PAYOR SETUP:

Now that the enrollment process is complete, it’s time to start and/or complete the payor setup in CPR+.

In Lauren’s column last week, she identified two important Emdeon links. The Medical Payor List link leads to a complete listing of all payors that will accept electronic 837P Medical claims via Emdeon (formerly known as WebMD).

Figure 1) Sample Medical Payor List

This list is organized by Model (Payor Type). The COMM (commercial) payors are listed first, alphabetically, by payor name. The BCBS (Blue Cross/Blue Shield) payors are listed next, then MCARE (Medicare), then MCAID (Medicaid) alphabetically by State. The most important piece of information on this list is the column marked ID. This is the identification number that Emdeon uses to determine the payor that will receive the claim. Since claim batch files can contain claims for various payors, this information is critical. The list contains an ID for both Medical (M) and Hospital (H) claims. We are only concerned with the medical payors. These are identified by an M in the LOB column.

This identification number needs to be entered in the WebMD Medical # field on the General Billing Info tab of the Insurance Company Setup screen (7-Databases, 4-Insurance Company). This number is also entered in the NAIC Payor ID field directly to the right of the WebMD Medical # field. The NAIC Payor ID is what identifies the primary payor on a secondary claim. Since both primary and secondary claims can be/are sent to Emdeon, the number is the same regardless. It is Emdeon’s responsibility to populate a different number if required by the destination payor.

Directly below the WebMD Medical # field is the Requires Invoice Type field. The invoice type selected drives other insurance options that may (or may not) need to be populated, based on the payor you are creating. Selecting the invoice type of WebMD Medical, Claimsnet and WebMD Pharmacy will open additional settings that can be viewed by clicking the Electronic Setup (F8) button at the bottom of the form. There are no additional insurance company settings in the Electronic Setup (F8) if the invoice type “Medicare EMC” is selected. Selecting one of the above mentioned invoice types will determine which electronic claim queue the invoices are directed to once they have been created. The electronic invoice creation process is the same as creating paper invoices, with the exception of WebMD Pharmacy.

WebMD Pharmacy, also known as NCPDP, or POS claims are created when the Pharmacist fills a prescription that has a WebMD Pharmacy payor assigned to the order. The entire Pharmacy Payor list can be found at this link: Pharmacy Payor List. In order to access the pharmacy list, please use: Login: cprplus, Password: 2689559.

For complete details on the additional insurance company settings, please refer to On Demand Class EBM005, EBM025 or contact Kim Carlsen today for personal training with one of our expert trainers.

Once electronic claims have been created, they simply need to be transmitted. As mentioned previously, the electronic invoice type that is selected during the payor creation process drives which electronic claim queue will receive the invoice. Medicare EMC and WebMD Medical Invoice types will create an 837P claim file (ASC X12 4010A).

CPR+ has four electronic claim queues and a Resubmit Electronic Claims queue.

Figure 2) Electronic Claims Menu

SENDING INITIAL CLAIM BATCHES:

Creating a claim file batch to send to Medicare is as easy as 1, 2, 3,...4.

1. Mark all claims that you want to send with the Status of “Transmit” by pressing the <Spacebar> one time or clicking on the Mark Transmit (Space) button.

2. Click on the Transmit Menu button or press the <F5> key and select Transmit Invoices Ready to Send (1).

3. CPR+ will check for formatting/data errors and if none are found, the following menu will appear:

Figure 3) Would You Like to Transmit?

4. Select Yes (1) to send the batch electronically. It’s that simple!

Once the batch has been transmitted successfully, a message box will display:

Figure 4) Transmission Successful

Answering Yes will mark the claim status as Sent. The claim status must be marked as Sent for the claim to be accepted.

Please tune in to Part 3 of this series to learn more on how and when to accept claims.

CREATING A CLAIM BATCH FOR WEBMD MEDICAL CLAIMS:

Creating a claim batch for WebMD Medical or Claimsnet can be slightly different from creating a Medicare batch, depending on payor requirements. There is a field called Filter by Payor: in the WebMD Medical and Claimsnet electronic claims queues. If the payor requires additional billing provider identifiers to be sent in the electronic claims batch, the payor name must be selected and all claims for that payor must be sent in a batch together. Hopefully this will go away with the upcoming implementation of the NPI only requirement. Now, follow steps 1, 2, 3 and 4 above.

Electronic WebMD Pharmacy/NCPDP claims can either be sent individually or in a batch in just three simple steps:

1. Mark the status as Ready by pressing the <Spacebar> one time or clicking on the Change Status (spacebar) button.

2. Click the Adjudicate Claims (Enter) button or press the <Enter> key.

3.  Select the Yes (1) menu option when the “Would You Like to Transmit” box appears.

WebMD Pharmacy/NCPDP claims are on-line adjudicated and return a response instantly. The response is displayed within CPR+ telling you if the claim was paid or rejected. Rejected claims can be edited and transmitted until a paid response is received.

Think it’s too easy to be true? Give it a try….

Hundreds of CPR+ customers sent nearly 1 million medical claims in 2007!

In Part 3 of this series, we will discuss retrieving reports, ERAs and accepting claims to remove them from the electronic claims queues.

Return to Top of Newsletter