Set Up the Claims Tab
The Claims tab on the Encounter Rate Billing Library Maintenance window contains a series of questions designed for configuring claims for the ER payer. Primary, secondary and tertiary claims for the payer can be configured separately.
- Open the Encounter Rate Billing library.
The Encounter Rate Billing Library Maintenance window opens.
- Select the Claims tab.
Existing Claim Detail Rules sets display as separate rows, with the current active row at the top of the list. Rows can be sorted by selecting on the Eff Date, Exp Date or Description column headings.
- Do one of the following:
- To add a Claim Detail Rules set, select open menu button and select New.
- To modify a Claim Detail Rules set, select the row from the list, and then select open menu button and select Open.
- To copy a Claim Detail Rules set, select the row from the list, and select open menu button and select Copy.
The Encounter Rate Claim Detail Rules window opens. - In the Effective Date and Expiration Date fields, enter an effective date and an expiration date for the claim detail rules. These fields are required.
Note: The dates cannot overlap between Claim Detail Rules sets and there can be no gaps in dates between Claim Detail Rules sets.
- In the Description field, enter a name for the claim detail rules. This field is required.
- Use the following table to select the appropriate settings for Primary Electronic Claims, Secondary Electronic Claims, and Tertiary Electronic Claims.
Option Description Include copay in ER amount Select this option to include the patient's copay in the encounter rate amount. Do not select this option to exclude the patient's copay from the encounter rate amount.
Display these line items on the claim: Select responses to the following questions in each section to define the format of the service line data on primary, secondary and tertiary claims. Do you send the ER SIM as a unique charge line on the claim? Select one of the following: Yes: To include the ER SIM code as a separate line item on claims. The following options become required:
Display narrative on the ER SIM charge line?
What is the ER SIM amount?
What data element is the ER SIM on the claim?
No: To exclude the ER SIM code from claims. The following options become unavailable and are set to <none>:
Display narrative on ER SIM charge line?
What is the ER SIM amount?
Is the ER SIM the first or the last line item?
What data element is the ER SIM on the claim?
What value code is sent on the claim?
What reason code is sent in the CAS segment? (Secondary and Tertiary sections only)
Display narrative on ER SIM charge Line? This option is available only if the Do you send the ER SIM as a unique charge line on the claim? option is set to Yes. Select one of the following: Yes: To include the narrative for the ER SIM charge line on claims.
No (default): To exclude the narrative for the ER SIM charge line from claims.
From what field should the narrative data pull from? This option is available only if the Display narrative on ER SIM charge line? option is set to Yes. Select one of the following: Charge Entry (default): To use the narrative from the Charge Posting screen on claims for the ER SIM charge line. One of the following will be used:
The narrative on the ER SIM charge line: This occurs when a narrative is pre-defined for the ER SIM code on the Other tab of the Service Items library, or upon rebill if the user manually enters a narrative after the ER SIM is inserted as a charge line from the billing process.
The narrative on the first charge line, if the ER SIM narrative is blank
Encounter Maintenance: To use the narrative from the Encounter Maintenance window on claims for the ER SIM charge line.
The narrative must be manually entered in the Encounter Rate sub-tab on the Billing & Collections tab of the Encounter Maintenance window.
All charge narratives when ER SIM only item on claim: To use the narratives for all charge lines from the Charge Posting screen on claims for the ER SIM. Multiple narratives are concatenated on the claim, and duplicate narratives are suppressed from the claim.
This option is available only if the Is the ER SIM the first or the last line item? option is set to Only.
Note: This option may be used with Encounter Rate billing for Med-Cal.What is the ER SIM amount? This option is available only if the Do you send the ER SIM as a unique charge line on the claim? option is set to Yes. The ER SIM amount is the value that displays on claims, not the value inserted on encounters. Select one of the following: <none> or leave blank
Encounter Rate
Sum of original covered charge lines: The sum of the charges must exclude alternate payers and charges indicated as excluded from the encounter rate amount.
Zero
Encounter Rate minus the sum of covered charges
Is the ER SIM the first or the last line item? This option is available only if the Do you send the ER SIM as a unique charge line on the claim? option is set to Yes. Select one of the following: <none> or leave blank
First: To send the ER SIM as the first line item on claims.
Last: To send the ER SIM as the last line item on claims,
Only: To send the ER SIM as the only line item on claims. The following options become unavailable and are set to <none>:
Do you send the original charge lines on the claim?
Do the original lines have a dollar amount or are they sent as $0?
What data element is the ER SIM on the claim? This option is available only if the Do you send the ER SIM as a unique charge line on the claim? option is set to Yes. This setting controls box 24D on 1500/837P claims and box 44 on UB/837I claims for the ER SIM. Select one of the following: <none> or leave blank
Value Code: To send a Value Code for the ER SIM on UB claims. This option is used for New York Medicaid. The following option becomes required:
What value code is sent on the claim?
CPT: To send the CPT4 code for the ER SIM on 1500 or UB claims.
First Charge Line CPT: To send the first charge CPT4 code for the ER SIM on 1500 or UB claims. The Encounter Rate SIM is populated as the first CPT in charge entry. This option is used for Medicare Part A and Florida Medicaid.
Revenue Code: To send only the Revenue Code for the ER SIM on UB claims. If selected, only the revenue code displays on the claim, not the CPT4 code.
What value code is sent on the claim? This option is available only if the Do you send the ER SIM as a unique charge line on the claim? option is set to Yes. This option is required if the What data element is the ER SIM on the claim? option is set to Value Code. Select one of the following: <none> or leave blank
A Value Code from the list.
Note: This option is used primarily for New York Medicaid.Do you send the original charge lines on the claim? Select one of the following: Yes: To include the original charges as separate line items on claims. The following option becomes required:
Do the original charge lines have a dollar amount or are they sent as $0?
No: To exclude the original charges from claims.
Do the original charge lines have a dollar amount or are they sent as $0? This option is required if the Do you send the original charge lines on the claim? option is set to Yes. Select one of the following: <none> or leave blank
Sent with the charge amount
Sent with a $0 amount
Copy Primary Claim Options? To copy settings from the Primary Electronic Claims section to the Secondary and/or Tertiary sections, select one of the following: Primary to All: To copy Primary settings to both the Secondary and Tertiary sections.
Primary to Secondary: To copy Primary settings to the Secondary section only.
Primary to Tertiary: To copy Primary settings to the Tertiary section only.
Note: Selecting a copy option overwrites any options previously selected in the Secondary and Tertiary sections. The new copied options are saved only when the OK button is selected. If the Cancel button is selected the new copied options are not saved.What reason code is sent in the CAS segment to auto balance the claim? This option is available in the Secondary and Tertiary sections only if the Do you send the ER SIM as a unique charge line on the claim? option is set to Yes. Select one of the following: <none> or leave blank
A Reason Code from the HIPAA X12 Standard Reason Codes library.
- To save changes and close the window, select OK.