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Intellect Electronic 837 Edits
Clearinghouses and direct claims processing payers, such as Medicare and MediCal/ MediCaid, run front-end edits which check for set conditions and, if not met, the entire batch of claims is rejected. For example, if the claim file has invalid zip codes, the entire batch may be rejected. Some carriers, like Medicare, provide a 997 to advise whether or not the batch of claims were accepted or rejected.
There are also second level claim edits where, if a claim fails, only that claim is rejected and the rest of the batch is still processed. These claims are on the Acknowledgement report which should be checked, and rejected claims should have the necessary corrections made and resubmitted for processing.
To reduce the number of rejected claims, Intellect has many Electronic 837 edits which scrub the claim prior to submitting the claim file. If any claims are found which do not pass our edits, Intellect removes those claim(s) from the batch. The claim(s) are included on the Intellect Electronic Billing Report with a Remark to indicate the reason the claim(s) were not submitted. If paper claims are printed after the electronic task runs, the claim may print to paper. The error should still be corrected so that the next claim transmits electronically. The Intellect edits do not encompass ALL edits which may be applied by the clearinghouse or direct submission payor.
Intellect also applies Warning edits. Claims which match these edits are submitted, and are on the Electronic Billing Report with a warning Remark. The Warning edits are informational only and do not prevent a claim from billing. Even though the claim is submitted, these claims should still be reviewed and corrections made to prevent future problems.
How Medicare EDI Claims Are Processed
Following are tables listing the Intellect Rejected Edits and Warning Edits, along with instructions where the data may be corrected.
|
Warning Message |
NOTE |
Screen |
Field |
|
WARNING: Ref Dr. NPI/TAX ID is blank |
Complete the blank field(s) |
Utility --►Referring |
NPI or Tax ID |
|
WARNING: Insurance address is blank |
Enter the Insurance street address or PO Box |
Utility --►Insurance |
Address |
|
WARNING: Insurance City/State/Zip is blank |
Enter the Insurance Zip Code |
Utility --►Insurance |
Zip Code |
|
WARNING: Hospital admission date is blank |
View the charges Ledger/Open Item to find the EN# (Encounter Number), and go to Charges/Encounter |
Charges --►Encounter |
Hospitalization From |
|
Rejected Message |
NOTE |
Screen |
Field |
|
Approved = charge amount
(See NOTE below titled: Electronic billing of Secondary Claims and the table with examples of submitted and non-submitted secondary claims) |
If the primary insurance approved something other than the charge amount:
OR If the Primary Insurance denied the claim:
|
Display the charges in Payment --►Open Item
Display the charges in Charges --►Modify. With the focus to the left of the charge, press N. |
Approved column: Enter the actual Approved Amount AND add a comment. NOTE: If Utility --►Set Up --►Parameter <Payment Comment on Statement> = Y then this comment appears on statements.
Approved box: enter 0 (zero). |
|
Bill Type not set up for this patient |
If the patient has an Encounter linked to the charges OR If the patient does not have an Encounter linked to the charges |
Charges --►Encounter --►UB Encounter
Utility --►Set Up --► Clinic |
Bill Type
Facility Identification Number |
|
CITY is blank for this patient |
|
Registration --►Regular or Registration --►Worker |
City |
|
DOB is invalid for this patient (this message prints if the DOB is null or greater than today's calendar date) |
|
Registration --►Regular or Registration --►Worker |
DOB |
|
Dr NPI/TAX ID is blank |
|
Utility --►Provider |
NPI |
|
GENDER is invalid for this patient |
|
Registration --►Regular or Registration --►Worker |
Gender |
|
Insured DOB is blank. |
|
Registration --►Regular Insurance |
Insured DOB |
|
Insurance Payer/Office code is blank |
Refer to the Payor list provided by the clearinghouse to obtain the Payor code. |
Utility --►Insurance |
Payor Office |
|
Missing CPT code for one or more charges.
|
|
Utility --►Procedure |
Verify the data in fields: Code R, Code C and Code M. If blank: contact PCS support for assistance. |
|
Missing or invalid data for insured. |
|
Registration --►Regular Insurance |
Verify that all fields pertaining to the Insured have valid information, ie: Last Name, First Name, Address, City, State, Zip, etc. |
|
No Diagnosis found for this charge. OR No Diagnosis found for charge(s). |
|
Charges --►Modify
AND Utility --►Diagnosis |
Verify valid Diagnosis codes are entered and the Rdx is completed.
Verify any diagnoses entered in Charges exist in table. |
|
No ICDA code for diagnosis.
|
|
Charges --►Modify
AND Utility --►Diagnosis |
Verify valid Diagnosis codes are entered and the Rdx is completed.
Verify any diagnoses entered in Charges exist in table. |
|
Paper billing only |
The procedure has been set up to allow paper billing only. |
Utility --►Procedure |
Billing |
|
Patient DOB is blank. |
|
Registration --►Regular |
DOB |
|
Place of service is not set up for this charge. |
|
Utility --► Facility |
POS1 OR if printing on Form F, or a customized form POS2 or POS3 |
|
Ref Dr. NPI/TAX ID is blank |
Complete the blank field(s) |
Utility --►Referring |
NPI and/or Tax ID |
|
Sex is not setup for this patient. |
|
Registration --►Regular |
(Patient) Gender |
|
Sex is not setup for this patient's insured. |
|
Registration --►Regular Insurance |
(Insured) Gender |
|
Zip code is blank for the insured. |
|
Registration --►Regular Insurance |
(Insured) Zip Code |
|
Zip code is blank for this patient. |
|
Registration --►Regular Demographic |
(Patient) Zip Code |
NOTE: Electronic billing of Secondary Claims:
When billing the secondary payor, the claim level of the electronic claim requires the amount the primary carrier actually approved to be part of the electronic claim. If the Approved is the same as the Charges, the claim is rejected. Therefore, Intellect has a new edit which catches this situation before the claim is submitted. The feature works as shown in the table below.
When primary payments are posted through Payment/Auto Payment, Intellect updates the database with the actual approved amount from the Electronic Admittance Advise (ERA).
When posting payments manually through Payment/Open Item, the focus stops at the ‘Approved’ column. The approved amount calculated at the time the charge was posted is displayed. If this is different than the actual approved amount on the Explanation of Benefits (EOB), enter the actual approved amount.
* Expected Approved: The approved amount captured at the time the charge was posted. If Pay Plans and Fee Schedules are not set up for the insurance, the amount of the charge is inserted into this field when the charge is posted.
** Actual Approved: The actual approved is either entered automatically when payments are posted through Payment/Auto Payment OR must be manually entered in the Approved column when posting payments through Payment/Open Item.
|
Example |
Charge |
* Expected Approved |
** Actual Approved |
Submitted |
|
1 |
100.00 |
100.00 |
0.00 |
No |
|
2 |
100.00 |
100.00 |
100.00 |
No |
|
3 |
100.00 |
80.00 |
100.00 |
No |
|
4 |
100.00 |
80.00 |
0.00 |
Yes |
|
5 |
100.00 |
80.00 |
80.00 |
Yes |
|
6 |
100.00 |
100.00 |
80.00 |
Yes |