Special Edition

Transcription

Special Edition

Practitioner’s Newsletter
Special Edition
February 2014 UPDATED
CONTENTS
PRACTITIONER’S NEWSLETTER—SPECIAL FEBRUARY EDITION .............................................................................................. 3
Claims Processing Solution (CPS)—Project Overview ........................................................................................................... 4
Technical Specifications .......................................................................................................................................................... 5
Explanation of Benefits (EOB) Codes Samples ....................................................................................................................... 9
Technical Specifications—Submission and Remittance Field Layouts ................................................................................. 11
APPENDIX A ............................................................................................................................................................................... 13
Software Vendors and Service Bureaux ................................................................................................................................ 13
General Medical Billing Systems .......................................................................................................................................... 13
Service Bureaux ..................................................................................................................................................................... 15
Chiropractic Billing Systems ................................................................................................................................................. 16
Optometric Billing Systems ................................................................................................................................................... 17
2
February 2014
P RACTITIONER ’ S N EWSLETTER —S PECIAL F EBRUARY E DITION
This special edition of the Practitioner’s Newsletter is to provide you with information regarding the new claims
processing system being introduced by Manitoba Health (MH) later in 2014. Inside this issue, you will find key
features of the new Claims Processing Solution (CPS) and how they may benefit your practices.
The purpose of this communication is to:
x
Provide an overview of the project.
x
Highlight key changes to claims submission.
x
Identify required technical changes that must be taken into consideration by all stakeholders, including
service providers, software vendors, service bureaux and office administrators.
We are committed to working with practitioners to support the transition to the new CPS. MH will continue to
provide you with updates on an ongoing basis. Our goal is to provide better customer service as part of this
initiative.
Should you have questions related to the project, we encourage you to contact our Claims Unit General Line at
204-786-7202 or 204-786-7355.
February 2014
3
C LAIMS P ROCESSING S OLUTION (CPS)—P ROJECT O VERVIEW
Manitoba Health (MH) is undertaking a project to replace the current billing system used to process provider
claims since 1968. This is an important project that will give MH the opportunity to deal with some longstanding
limitations of the existing system.
The new CPS is a state-of-the-art application that will benefit providers and the government. Although the current
system has automated processes, it requires significant manual intervention. With the total number of claims and
payments increasing annually, significant negative impacts on service to practitioners were projected without a
system upgrade. The CPS will allow more efficient processing by using leading technology to adjudicate claims
electronically, while maintaining the security of provincial data.
The new CPS is currently undergoing final development and testing. The project has scheduled a go-live for the
latter half of 2014. A number of factors will determine the final go-live date, including feedback from providers.
MH will update you on the timeframes for go-live over the coming months.
The system has been designed with the intent for minimal impact to your practice management system. MH
will continue to lead policy development related to processing and payment of medical claims, and continue to
process these claims in-house with provincial employees. With the CPS, the method of claims submission will
remain consistent with current practice.
There will be certain changes associated with the CPS that you and your billing staff will need to adopt in
order to submit claims. Some of the submission file data fields have been modified. There are a few new
mandatory fields, for example, PHIN must be included or the claim will be rejected.
Vendors and service bureaux have already been provided with the technical specifications to make the necessary
changes to your practice management systems. The information provided to vendors and service bureaux is
included for your information (please see Technical Specifications, p.5). A listing of vendors and service
bureaux approved for Manitoba billing is also included if you are in need of one for your practice (Appendix A).
The new CPS has a number of new key features of benefit to practitioners. One of the key features is an enhanced
claims adjudication process. This is intended to provide consistency in adjudication and less manual intervention,
which will reduce the time required to process claims.
Another feature is improved explanations that accompany processed claims. Explanation of Benefits (EOB)
codes will be replacing Disposal Codes on the remittance advice. EOB codes will provide specific details
regarding the claim status (i.e. paid, rejected, reduced, pending), and what action to take, if required, for a claim to
be processed. More details and examples are provided in the Technical Specifications.
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February 2014
T ECHNICAL S PECIFICATIONS
Note: MH has provided these technical specifications to vendors and service bureaux.
Disposal Codes–Replaced with Explanation of Benefit (EOB) Codes on Record Type 3:
Currently there are 50 disposal codes listed in the Manitoba Physician’s Manual. These codes have provided
limited explanation of why a claim has been changed, reduced or rejected. Manitoba Health (MH) will be
replacing the disposal codes with Explanation of Benefit (EOB) codes. These codes will provide a more detailed
account of a claim’s status on the remittance file. A small sample of current disposal codes and some of the new
draft EOB codes are attached to this package, for information only.
The EOB codes will replace the existing disposal code positions on the remittance advice record type 3 and 8 in
columns 66 to 71.
The current pending codes on record type 1, 4, and 6 of 71, 72, 73 and 74 will be amalgamated to a single code of
“77” for all pending claims in column 66 to 67 and will be reported on record type 6 only. A claim that contains
pending code 77 indicates that a claim is still in progress at MH and will be resolved on a future remittance.
Microfilm Field on Record Types 2, 5 and 7.
For electronic claims the microfilm number field on the remittance advice record types 2, 5 and 7 in columns 6471 is changing to an all numeric 8 digit key where there is no breakdown of the first 2 characters representing the
month (e.g. TA, TB, etc).
Currently these numbers roll over annually however in the new CPS these numbers will only roll over after 100
million claims are submitted to MH.
Submission File Data Field Changes
In order to reduce the number of claims requiring manual intervention, and therefore to expedite payment, some
of the following submission file data fields have been changed:
a) PHIN
b) Start and/or Stop Time
c) Bilateral/Incision Indicator
d) Line Level Diagnostic Codes (ICD9)
e) Non-Resident Birth Date
f) On-Call Indicator
g) Pre-Authorized Indicator
h) Number of Patients
i)
Split Indicator
We encourage you to start populating all of these fields, with the exception of the Split Indicator, as soon as you
have made the changes to your system.
a) PHIN
Practitioners have been capturing the PHIN as the unique identifier on their records for many years. The PHIN
will be a mandatory key field when the new system is implemented. Claims will be submitted with both the 6
digit registration number and the 9 digit PHIN populated. This field will remain on record type 4 column 59 to 67
of the submission record and record types 6 and 8 columns 41 to 52 on the remittance advice.
February 2014
5
b) Start and/or Stop Time Record Type 6
Start and/or stop times, in 24 hour time format, will be required fields for specific tariffs in the new system. Times
should not be provided in the remarks section unless two times are required (e.g. patient seen twice in a day –
should be billed as 78509 X 2 on one line–need 2 start and stop times for one line so remarks would be
necessary). The lists below are not exhaustive and are only meant as examples of where times would be required.
Start times are in columns 63-66 and stop times are in columns 67-70.
The following benefits must have start time populated:
x
75553, 75555, 78000, 78001, 78005, 78474, 78576, 78605, 78608, 78944, 78958, 79727
x
If more than one examination type in a day (e.g. complete history and physical exam and a regional exam
for the same patient on the same day) then both benefits should have start times entered.
x
Obstetrical benefits 34800, 34803, 34822, 34824, 34825, 34826 and surgical procedures billed with a
premium require time of delivery to be entered.
x
Surgical procedures billed with a premium require start times to be entered.
x
Any benefit billed in conjunction with another where start time would support payment of both benefits.
The following benefits must have start and stop times populated:
x
20338
x
22370 should have the start and stop times when invoiced with an anaesthetic procedure
x
75556, 75557, 75558
x
All anaesthetic procedures (prefix 4 benefits).
c) Bilateral/Incision Indicator on Record Type 6
The role of submission file record type 6 column 71 has been expanded to indicate when procedures are done
bilaterally as well as procedures done through the same or separate incisions. This indicator will be a required
field for specific tariffs in the new system and this field will be blank when not applicable.
Valid values for this field are as follows:
x
B–Bilateral
x
S–Same incision
x
D–Different incision
x
Blank–If not applicable to the line item
d) Line Level Diagnostic Codes (ICD9)
Submission files must allow for separate ICD’s per line or practitioners must submit the tariffs on separate claims
with the appropriate ICD. Claims will reject if an ICD9 code is submitted and is not found in the ICD9 catalogue.
Practitioners will be required to submit claims to the 4th and 5th character of the ICD where applicable. This means
that if a 5 digit ICD is available and only 4 digits are submitted the claim will be rejected in some scenarios.
e) Non-Resident Birth Date on Record Type 7
Increase the length of the birth date on record type 7 to 8 characters from the current 6 characters. In order to
allow vendors to implement these changes in advance of the go live date, CPS will be reading the non-resident
birth date from column 27 to 34 while the legacy system will continue to use column 21 through 26 for the 6
character birth date. If vendors prefer to populate both, that will not cause a problem in either system.
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February 2014
f) On-Call Indicator on Record Type 3
A new On-Call Indicator field will be added to the submission record type 3 in column 67 to depict if the service
was provided during a time when the service provider was on-call. If applicable this field should contain a value
of “C” otherwise the field is left blank.
g) Pre-Authorized Indicator on Record Type 3
The Pre-Authorized Indicator is used to report that the provider obtained prior approval from MH for coverage of
a specific service (e.g. rhinoplasty for non cosmetic purposes). This field should contain a “P” in column 66 on
record type 3 if the provider has received pre-authorization for the procedure.
h) Number of Patients on Record Type 6
The number of patients in a group psychotherapy session or team conference tariffs currently reported in column
54 is moving to columns 61-62. Column 54 will be renamed to “Split Indicator” and is explained below.
i) Split Indicator on Record Type 6
Column 54 will be renamed to “Split Indicator” and will indicate instructions on how to split claims for team
surgeries, complete history and examinations done for hospital and CTU admissions, etc. The expanded values
include the following:
x
E–Used to indicate when the tariff chosen is similar or equal to another service that exists today
x
L–Used when requesting less than the standard tariff rate. Some examples are listed below:
x
Rule of Application 31–Postoperative Surgical Care is the responsibility of the surgeon. If a
postoperative patient is transferred to the care of another physician, that physician may claim
for the services rendered, and benefits paid to this physician may be deducted from payment
made to the surgeon up to a maximum of 15% of the surgeon’s fee.
x
Rule of Application 40–Where an Open Reduction is Followed by a Second Open
Reduction by the same physician within the three (3) week period, 100% of the listed benefit
will be paid for the first open reduction and 75% for the second reduction. The circumstances
of the second requirement must be given by Special Report to justify this assessment.
x
Benefit catalogue items with notes within the Physician’s Manual advising to submit at a
reduced rate (e.g. 25105).
x
A–Admission (complete physical exam for admission to hospital)
x
C–CTU (complete physical exam billed from CTU facilities 373, 375, 393, 394, 396, 397 or 399)
x
S–Split Surgeries–Rule of Application #30 - When Two Surgeons are involved in the management
of a surgical case, by prior agreement between the surgeons, the total fee may be apportioned in
relation to the responsibility taken and the work done. Each surgeon should send in his/her own claim
showing the agreed apportionment to each surgeon.
x
G-General Anaesthetic
February 2014
7
General Information for Vendors
8
•
User sites continue to have a range of difficulty interpreting remittance advice or
understanding the reports based on reconciliation of the remittance files that MH provides
twice monthly. We ask that vendors continue to work with us to try to resolve these issues
and together we can continue to educate the users on how to reconcile their accounts
correctly.
•
MH continues to require that when new user site numbers are assigned, whether to an
existing user or a user changing software vendors, they must successfully complete testing
before that user site number will be activated. This requirement ensures that the user is able to
produce the test submission and be able to reconcile all their accounts properly as well as a
smooth go live transition.
•
When a user changes from one vendor to another a new electronic user number will be
required. Functionally, this will mean that users will continue downloading remittance files
from the old user number using the old vendor software until all claims have been reconciled.
Once testing is complete under the new user number claims can be submitted through the new
user number and software and do those reconciliations as well. Users will be running 2 billing
systems & user numbers concurrently until all claims are reconciled on the old user number.
This will keep the reconciliations and submissions clean and concise for the user sites.
•
Updated File Layouts are included with this package specifying where on the records these
fields should be populated.
February 2014
E XPLANATION OF B ENEFITS (EOB) CODES S AMPLES
This list is not finalized and is not intended to be used for any purpose other than to give some draft
examples of the upcoming changes.
Current Disposal Code
Disposal Code 11–Service
included in bloc fee–
service assessed
accordingly.
New EOB Codes
O8–This service was rejected as it cannot be claimed on the same
day as the benefit paid for ECT.
O0–This service was rejected as it cannot be claimed on the same
day with the benefit paid for a consultation.
P2–This service was rejected as it cannot be claimed on the same
day as the benefit paid for psychotherapy.
P9–This service was rejected as local anaesthetic is included in the
paid procedure.
Q2–This service was rejected as it cannot be claimed in addition to
the benefit paid for studies testing sleep disorders, overnight
recording, telemetry or other ambulatory EEG monitoring.
Disposal Code 21–Service
included in operation, or
anaesthetic fee–service
assessed accordingly.
N4–This service was rejected as a visit fee cannot be claimed at
the same sitting with 23192.
O7–This service was rejected as it is included in the benefit paid
for surgical assistant within the 21 day post-op period.
P5–This service was rejected as it is included in the benefit paid
for the anaesthetic procedural services.
P6–This service was rejected as this independent procedure service
cannot be claimed as it is an integral part of a total paid service.
P7–This service was rejected as diagnostic laparoscopy is included
in the benefit paid for the laparoscopic operative procedure.
U5–This service was rejected as this cast benefit is included
within 21 days of the benefit paid for the surgical procedure.
Disposal Code 51–Fee has
been reduced to benefit
level.
R1–This service was rejected as it is included in the benefit paid
for palliative care counselling.
R2–This service was rejected as it cannot be claimed with the
benefit paid for patient care family conference.
R5–This service was rejected as individual psychotherapy and
psychiatric care cannot be claimed on the same day by the same
psychiatrist. One of these services was previously paid.
R6–This service was rejected as technical or professional services
are included in the benefit paid for the related total benefit.
R8–This service was rejected as it cannot be claimed with the
benefit paid for special call.
February 2014
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Disposal Code 17–another
doctor charged for
identical services–service
rejected.
T4–This service was rejected as it is included in the benefit paid to
another provider for the related lung function test.
V0–This service was rejected as the frequency limit of one
botulinum toxin injection per 12 weeks has been reached. This
service has been paid to you or another provider during this time
span for this patient.
W3–This service was rejected as the frequency limit of one service
per 21 days has been reached. This service has been paid to you or
another provider during this time span for this patient.
W4–This service was rejected as the frequency limit as outlined in
Rule of Application 44 has been reached. This service has been
paid to you or another provider during this time span for this
patient.
W6–This service was rejected as the frequency limit of one service
per two weeks has been reached. This service has been paid to
you or another provider during this time span for this patient.
Disposal Code 15–Patient
identified as a resident of
another province or
territory.
A4–This claim was refused as given name of reciprocal patient is
mandatory for a non-resident claim.
A5–This claim was refused as surname of reciprocal patient is
A6–This claim was refused as birth year of reciprocal patient is
A7–This claim was refused as birth month of reciprocal patient is
A8–This claim was refused as birth day of reciprocal patient is
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February 2014
T ECHNICAL S PECIFICATIONS —S UBMISSION AND R EMITTANCE F IELD L AYOUTS
February 2014
11
12
February 2014
APPENDIX A
S OFTWARE V ENDORS AND S ERVICE B UREAUX
The following list contains names, addresses and phone numbers of medical software vendors who currently have
sites billing claims electronically to Manitoba Health. Manitoba Health suggests you contact several different
software vendors and request practitioner references from each vendor you contact, to assist you in your choice of
vendor.
General Medical Billing Systems
ABC Medical System
63 Waterbury Drive
Winnipeg, MB R3P 1R6
Contact: Dr Rajpal Ahluwalia
Ph: 204-452-2220
Fx: 204-415-6590
E: [email protected]
July 29 Consulting Inc.
23-845 Dakota St, Suite 187
Winnipeg, MB R2M 5M3
Contact: Sandy Sethi
Ph: 204-480-9135
Fx: 204-480-9135
Web: www.mbebilling.com
Asystar Medical Records Solutions
421 Winterton Avenue
Winnipeg, MB
R2K 1K5
Contact: Bonny Muzyka-Dixon
Ph: 204-663-7742
Fx: 204-221-7780
Web: www.asystar.com
Max Systems Inc.
209-1100 Concordia Avenue
Winnipeg, MB R2K 4B8
Contact: Barry F Banek
Ph: 204-786-1460 ext. 210
Fx: 204-786-1522
Web: www.maxsystems.com
Code-Med
Suite 306, 162-2025 Corydon Avenue
Winnipeg, MB R3P 0N5
Contact: Nathan Hiebert
Ph: 204-489-7522
Fx: 204-487-2604
Web: www.code-med.com
McKeever’s Software Wizardry
12077-256th Street
Maple Ridge, BC V4R 1B5
Contact: Bob & Judy McKeever
Ph: 1-800-663-5178
Fx: 1-604-462-8214
Global Office Software Inc. (Great White North)
Unit 157, 99 Scurfield Boulevard
Winnipeg, MB R3Y 1Y1
Contact: Terry Davison
Ph: 204-480-8773
Web: www.globalofficesoftware.com
Med Access Inc
7-2250 Leckie Road
Kelowna, BC V1X 7K1
Contact: Karen Hansen
Ph: 1-250-448-7788 ext. 6600
Help Desk (toll-free): 1-888-781-5553
February 2014
13
Infonet Global, Inc.
18 Maple Cliff Cove
St. Andrews, MB R1A 2Y7
Contact: Huan To
Ph: 204-295-7107
Fx: 204-633-6840
Medical Billing Data Services (2010) Ltd
132 Riverbend Crescent
Winnipeg, MB R3J 1K3
Contact: John Allegro
Ph: 204-800-9485
Cell: 204-797-2510
Fx: 204-589-8298
Jonoke Software Development Inc.
3450 78th Avenue
Edmonton, AB T6B 2X9
Contact: Aaron Bevan
Ph: 1-800-254-0739
Fx: 1-780-448-3741
Web: www.jonoke.com
PeppEHR
1050 Lelia Avenue
PO Box 49128
Winnipeg, MB R2V 4G8
Ph: 1-855-455-0202
Web: www.peppEHR.com
QHR Technologies, Inc. EMR Division
Suite 300, 1620 Dickson Avenue
Kelowna, BC V1Y 9Y2
Ph: 1-866-454-4681
Fx: 1-866-577-1075
Web: www.qhrtechnologies.com
14
February 2014
Service Bureaux
Asystar Medical Records Solutions
421 Winterton Avenue
Winnipeg, MB R2K 1K5
Ph: 204-663-7742
Fx: 204-221-7780
Contact: Bonny Muzyka-Dixon
Web: www.asystar.com
Med Access Inc
7-2250 Leckie Road
Kelowna, BC V1X 7K1
Contact : Karen Hansen
Ph: 1-250-448-7788 ext. 6600
BFB Solutions
Ph: 204-786-1460 ext. 210
Fx: 204-786-1522
Email: [email protected]
Ph: 204-800-9485
Cell: 204-797-2510
Fx: 204-589-8298
Billing Options Ltd.
454 River Road
St. Andrews, MB R1A 3C1
Contact: Gail Masson
Ph: 204-981-7662
Fx: 204-282-0370
Web: www.billingoptions.ca
Sunbaked Software Inc
ChiroSUITE software (www.chirosuite.ca)
0103, 10357-109 Street S W
Edmonton, AB T5J 1N3
Contact: Brock Denys
Ph: 1-780-434-7376
Fx: 1-780-669-5852
Web: www.sunbaked.com
Code-Med
Suite 306, 162-2025 Corydon Avenue
Winnipeg, MB R3P 0N5
Contact: Linda Hiebert
Ph: 204-489-7522
Fx: 204-487-2604
Web: www.code-med.com
SWEP Management Ltd
1760 Ness Avenue
Winnipeg, MB R3J 0Y1
Contact: Lidia Ghobrial-Zaki
Ph: 204-988-4860
Fx: 204-988-4870
Web: www.swepmanagement.ca
Ph: 204-480-8773
July 29 Hosted
23-845 Dakota St, Suite 187
Winnipeg, MB R2M 5M3
Contact: Sandy Sethi
Ph: 204-480-9135
Fx: 204-480-9135
Web: www.mbebilling.com
February 2014
15
Chiropractic Billing Systems
ABC Medical System
63 Waterbury Drive
Contact : Dr Rajpal Ahluwalia
Ph: 204-452-2220
Fx: 204-415-6590
Nexyka Inc.
35 19th Avenue
Lachine, QC H8S 3R7
Ph: 1-877-891-3657
Fx: 1-514-313-5446
Web: www.nexysoft.com
Atlas Chiropractic System
Brock Street East
Tillsonburg, ON N4G 1Z5
Contact: Dr. Stephanie Laverdiere
Ph: 1-877-602-8527
Web: www.atlaschirosys.com
Patient Management Programme (PMP) 30
20 Victoria Street, Suite 200
Toronto, ON M5C 2N8
Contact: Liz Pridham
Ph: 1-800-561-7361
Fax: 1-416-860-0857
Website: www.chiropractic.on.ca
Ph: 204-480-8773
Platinum System C.R. Corp
Suite 103, Building 4
Harbour Industrial Estate
St. Michael, Barbados BB11000
Toll Free: 1-888-880-8602
Fx: 1-866-737-2712
Web: www.platinumsystem.com
Max Systems Inc.
Ph: 204-786-1460 ext. 210
Fx: 204-786-1522
Web: www.dcmax.ca
PeppEHR
1050 Leila Ave
PO Box 49128
Winnipeg, MB R2V 4G8
Ph: 1-855-455-0202
Web: www.peppEHR.com
Med Access Inc
7-2250 Leckie Road
Kelowna, BC V1X 7K1
Contact: Karen Hansen
Ph: 1-250-448-7788 ext. 6600
Ph: 204-800-9485
Cell: 204-797-2510
Fx: 204-589-8298
16
February 2014
Optometric Billing Systems
ABC Medical System
63 Waterbury Drive
USA Contact: Dr Rajpal Ahluwalia
Ph : 204-452-2220
Fx : 204-415-6590
My Vision Express
3050 Universal Blvd, Suite 120
Weston, FL 33331
Contact: Vipul Katyal
Ph: 1-877-882-7456
Fx: 1-877-882-0329
W: www.myvisionexpress.com
Ph: 204-480-8773
Ocuco Canada Inc.
Suite 2300 – 550 Burrard Street
Bentall 5, Box 30
Vancouver, BC V6C 2B5
Contact: Dermot Walsh
Ph: 204-1-860-432-3320
C: 1-860-899-6842
Fx: 1-860-748-4937
W: www.ocuco.com
Max Systems Inc.
Ph: 204-786-1460 ext. 210
Fx: 204-786-1522
Web: www.maxsystems.com
OSI (Optometric Services Inc)
4 Pl. Du Commerce, Suite 460
Montreal, QC H3E 1J4
Ph: 1-514-762-2020
Fx: 1-514-762-9933
Contact: Yves Desrosiers
Web: www.optosys2.com
Ph: 204-800-9485
Cell: 204-797-2510
Fx: 204-589-8298
MSF Computing Inc.
1189 Talwood Court
Peterborough, ON K9J 7X4
Contact: Scott Farley
Ph: 1-519-749-0374
Web: www.msfci.com
February 2014
17

Special Edition

Transcription

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