errors refer to those where only one individual claim is affected while account level errors refer to an issue that would affect all current and future claims produced from the patient’s account. Account level errors are corrected within the HealthQuest (HQ) system.
The account level errors that need to be corrected generally fall into the following categories. Each error must be individually scrutinized and corrected before the claim can be transmitted.
§ Transmission Acknowledgement Errors:
An error in the Transmission Acknowledgement indicates that the payer has not loaded the claims in the transmitted batch into their system for adjudication.
§ Scrubber Errors:
Scrubber errors occur when a set of circumstances exists on a claim as defined in an MCMS edit. MCMS edits are written by EC Systems and Assistant Operations Specialists in response to HIPAA compliance, Operational procedures, or Payer relation issues.
§ Validator Errors:
Validator errors occur when a set of circumstances exists on a claim as defined by the Instream Validator tool. The Validator tool checks for HIPAA compliance issues and can validate values and check date dependencies.
§ Payer Report Errors:
Payer Claim Report errors occur when claims have been received into a payer’s adjudication system, reviewed, and found to have errors. These errors are returned on the payer or clearinghouse reports and must be corrected before claims can be re-submitted.
See Map A08 Level 2 for more information on correcting account level errors.
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Patient Financial Services (PFS) Enterprise Process Map Guideline
(Last Updated: 08/21/06)
Enterprise Task
Subject: Claims Submission
Map: A03__ Correct Claim Level Errors
Task: A0301__Select Claim(s) to Review
Task Description:
Create a list of claims to review by performing the following steps:
1. Open MCMS
2. Enter the user name and password
3. Select production