Transcript Pre-Adjudication

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Copyright © 2014 TriZetto Corporation
ClaimsExchange®
A Multifaceted Tool
Jenni Lynn and Sandi Frederick
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Copyright © 2014 TriZetto Corporation
What is ClaimsExchange?
 Connects Payers to PPOs for electronic claims repricing
 Multifaceted tool
 Multilayered, multidimensional, versatile and comprehensive
 Complex, complicated, involved
 Hosted java based application
 Fully Integrated with QicLink™ and FACETS™
 Real time web service interface with NetworX®
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Benefits
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Real time interface to QicLink™
Flexible matching for eligibility and providers
Automated workflow solutions
One connection point to multiple trading partners
Savings opportunities
Potential revenue stream
Comprehensive Reporting
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Agenda
 Pre-Adjudication
 Post Adjudication Solutions
 Reporting
 Enhancements
 User Group meeting
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Pre-Adjudication
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Copyright © 2014 TriZetto Corporation
Pre-Adjudication - Claim Acquisition
 837 Batch
 4010 – 997 available
 5010 – 997 available
 THG
 4010
 5010
 ECSIF
 Post Adjudication ECSIF
 Pre-adjudication
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Pre-Adjudication – Data Entry
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Copyright © 2014 TriZetto Corporation
Pre-Adjudication - Real Time Matching
 Real-Time Eligibility and Provider matching
 Using SQL
 Configurable settings
 Eligibility Matching Options
 SSN, Member ID or both (order can be defined)
 Define number of characters to use for Member ID
 Search Like IDs
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Pre-Adjudication - Real Time Matching
 Original Provider Matching Options
 Match using Tax ID, NPI or both (order can be defined)
 Name match is required
 Address – Sequential or exact match
 Use Service or Billing address
 Define number of characters to use for provider name
 Require Rendering Provider match
 Ignore Rendering Provider for match
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Pre-Adjudication - Real Time Matching
 New Provider Matching Option
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Independent of other matching options
Separate criteria for Institutional versus Professional
Flexibility accommodates unique data issues
Map claim data elements to QicLink™ fields for matching
Require few or many data elements
Multiple passes with unique criteria - Ranking
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Pre-Adjudication - Real Time Matching
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Pre-Adjudication - Real Time Matching
Claim Information
QicLink™ provider fields
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Billing provider
 NPI, TIN, NAME, LAST, FIRST,
ADDR1 ADDR2, CITY, STATE, ZIP
PayTo provider
 NPI, TIN, NAME, ADDR1, ADDR2,
CITY, STATE, ZIP
Practice provider (service or facility)
 NPI, TIN, NAME, ADDR1, ADDR2,
CITY, STATE, ZIP
Referring provider
 NPI
Rendering
 NPI, TIN, LAST, FIRST
Print checks to
Specialty
Status
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Sequence number
Provider ID
NPI
First name
Last name
Address 1 & Address 2
City, State, Zip
Status
Term date
Print check
Alfa 1 & 2
Suffix
Category
Specialty code 1 & 2
Tax ID
835Option
Pre-Adjudication - Real Time Matching
 Internal sequence numbers exported
 THG, Batch 837 and ECSIF
 CBJ bypasses matching
 Multiple directories supported
 Export includes
 PCM code of repricing entity
 EOB codes - QicLink™ remark codes
 PPO comments can be exported or suppressed
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Pre-Adjudication – Automated Workflow
 Eliminate manual processes and paper handling
 Complex sorting decisions made automatically
 Over 100 data elements with unlimited combinations
to use for routing
 Apply business rules to streamline your workflow
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Automated Workflow – Routing Rules
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Age
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ASA Code(s)
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Claim Submitter
Owner ID
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Claim Status
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Contract Network ID
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CPT-4 Procedure
Modifier Code(s)
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DRG Code(s)
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All Remaining Code(s)
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Group Name
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Group Number
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Group Number Prefix
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HCPCS Code(s)-Line
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HCPCS Procedure
Claim – All
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ICD-9 Procedure-All
ICD-9 Diagnosis-Line
ICD-9 Diagnosis-Other
ICD-9 DiagnosisPrimary Code(s)
ICD-9 Diagnosis-All
Code(s)
ICD-9 Procedure Primary Code(s)
ICD-9 Procedure Other Code(s)
Patient Name
Employment Related
Accident(Other)
Related
Accident(Auto) Related
Insured ID
Provider Zip Code
Multiple Surgical
Procedure Codes
Network Code
 Place of Service
Code(s)
 Provider Zip Code(s) 3 digits
 Provider Type Code(s)
 Provider ID(s)
 Provider State(s)
 QC2PlanNum
 QC2ProviderComment
 Contract Information
Reference ID
 Claim Routing Code(s)
 Revenue Code(s)
 Submitter ID
 Submitter Type
 Provider Specialty
Code(s)
 Type Of Service
Code(s)
 Type Of Bill Code(s)
ETC … ETC …. ETC
Automated Workflow – Code Types
Automated Workflow - Code Types
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Applying the Functionality
 Business Rule
 Review Professional claims with final non-contracted
determinations when the type of service is an ancillary type of
service (x-ray, lab, anesthesia) performed in a hospital setting.
 Logic
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First qualifier – Non-contracted completed claims
Second qualifier – HCFA claim type
Third qualifier – procedure codes for ancillary services
Fourth qualifier – place of service
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Applying the Functionality
Code Group “Ancillary Services”:
CPT-4 Procedure Code(s) - Line = 70010-89399,00100-01999 AND
Place of Service Code(s) = 81,24,21-22 AND
Claim Source Code = p,P,h,H
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One Connection
• Eligibility matched and GBO information is pulled
Typ PPO
CkG
M PPI
MTP
JOD
GAL
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OOA
PPI
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PCP PPO OOA 2nd PC
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P/P
P/P
P/M
P/M
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COB PPO L/P MOD PPO
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Cd
Fund
One Connection
 GBO, PMA and PCR is pulled
 Multi-tiered routing until claim is completed
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Post - Adjudication
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Designed for discounts on out-of-network claims
Multi-tiered capability – stack your OON vendors
Claim selection after adjudication in QicLink™.
Claims are on hold in QicLink
Adjudication information extracted
No transaction fees to payer
EOB language requirements are automated
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Post – Adjudication
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Post - Adjudication
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Post – Adjudication Claim Display
Claim detail displays Charges, Allowed, Negotiated and Savings fields
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QicLink™ XPARHM screen
Repricing History Inquiry Screen
xparhm
Claim Number ................. 9600103001
Payer Claim ID ...................
Original Process Date ............
Date Sent to Out .................
Date Returned ....................
Original Allowable Charges .......
Negotiated Charge ................
Savings Amount ...................
Contract Used ....................
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Copyright © 2014 TriZetto Corporation
PA9600103001
08/20/2012
08/20/2012
08/20/2012
403.26
223.20
180.06
PHX
*Negotiated claim*
EOB Cross Reference
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Post - Adjudication
 Other Service offerings
 Fraud Waste and Abuse review
 Editing and Hospital Bill Review
 Combine with Out of Network
 Savings opportunities
 Cost - Percent of savings to vendor
 Transaction fees $.00
 No cost unless savings are recognized
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Post - Adjudication
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Automated solutions
Option to select all claims by group or default
Separate exclusion programs
Claims on hold
No results – release to check cycle
Bill review update automated – hospital signoff
Editing and FWA recommendations
 Routed for review and detailed vendor reports provided
 Update to payment system manual
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Post - Adjudication
 Potential Revenue Stream
 All solutions – FWA, Editing, Hospital Bill review and OON
 ClaimsExchange fees - $0.00 for post adjudication
 Vendor Agreement 25% of savings
 Savings – Monthly - $100,000 Annual - $1,200,000
 Vendor fee 25% – Monthly $25,000 Annual - $300,000
 Administrative fee 5% – Monthly $5000 Annual - $60,000
 Employer Group Net savings – $840,000 or 70%
 Annual revenue - $60,000
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Comprehensive Reporting
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Crystal Reports through the application
Ability to export reports in all formats
Ability to export data only
32 standard reports
Report types
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Inventory
Batch reconciliation
Productivity
Savings
Turnaround time
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Comprehensive Reporting
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Comprehensive Reporting
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Enhancements
 Q4 2013
 14 Enhancements
 6 internal
 8 external
 Q2 2014
 22 Enhancements
 7 internal
 15 external
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Enhancements
 Q2 2014
 Normalization of provider data
 Custom interface for ACS - new trading partner
 Provider matching
 Strip special characters from all compare fields
 Compare length options All, numeric, 1- 20
 Compare defined values to 835 processing option
 ECSIF Modifications
 diagnosis codes, diagnosis pointer and total charges
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Enhancements
 Q2 2014
 User Functionality
 Reprice icon disabled for externally priced claims
 Patient Plan now displays in contract information
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Enhancements – HCFA 1500
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Enhancements – HCFA 1500 Wizard
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Enhancements – Search Option
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Enhancements – Claim Inquiry
 Claim Inquiry Enhancement
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Initiate a claim inquiry search
Select a claim in error status
New target claim icon enabled
Click on icon
 User is taken to mailbox
 Selected claim is highlighted and user can work claim
 Target icon has a green background
 Requirements
 Claim in error status
 User has update claim permissions
 User has access to the mailbox
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Enhancements – Claim Inquiry
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Enhancements
What would you wish for?
 ClaimsExchange® User Group
 Wednesday 10:30
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Workshop Survey
We would like to extend you an opportunity
to provide candid feedback.
During the workshop you should’ve received an e-mail
notification for you to take an on-line survey.
If you could take a few minutes to complete at this time ,
we would greatly value your feedback. For your convenience,
the survey will be available throughout the remainder of the conference
should you not be able to complete immediately.
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Thank You!
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