Help Desk Message Center User Guide V1.0

Credit Balance

User Guide

Version 1.0

National Government ServicesCredit Balance

User Guide

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User Guide

Table of Contents

Part I: Introduction

Overview

Objectives

Part 2: Login to Credit Balance

Part 3: Low-Utilization Providers

Determine Low-Utilization Providers

Part 4: Import Status......

Load Provider Status

Load Electronic 838 Status

Part 5: Enter/Edit Data

Certification Screen

838 Details Screen

Exclude Provider Screen

Load Provider Data

Part 6: View Credit Balance Status

View Status Screen

Part 9: System Access Roles

New Terms

Appendix A. CMS 838 Instructions

Appendix B. 838 Credit Balance Report Detail Page

Appendix C. Credit Balance Report Provider Instructions

Appendix D. Phone Note Table

Appendix E. Credit Balance Statuses

Index

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Part I: Introduction

Overview

This Credit Balance User Guide will cover topics of interest to View-Only users, Account Representatives, Claim Representatives and Customer Service Representatives.

Providers are required to submit a Certification Page communicating that they have reviewed their records and determined any credit balance claims. If they identify credit balance claim claims, the Provider is required to resolve the credit balance claim. Hence, providers are required to adjust claims which were determined to have been overpaid either through the direct data entry (DDE) system or by a paper adjustment submission. When the provider enters the credit balance data, the system will check to assure that an adjustment has been completed. The Credit Balance application comes into play when the provider transmits the Certification and 838 Detail page at the end of each quarter.

What is a “credit balance” and the Credit Balance application? The best way to explain this is to start at the beginning – with the CMS-838. The CMS-838 is used specifically to monitor identification and recovery of “credit balances”owed to Medicare. A “credit balance” is an improper excess payment made to a provider as the result of a patient billing or claims processing error. Some examples of Medicare credit balances may include instances where a provider is:

• Paid twice for the same service either by Medicare or by Medicare and another insurer.
• Paid for services planned but not performed or for non-covered services.
• Overpaid because of errors made in calculating beneficiary deductible and/or co-insurance amounts.
• A hospital that bills, and is paid, for outpatient services included in a beneficiary’s inpatient claim.

Credit Balances would not include proper payments made by Medicare in excess of a provider’s charges such as DRG payments made to hospitals under the Medicare prospective system.

The Credit Balance applicationcan receive information from the Fiscal Intermediary Standard System (FISS), CMS Systems and/or via manual data entry. Each quarter (Jan-March, due by April 30th; April-June, due by July 30th; July-Sept., due Oct. 30th; Oct.-Dec., due by Jan. 30th) “non-low utilization” providers are required to submit hardcopy documentation to National Government Services (NGS) certifying their credit balance status: zero balance, adjustment submitted, etc. The NGS Account Representative, upon receipt, enters the certification information into the Credit Balance application.

Below is a graphical representation of the Credit Balance process flow. All providers must mail or fax a credit balance certification page to NGS each quarter. The certification page will indicate whether or not the provider has a credit balance for that period. If they do not have a credit balance, the certification page is all that is required. If the provider does have a credit balance, they are also required to submit an 838 Detail Page (see Appendix B. 838 Credit Balance Report Detail Page) which provides information on the claims involved in the overpayment.

If the provider chooses to submit the 838 Detail via mail or fax, a representative from Overpayment Recovery enters the 838 detail into the Credit Balance application. The provider may also choose to enter the 838 Detail themselves using the DataCenter’s direct data entry (DDE). If the data is entered in this manner, the 838 data is automatically transferred from the data center to the Credit Balance application.

All “non-low utilization” providers which have credit balances are required to submit the claims that have been identified with a credit balance on the 838 Detail Report. Currently, the 838 Detail Report can be received at NGS manually via mail or fax. It can also be received electronically through the CMS mainframe systems(DataCenter’s direct data entry (DDE)).

Once the 838 Detail Report Information is received and populated into the Credit Balance application, the Credit Balance application validates receipt of the credit balance adjustments and updates the claim status.

Objectives

The objectives of this user guide include the following:

• Importing Electronic 838 Data.
• Entering and/or editing data on the Certification Page.
• Entering and/or editing the 838 claim detail data.
• Automatically validating claim adjustments.
• Generating CMS reports.
• Viewing credit balance statuses.
• Loading providers.
• Entering and/or editing provider contact and authorizing officialdata.
• Maintaining credit balance holds.
• Excluding providers from the Credit Balance tracking process.

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Part 2: Login to Credit Balance

In order to answer provider questions regarding credit balance reports which have been submitted to NGS you will need to know how to access the Credit Balance application. This application houses data which was entered either by Overpayment Recovery from paper 838 forms or by the provider via the DataCenter’s direct data entry (DDE).

To begin using the Credit Balance application you need to login to the system. Follow the steps below to login to the Credit Balance application.

1. Open Internet Explorer and navigate tocreditbalance.corp.ngsmedicare.com. The Credit Balance signon screen will be displayed.

1. Enter your NGS Network User ID. For example, firstname.lastname (e.g., joe.shmoe)
2. Enter your NGS Network Password.
3. Click .
4. The Credit Balance Application Home page is displayed.

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Part 3: Low-Utilization Providers

The View Status screen is the first screen you see when you log into the Credit Balance application. This screen displays summary information about the provider’s credit balance status. This is also where you search for a specific provider to answer questions.

Low Utilization providers will submit the Certification page to certify that they are a low utilization provider. Low-utilization is determined based on the number of paid claims being less than twenty-five (25) for the previous twelve (12) months.

Determine Low-Utilization Providers

1. From the main Credit Balance Applicationmain page enter the appropriate ID in the Provider ID field.

1. The Quarter Enddate defaults to the current quarter end date.

1. Click to display the provider information.

1. The appropriate Workload number is automatically populatedor can be selected from the drop-down. The list of values will display if the provider has more than one workload.

1. Click the Provider Details link to display provider information.Click the Provider Details link again to hide the detail information.This is used to confirm that you have to correct provider.
2. Select the Certification tab to view the Low Utilization and Low Utilization Validation Date fields.

1. After viewing the the Low Utilization and Low Utilization Validation Date fieldsselect the View Status tab to use Phone Notifications to document your interaction with the provider.
2. Scroll to the bottom of the View Status screen to view Phone Notifications details. There is a separate scroll bar for this section if there are numerous phone notifications listed.

1. To add an update to the Phone Notifications, click . This displays an Edit Phone Note pop-up box. When a provider calls with a credit balance issue, this is where you log information about the call.

1. Click to display a list of options for Phone Notes. Select the appropriate issue (see Appendix D Phone Note Table) the provider called about from this drop-down list.

1. Click to save your changes or to cancel the process. This will close the pop-up box and return you to the View Status page.

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Part 4: Import Status

Load Provider Status

This process happens at the beginning of each quarter. To view the status of the Loading of Providers follow the steps listed below.

1. Click the Import Status tab to move to the Import Status screen.

1. The Workload corresponds to the FISS workload.
2. The Run Date corresponds to the date the provider workload was loaded into the Credit Balance application
3. The Count field indicates the number of providers loaded from FISS into the Credit Balance application
4. The Status field indicates if the load was “Successful” or if the load “Failed”.

Load Electronic 838 Status

The Credit Balance application allows the automatic importation of data from CMS data centers (DDE) to the Credit Balance application. This import happens on a weekly basis over the weekend via a batch process ran on the mainframe. The batch process creates a flat file which is automatically uploaded from the mainframe to the Credit Balance application.

To view the status of the Loading of Electronic 838 Information follow the steps listed below.

1. Click the Import Status tab to move to the Import Status screen.

1. The Workload corresponds to the FISS workload.

1. The Run Date corresponds to the date the provider workload was loaded into the Credit Balance application.
2. The Count field indicates the number of providers loaded from FISS into the Credit Balance application.
3. The Status field indicates if the load was “Successful” or if the load “Failed”.

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Part 5: Enter/Edit Data

Certification Screen

The Cerfitication screen is the electronic version of the provider’s quarterly certification page. This screen is a summary which displays information about what the provider submitted on the certification page they mailed/faxed to NGS.

The Account Representatives enter information from mailed and/or faxed copies of the Provider’s Credit Balance Certification documentation. The Certification page is used for this task.

1. Click the Certification tab to move to the Certification screen.

1. Click the Provider Details link to display provider information.
2. Click the Provider Details link again to hide the detail information.
3. Using provider documentation on a quarterly basis, the Account Representative must verify the following information:

1. Contact First Name: Enter the contact’s first name.
2. Contact Last Name: Enter the contact’s last name.
3. Contact Phone: Enter the contact’s nine (9) digit phone number, including dashes. If dashes are not included, an error will occur.
4. Contact Fax: Enter the contact’s nine (9) digit fax number, including dashes. If dashes are not included, an error will occur. This is an optional field.
5. Authorizing Official First Name: Enter the first name of the authorizing official.
6. Authorizing Official Last Name: Enter the last name of the autorizing official.
7. Authorizing Official Title: Enter the title of the authorizing official.
8. Authorizing Official Date Signed: Enter the date the authorizing official signed the form.

1. TheExclude checkbox will be selected if the provider has been excluded from the 838 process.
2. An Exclude Reason will be displayed if the provider has been excluded from the 838 process.
3. An Exclude Date will be displayed if the provider has been excluded from the 838 process. The year must be entered as a four-digit year or an error will occur.
4. An Include Date will be displayedif the provider has been previously excluded from the 838 process and is now to be included again. The year must be entered as a four-digit year or an error will occur.
5. The Low Utilization checkbox is selected when the provider is designated as a low utilization provider.
6. ALow Utilization Validation Date will be displayed if the provider has been excluded from the 838 process.
7. Select one of the following radio buttons for the CMS-838 Status:

1. Electronic CMS-838 Submitted: The CMS-838 report was submitted electronically.
2. Hardcopy CMS-838 Submitted: The CMS-838 report was submitted via hardcopy.
3. Zero Credit Balance: The provider has a zero ($0.00) credit balance and does not need to submit the 838 Detail report.
4. Not Submitted: The provider has not submitted a CMS-838 report.
5. Enter the Receipt Date of the CMS Certification report.
6. The Suspension Warning Letter Date is populated when the Suspension Warning Letter is generated.
7. The Due Date is populated by the Generate Suspension Warning Letter.
8. The Payment Suspension Effective Date is populated when the Credit Balance Hold Report is generated.
9. The Payment Suspension Removed Date is populated when the Credit Balance Release Hold Report is generated.

1. Click to add Certification Remarks. A pop-up box is displayed.

1. Type your remarks in the space provided then click to save the remarks.
2. Click to save all changes/updates.

838 Details Screen

The 838 Details screen is an electronic version of the provider’s quarterly 838 Detail Report (see Appendix B. 838 Credit Balance Report Detail Page). This screen is a summary which displays information about the claims associated with the credit balance.

1. Click the 838 Details tab to move to the 838 Details screen.

1. Click the Provider Details link to display provider information.
2. Click the Provider Details link again to hide the detail information.

1. You can click one of the links in the Listing of Credit Balances Available area to change the display in the Credit Balance Detail Information section.
2. You can click under Search By in the Listing of Credit Balances Available section and select a search option. (See Appendix E. Credit Balance Statuses for detailed information.)

1. When you click your choice to select it you must then click . Then the data will be updated on the screen accordingly.

1. Click to save any changes made up to this point.
2. To add new Claim Remarks, scroll to the bottom of the screen and the bottom of the Claim Remarks section then click . A Remarks pop-up box will be displayed.

1. Enter your remarks in the text box then click to save your changes or to cancel the process. The system will close the pop-up box and return you to the 838 Details screen.
2. Click to add new claims for the same provider.

1. Enter the following fields from the provider’s hardcopy 838 report:

1. HIC Number
2. ICN Number
3. NPI
4. Adjust Status: This field is automatically populated by the system.
5. Last Name
6. First Name
7. Bill Type: Select the appropriate type from the drop-down list.
8. Medicare Part: The Credit Balance system populates this field based on the Bill Type.
9. Admission Date
10. Discharge Date
11. Paid Date
12. Cost Report
13. Credit Balance
14. Amount Repaid
15. Method of Payment: Select the appropriate payment method from the drop-down list.
16. Amount Outstanding: This is automatically calculated by the system.
17. Credit Reason: Select the appropriate reason from the drop-down list.
18. Value Code: Select the appropriate code from the drop-down list.
19. Primary Payer Name: Enter the complete name of the primary payer.
20. Payer Address: Enter the Payer’s complete street/mailing address.
21. PayerCity: Enter the Payer’s city of residence.
22. PayerState & Zip: Select the Payer’s state of residence from the drop-down list. Enter the Payer’s postal zip code in the text box.
23. Original Date: This is automatically entered by the system.
24. Last Claim Amended Date: This is automatically entered by the system.

1. Click to save your updates when you have more work to do on a specific provider’s 838 report.
2. Click when you have completed entering all data for a specific provider’s 838 report.Once complete is selected, amended tracking will start. Do NOT select complete until you have completed entering all 838 credit balance claims for a particular provider.

1. Click to validate the provider’s claims. A report is printed which can then be used to validate the provider’s claims.

Exclude Provider Screen

The Exclude Provider page of the system is used to exlucde low utilization provider’s from the required 838 reporting.