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New 1500 format and 837 electronic claim task list

There are several tasks that need to be completed for modification to the new claim formats. The assumption is that the NPI numbers  have been entered.  

Note: There is a new rule for addresses – no special characters are allowed in any address for patient, guarantor, facility or third party. Special character include periods, dashes, pound signs and any other non-numeric or non-alphabetic character.When you add or update any of these addresses, the system will prompt with the message "Invalid Format".

For any existing addresses that have not been cleared of the special character, PDM will remove the special characters when the claim is formatted for both the new 1500 and 837 claim formats.

PREPARATION

  1. Load taxonomy (specialty) codes for entities. Visit the following site to determine your taxonomy (specialty) code: http://www.wpc-edi.com/codes/taxonomy.  Let PDM know what code you need to use and we will write a query to default the values.

  2. Load the claim 'Filing Codes'. The 837 electronic claim requires a 'filing code' for each third party.

    • Please run the following query. Send us the results and we will send you an Excel spreadsheet to fill out.

      SELECT ATTHTKEY, ATTHNAME, ATTHNAM2, ATTHVSCT FROM ATTHIRD WITH(NOLOCK) ORDER BY ATTHTKEY

    • Fill out the Filing Code column using the following values. Also, refer to page 112/113 of the 837- Professional manual.

      09 - Self-Pay
      10 - Central Cerfication
      11 - Other Non-Federal Organization
      12 - Preferred Provider Organization (PPO
      13 - Point of Service (POS)
      14 - Exclusive Provider Organization (EPO)
      15 - Indemnity Insurance
      16 - Health Maintenance Organization (HMO) Meciare Risk
      AM - Automobile Medical
      BL - Blue Cross/Blue Shield
      CH - Champus
      CI - Commercial Insurance Co.
      DS - Disability
      HM - Health Maintenance Organization
      LI - Liability
      LM - Liability Medical
      MB - Medicare Part B
      MC - Medicaid
      OF - Other Federal Program
      TV - Title V
      VA - Veteran Administration Plan
      WC - Worker's Compenastion Health Claim
      ZZ - Mutually Defined

    • Return the spreadsheet to PDM who will generate a query for you that will populate the filing codes.

      Apply the query to both the test system and production systems. The query can be applied at any time prior to conversion.

  3. Schedule the conversion date with GHN. Contact GHN and get the conversion dates and instructions for sending test files and as well as scheduling your production date. This should be done as soon as possible.

  4. Order a box of new 1500 claim forms.


TEST SYSTEM

Test Snapshot with Original Claim Format
  1. Apply the snapshot to the test system.

  2. Verify current claims continue to format correctly. The first thing to do is verify your current claims are still formatting correctly. Once you have unfiled, rebilled, and reformatted some claims you can move the snapshot to production. There will be no change to your current claims until the conversion function is executed. That will completed after the test and conversion is completed with GHN.

  3. Validate and test any other service requests shipped in the snapshot. Once all service requests have been tested, the snapshot can be moved to production.

Test Snapshot with New Claim Format
  1. Run the query for unfiled claims in the test system and file all claims in review status. Before you can run the PiMS conversion, all unfiled claims must be filed and the electronic claims in the print file must be processed. File all unfiled claims and then empty the print file for electronic claims by selecting the Print Billing Correspondence function and selecting the Electronic Claims option.

    Run the following query to identify any claim that must be filed:
    SELECT AACSAKEY, AACLCLNO FROM AACLAIMC WITH(NOLOCK) WHERE AACLCYST = 'RV' and AACLCTYP <> 'H'

  2. Execute the PiMS conversion function.The function "Activate 1500-837 Claim" is under File on your master frame. THIS IS DONE ONE TIME ONLY. This functions creates the new claim formats for all new claims, rebills, and reformatted claims.

    After this process is done, any old claims can be unfiled, but must be reformatted before you can file the claim. There is a message presented in the File a Claim function that will prompt you to reformat if you have forgotten.

  3. Coordinate the test file with GHN Create new claims and rebill and reformat old claims for GHN's testing requirements. Submit the test file to GHN. When GHN has validated the test file, schedule your production conversion date. The test file will be in the directory, EXTRACT, under the test environment directory. The file will be called SSI837.000.

  4. Test print 1500 forms. Print a varity of test claims. All printers are different and use different drivers so the printing of claims may require customization. Contact PDM if there are any issues with printing.


PRODUCTION SYSTEM

End of Day Before GHN Conversion Date
  1. At this time stop the thin client service and have all users sign off/on.

  2. Run the PiMS Background Billing. Sign on to PiMS using PDM's technical frame, ARARFRPM.  Select File-Background-Background Billing. The window that will bill any posted charges will open. When it has closed continue to the next step.

  3. Run the query for unfiled claims in the test system and file all claims in review status. Before you can run the PiMS conversion, all unfiled claims must be filed. Run the following query to identify any claim that must be filed:

    SELECT AACSAKEY, AACLCLNO FROM AACLAIMC WITH(NOLOCK) WHERE AACLCYST = 'RV'

  4. Generate the final GHN file in the old format.Create the final file for electronic claims by selecting the Print Billing Correspondence function and selecting the Electronic Claims option. Upload/submit the file to GHN for processing.

  5. Print claims in the old format. Select the Print Billing Correspondence function and selecting the Printed Claims option. Verify the claims printed correctly.

  6. Apply the snapshot to the system (if not previously applied).

  7. Execute the PiMS conversion function.The function "Activate 1500-837 Claim" is under File on your master frame. THIS IS DONE ONE TIME ONLY. This functions creates the new claim formats for all new claims, rebills, and reformatted claims.

  8. Change paper. Change the 1500 paper forms.


VIEWING/PRINTING CLAIMS

View Claim Form

The View Claim Form function will work for both old claims and new claims. Any new claim will be viewed with the new NPI fields. If the claim is new or rebilled or reformatted, the 1500 background form will be the new one. If it is an old claim, not reformatted or rebilled, it will display the previous 1500 background image.

View Claim 837 Form

The new View 837 Claim function is a set of screens where you can view the contents of what was sent when a claim is transmitted in the electronic 837 format. The screen labels are compatible to the 837 file format.

The same fields will be used from the Third Party profile – Primary Transmission Type. If this is set to E, then those claims will be processed as a 837 format. If it is set to P, then those claims will be processed for a paper claim using the 1500 format. At this time, all secondary claims are processed as paper claims.

However, you can use both view functions, View Claim Form and View 837 Claim Form, to view either claim. Do not get confused if you are use View 837 for a paper claim – it is just a view. In the print file, the claim would have been sent as a P type. Likewise, using View Claim Form for a 837 claim is just a view – not how is was transmitted.

Print Claim Form

After conversion, the Print Claim Form function will only work with the new claim format. In order to reprint an existing claim, it should be first rebilled or reformatted. The new formatted 1500 claims can always be printed, even if the claim was originally sent as an 837 electronic claim.

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