Epremis billing software

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.