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P131 – Billing – Claim Edits Operational Procedure

Revenue Cycle Operations

Revenue Cycle Systems Department

Last Updated 7/31/2018

Table of Contents

1. Overview

2. Purpose

3. Roles and Responsibilities

4. Claims Processing Overview

5. Claim Edits

5

6

5.1 Overview

5.2 Error Codes

6. Types of Edits

6.1 Inpatient Edits

6.2 Outpatient Edits

6.3 Other Edits

7. Integration Between 3M and Epic

8. Resolution of Claim Edits

8.1 Viewing Claim Edits

8.2 Resolving Claim Edits

1. Overview

Claim Edits are used to identify issues with insurance claims before the claims are sent to ePremis and subsequently to the payer. Claim edits are triggered after billing is initiated, during claims processing. Claim edits will prevent claims from being sent out and prompt operational users to resolve errors as necessary. Resolving claim edits is a critical component of revenue cycle operations, as they help to prevent denials which can cause a delay in financial reimbursement for rendered services.

2. Purpose

The purpose of this procedure document is to review the claim edits process at NYU Langone Health including the teams involved, different applications used, and the steps to monitoring and updating claim edits. Additionally, the impact on financial reimbursement will be reviewed.

3. Roles and Responsibilities

3.1 Revenue Cycle Systems (RCS) – The RCS Team is responsible for creating new claim edits and updating existing claim edits in Epic. The RCS Team receives requests for these to be built based on requests received from Revenue Cycle Operations.

3.2 Revenue Cycle Operations (Billing Office, Revenue Management, Revenue Initiatives) - Revenue Cycle Operations teams send requests to the RCS team for review and implementation. These requests can include new edits or modifications to existing edits. In addition to new requests or modifications, Revenue Cycle Operations is responsible for the resolution of claim edits and ensuring clean claims are sent to the payer to prevent denials.

3.3 Health Information Management team (HIM) - HIM plays an integral role in claim edits due to their responsibility in coding accounts. Much of the information that is coded on an account is included on the claim.

3.4 Center for Medicare and Medicaid Services (CMS) – The Center for Medicare and Medicaid Services is responsible for releasing new claim edits in order to promote national correct coding methodologies and to control improper coding and therefore incorrect payment on claims.

4. Claims Processing Overview

Claims processing is the process in which the system automatically searches overnight for charges that are ready to be sent on claims, as well as for claims that previously had errors but are now ready to be sent out. At NYU Langone Health, we process claims in Epic. Claims are sent to ePremis and then to the insurance payer. The payer then determines how claims are paid, rejected, or denied. An electronic remittance advice (ERA), details the notice of and explanation of reasons for payment, rejection, or denial of a claim by the payer to the beneficiary.

Claims processing occurs in the revenue cycle after a patient is discharged and coding is complete, once Discharge Not Billed (DNB) errors are resolved, and billing is successfully initiated. When billing is initiated on an account with no errors, the claim is added to the claims queue.

4. Claims Processing Overview (cont.)

A claim run created during claims processing checks all claims in the queue for errors. If there is an issue, the system will flag the claim with a claim edit. Claim edits are routed to Claim Edit workqueues for review based on the type of error –master file or user error. After claim edits are resolved in a workqueue, they re-enter the claims queue in the process to be sent to ePremis.

5. Claim Edits

5.1 Overview

Claim edits check for inaccurate or missing information on claims that might cause a denial of financial reimbursement. These edits can be industry-wide, specific to a payer, or an organization. When claims are processed, at NYU Langone Health, the claims are configured and checked for errors based on settings specified in the Claim Definition File (CDF). Claim edits are built in Epic within each CDF by the Revenue Cycle Systems team. We have 12 main payer CDFs where these edits are stored, 6 of which are specific to Cancer Center. The RCS team builds the custom edits, CMS regulated edits, payer specific edits, and/or 3M Edits that are stored within the CDFs. It is important to note that many of these edits are repeated throughout the CDFs, where they are applicable to multiple payers. Conversely, other edits may be payer-specific and therefore only are stored within one CDF, such as the Blue Cross CDF.

When claims are processed, they are checked for edits according to the claim definition file associated with the plan or payer. The RCS team builds these errors within the CDF. When a claim triggers an edit, it is sent to the claim error pool. The claim error pool is filtered based on Claim Edit workqueues, which are built based on different teams assigned to review each edit check.

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5. Claim Edits (cont.)

5.2 Error Codes

Error codes are used to group similar edits for follow-up and review by the appropriate teams. Registrars are responsible for fixing registration issues, billers for billing, and coders for coding. These error codes are also used to drive claim edits to claim edit workqueues. A claim can have multiple errors in which case the claim would be present on multiple workqueues owned by different users. This allows the claim edits to be resolved more efficiently, expediting the process of getting a clean claim out the door. The owner of the claim edit would only be responsible for resolving their appropriate edit.

User errors occur when users leave out information or enter incorrect information. Master File errors occur on claims when there is crucial missing information on the claim that should be included based on build in the system, like an NPI or hospital address.

Error codes are categorized by error code group, which relate to a specific error source. User error codes (Level 100-300) are sent to front-end user workqueues where they are reviewed and resolved. Other error codes that are built out in Epic by the Revenue Cycle Systems team are typically sent to back-end teams for review and are often Master File Errors. Master file claim edit errors are sent to the appropriate team’s workqueue for review, which can include MCIT teams such as ADT, SER (Provider), or RCS Team. Some examples of error code edits are shown below:

· 100 Level Error Code –Registration Error; Registrar will review

· 200 Level Error Code – Billing Error; Biller will review

· 300 Level Error Code – Coding Error; Coder will review an error source of

· 400 Level Error Code – Financial Class not mapped in the CDF; MCIT Analyst will review

· 500 Level Error Code – Federal Tax ID or Billing Provider SSN missing; MCIT Analyst will review

· 600 – Claim needs to go through 3M CGS; RCS Analyst will review

· 800 – SPARCS Error; RCS Analyst will Review

5. Claim Edits (cont.)

5.2 Error Codes

Owner

Error Code Group

Error Source

Registrar

100

Registration

Biller

200

Billing

Coder

300

Coding

MCIT Analyst

400

Master File Error

MCIT Analyst

500

Master File Error

RCS Analyst

600

3M Core Grouping Software

RCS Analyst

800

SPARCS Error

It is important to note that the different edits in Epic (DNB Edits, Claim Edits, Stop Bills, etc.) must be properly resolved to prevent future claim edit issues. If a front-end user incorrectly overrides a DNB edit, as the billing workflow continues and claims processing begins, a claim edit may fire on an account and prevent the claim from being sent out. Additionally, overriding front-end edits may eventually cause a claim edit for review by a back-end team.