dTHOMAS/THOMAS-Lite Blue Cross Blue Shield of Michigan-EDI and

Transcription

dTHOMAS/THOMAS-Lite
Blue Cross Blue Shield of Michigan-EDI
and
Genius Solutions, Inc.
Free Informational Forum
Spring 2005
Table of Contents
Chapter 1:
When Might You Need a New TPA ...................................................................................................3
Chapter 2:
Updating dTHOMAS/THOMAS-Lite ..................................................................................................3
Chapter 3:
Payer/Payor Numbers ........................................................................................................................4
Chapter 4:
Add Taxonomy Code and NPI............................................................................................................6
Chapter 5:
Preparing in the ANSI Format ............................................................................................................6
Chapter 6:
The Pre-Billing Report ........................................................................................................................7
Chapter 7:
Reports ...............................................................................................................................................10
1. Status of Last Transmission .................................................................................................11
2. Broadcast Message...............................................................................................................12
3. 997 Report .............................................................................................................................13
4. BCBSM U227 Report ............................................................................................................14
Common Front-End Edits
5. WPS and MEDB Report ........................................................................................................17
6. 835 Report .............................................................................................................................18
WPS Input Sheet for ERA Providers
7. PRPRV Provider Authorization Report..................................................................................20
8. Troubleshooting Ideas ...........................................................................................................21
Chapter 8:
Claim Preparation Tips .......................................................................................................................24
Chapter 9:
Status Inquiry......................................................................................................................................26
Chapter 10:
Chiropractic Setup for X-Rays for dTHOMAS……………………………………………………………..32
Chapter 11:
Chiropractic Setup for X-Rays for THOMAS-Lite………………………………………………………….35
Chapter 12:
Current Events....................................................................................................................................38
Appendix A
How to Start Sending Claims Electronically .......................................................................................42
Appendix B
Genius Solutions Contact List ............................................................................................................49
Seminar Questions
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Chapter 1:
When Might You Need To Change Your TPA?
In cases where there has been a change to your provider ID number, a new provider is being added, or a new tax
ID number you may need to change your TPA.
These steps should be followed when a change is made:
A. Trading Partner Agreement
BCBSM EDI requires that you complete their EDI Trading Partner Agreement (TPA) prior to the
submission of any ANSI electronic claims. The TPA should to be filled out BCBSM Web Site
(www.bcbsm.com). If you have not filled out the TPA, contact a BCBSM EDI TPA administrator at 248-4862292 or EDISupport@bcbsm.com.
B. There Are Two Types Of TPA’s, The Submitter And The Provider.
1. Submitter Portion:
Starts with your billing location code (c0xxx) which is now called your BCBSM submitter. In this section of
the agreement, you will provide your authorized parties name, title, phone number and email address if
you have one. If you have more than one BCBSM submitter code, you will need to do a TPA for each
one.
2. Provider Portion:
Used to document the various identification numbers your providers use for different insurance carriers.
i.e. Medicare, BCBSM, Blue Care Network, Medicaid. It is important to note that BCBSM now requires
you to use your full BCBSM 10 digit PIN for all BCBSM claims.
Any questions regarding PIN numbers call: BCBSM Provider Enrollment number 800-822-2761 or
ProviderEnroll@bcbsm.com
C. Client Information Verification Form
The Genius Solutions, Inc. Client Information Verification Sheet must be completed and faxed to Genius
Solutions at 586-751-3016 if you have added another BCBSM submitter code or you are a new client. You
must complete a Client Information Verification Sheet for each BCBSM submitter code that you use. Please
contact Genius Solutions, Inc. to obtain the Client Data Verification Form.
Upon receipt of the Client Information Verification Sheet, Genius Solutions, Inc. will inform BCBSM EDI
department that you are ready to start sending ANSI claims with the new BCBSM submitter code. Allow one
week from faxing the sheet before sending claims.
Chapter 2:
Updating dTHOMAS/THOMAS-Lite
In order to take advantage of the latest ANSI capabilities within THOMAS, it is necessary to update to the latest
version of your THOMAS. Clients should use their THOMAS AutoUpdate icon
.
If you are interested in Auto Updating via the Internet please contact Genius Solutions, Inc. It is, in most
cases faster, easier, less expensive and eliminates busy signals.
Remember you must have everyone exit THOMAS before using the THOMAS AutoUpdate program and backup
your data. Failure to do so may result in a failed update or corrupted data and is a user error that may require
Genius Solutions, Inc. intervention.
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Chapter 3:
Payer/Payor Numbers
In order to send commercial claims to BCBSM-EDI a Payer/Payor ID and/or Claim Office number must be entered
on the Insurance Code File screen for each carrier to which you are sending electronically. Complete the ANSI
Payer/Payor ID and Claim Office number, if applicable, in the Insurance Code File.
You may get the latest BCBSM EDI Professional Commercial Payer/Payor List by searching for the “Professional
Commercial Payer/Payor List” at the following websites: www.bcbsm.com or www.geniussolutions.com (click
LINKS) and then click on EDI Payer/Payor List. See sample below.
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A. Add ANSI Payer/Payor ID Numbers
To manually add a new Payer/Payor ID number.
Adding an ANSI Payer/Payor ID
Follow these steps from the Main Menu:
1) ║4║ Code Files
2) ║6║ Insurance Companies
3) ║F║ Find the Insurance Code that needs the addition of a Payer/Payor ID
4) ║C║ To change
5) Add the Payer/Payor ID in the field labeled ANSI Payer/Payor ID
6) Add the Claim Office Number in the field labeled ANSI CLM-OFF number, if applicable
7) Save your work
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Chapter 4:
Add The Taxonomy Code And NPI
A. Taxonomy
The ANSI electronic claim format requires the reporting of a taxonomy code on all electronic claim forms. The
taxonomy code identifies the education level and specialty of the provider. You may obtain the list from
www.geniussolutions.com on-line or you can contact your preferred submitter for additional assistance.
B. NPI
According to HIPAA, health care providers may apply for NPI numbers (National Provider Identifier) as of May
23, 2005. Currently in dTHOMAS and THOMAS-Lite there is a field titled National Provider ID. At this time it
is not needed for the processing of ANSI claims so Genius Solutions, Inc. asks that you do not make any
changes in this screen at this time. If you have any questions please do not hesitate to call the Genius
Solutions Technical Support Department.
To view the NPI field, follow these steps from the Main Menu:
1) ║4║ Code Files
2) ║4║ Doctor Codes
3) ║S║ License
) Tip: Do not make any changes within the National Provider Field (NPI).
Chapter 5:
Preparing In The ANSI Format For BCBSM
A. In order to prepare claims in the ANSI format, from the Main Menu select:
1) ║5║ Insurance Billing
2) ║A║ ANSI 837
3) ║1║ BCBSM
4) Complete the claim preparation process by using standard claim preparation techniques.
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Chapter 6:
Pre-Billing Report
Prior to preparing the file, you will have the option to view or print the Pre-Billing Report. The Pre-Billing report is
designed to look for common errors within the claims you are preparing. dTHOMAS will suppress claims from the
file that may cause front-end edits or rejections. You should review the Pre-Billing Report for any errors and make
any necessary corrections. Once the corrections are made, the claims will be included in your next file, as long as
the billing status is selected in preparation. The file name “a01-0033” indicates the format the sequential file
number. Each time you prepare a new claim file, the file number will be incremented by one, even if a claim file is
not generated.
It is very important that you match the Output File Name that appears on the Pre-Billing Report to that of
the Batch number on the received 997 Acknowledgement report.
If you receive a “Rejected” 997 Acknowledgement Report for your file, it is important that you contact Genius
Solutions Technical Support Department. You may fax the Rejected 997 Acknowledgement Report to 586-7513016.
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A. Pre-Billing Errors
The following table contains some of the errors THOMAS checks on the Pre-Billing Report.
MESSAGE
Doctor Code File
No Doctor Last Name
Taxonomy not 10 digits
No Tax ID
Referring Phy Code File
No Ref Phys
No Ref Phys Name
No Attending Phys
No Attending Phys Name
No Ordering Phys
No Ordering Phys Name
Insurance Code File
No Payer/Payor ID
Invalid Payer/Payor ID
Ins Name Invalid
Ins Addr Invalid
Ins City Invalid
Ins State Invalid
Ins Zip Invalid
Patient Information
No Patient Addr
No Patient City
No Patient State
No Patient Zip
No Patient Birth date
Policy Information
No Policy Addr
No Policy City
No Policy State
No Policy Zip
No Policy
(** Policy does not match **)
MR2 & empty indicator
MR with relationship not self
Bad Contract Number
(** BAD CONTRACT **)
Invalid relationship
REASON
Doctor’s last name not completed.
Taxonomy is not 10 digits.
No Social Security or Employer ID.
Referring physician code listed on the header (Zoom) is not found in the referring
physician code file.
Referring physician’s last name/first name or full name is not completed.
Attending physician code listed on the header (Zoom) is not found in the referring
Attending physician’s last name/first name or full name is not completed.
Ordering physician code listed on the header (Zoom) is not found in the referring
Ordering physician’s last name/first name or full name is not completed.
Claim is marked with type (E)lectronic and there is no Payer/Payor id in the
insurance file
Payer/Payor ID is missing or 1 character.
Length of Insurance Name is less than 1 character.
Length of Insurance Addr+Addr2 is less than 1 character.
Length of Insurance City is less than 2 characters.
Length of Insurance State is less than 2 characters.
Length of Insurance Zip is less than 3 characters.
Missing address in patient information.
City is missing or 1 character in patient information in patient information.
Length of State is less than 2 characters or the first character is not alpha in
patient information.
Missing zip in patient information.
Missing birth date in patient information.
Missing address in policy information.
City is missing or 1 character in policy information.
Length of State is less than 2 characters or the first character is not alpha in policy
information.
Missing zip in policy information.
The policy listed on the claim is not found in the policy holder information.
Medicare is secondary and the secondary insurance indicator is missing.
Form 2 with relationship not equal to self.
Contract number is less than 2 characters.
Relationship does not equal 1-4 in policy holder information.
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Mcare requires service code
Transaction Information
Invalid Modifier
No POS
No DX (* No DX*)
No Transaction to bill
(*Not Bill*)
No Transaction to status
(*Status*)
No Service Date
Line will not bill! Zero/Neg
balance
Insurance Company Type is “E” (Mcare) relationships is not self (1) and the
service code field is empty.
Modifier 1 or 2 is only 1 character.
Place of Service not on the line of service.
Diagnosis not on the claim header or on the line of service.
All transactions are marked Not billable.
No transaction marked (I)nquiry.
No Date of Service on the Transaction.
Michigan Customers: Numerous customers have indicated receiving U277
rejections when submitting claims with lines of service that have no balance, or
equal (0.00) in value. As an example, this can occur when submitting a
secondary claim with a line of service that was adjusted (participating adjustment
"PARADJ") during the time of primary insurance payment posting. As a result, a
modification was made to the ANSI claim preparation program that will now omit
lines of service from being sent electronically if the line of service has a zero
(0.00) balance. Any claim line found to have a zero balance will be listed on the
prebilling report with the following message: " Line will not bill! Zero/Neg balance"
One exception to this change is the submission of Capitated service lines where
no charge is required, but the submission of the line of service is still mandatory.
The software will review the patient's policy to determine if the line of service
applies to a Capitated insurance policy.
If for any reason your office believes it needs the ability to submit claim service
lines with a zero charge, please contact Genius Solutions, Inc Technical Support.
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Chapter 7:
Reports
A. Summary of Responses from EDI Client
Claims submitted in the ANSI format should have the following reports available.
Appears immediately following the
transmission of a file or when picking up
response files.
Appears immediately following the
transmission of a file or when picking up
response files..
Status of Last Transmission Report
Broadcast Message
997Acknowledgement Report
Available approximately 24 hours following
the transmission of a file.
U277 BCBSM Unsolicited Report
MEDB (WPS Medicare) Report
835 Report
These appear when claims are completely
processed by the Payer/Payor. Expect 2
weeks for Medicare and 7-10 days for
BCBS/BCN.
PRPRV Report
Report appears after a change in the provider
code listed under Submitter ID.
The next section of this document will explain the relevance of each of these ANSI reports.
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1. Status of Last Transmission
This is your receipt that BCBSM EDI received your file. On this report, it does show the number of claims that
were sent. If your Status does not say "ANSI" next to the date, time and BCBS submitter code, you are
probably not sending ANSI claims.
If you do not receive a Status of Last Transmission when sending claims, Genius Solutions, Inc. recommends
you dial BCBSM again, but leave the file name blank when the program asks you to enter a file name for
transmission. This will cause your modem to dial in again, but not attempt to send a file, just get your Status
of Last Transmission. You should always get the Status of Last Transmission before trying to send the file
again, or a different file, because you can only get the status of the last file you tried to send. If you receive
"duplicate file,” you know BCBSM already received the file you are trying to send.
If your Status says, "Unrecognized Format,” your claims did not go through properly. Usually this is caused
by a bad connection to BCBSM's modem. Try sending the same file name again, and if the problem
continues, you should contact Genius Solutions Technical Department to assist in trouble shooting the
problem.
XXX
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2. Broadcast Message
This is a message page supplied by the EDI department of BCBSM. It is often the first notice of changes
occurring at BCBSM EDI.
) TIP: We highly recommend this be read on a regular basis to view any changes from EDI. For example the
Payer/Payor ID changes may be indicated here.
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3. 997 Report
This report should be available within 24 hours following the successful transmission of an ANSI file. An
“Accepted” status indicates that your file was accepted by BCBSM EDI and will be forwarded to the EDI
claims front end editing program. You may still receive individual claim edits/rejections on a subsequent
U277 BCBSM Unsolicited Report.
If you receive a “Rejected” status for a file you have submitted, please contact the Genius Solutions Technical
Support Department immediately for assistance. None of the claims within the “Rejected” file will be reviewed
by BCBSM for payment, a correction to the file must be made, and ALL claims must be resubmitted.
) TIP: Make sure the Batch file matches the file name on the Prebilling report. It is also helpful to attatch the 997
Report to the Prebilling report for quick referencing.
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4. BCBSM U277 Report
This report is also known as the BCBSM EDI Unsolicited Print Report. This is the text style report from
BCBSM EDI that indicates individual claims that have been “front-end edit” rejected. All claims listed on this
report must be corrected and resubmitted. A detailed explanation of the rejection is indicated with each claim
that has been listed. Once claims pass front end editing, they are forwarded to payers for processing.
Contract #
*XYZ123456789
Account #
Data
Directory Claim #
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A. Commonly Seen Errors by the Genius Solutions Support Department
These front-end edit codes with their descriptions are the edits most commonly seen in the Genius Solution
Technical Support Department. Here are a few suggestions to help correct these edits. For some of these
edits Technical Support suggests that you contact them for assistance.
) TIP: Claims that front end edit should be corrected and resubmitted as an original claim. Whenever you make
changes or corrections to a claim that has already been billed, be sure that you change the status of your claim to
one of the following Unbilled, Re-Billed, Secondary or Inquiry so they bill out again.
1. A3,24,85,Y – Medicare B P002; P001 BSBC or BCN; P004 BCBS only; P003 Commercial. This is
regarding all provider ID numbers and tax ID numbers that are incorrect or unauthorized. Make sure that
the TPA is filled out correctly. If the TPA is correct then check your provider information in the Code Files.
Another reason to get this edit is an invalid SOP (source of pay) for the Payer/Payor ID number reported.
To correct:
From Main Menu > 4 Code File > 4 Doctor Codes > press S for License and be sure all provider numbers
are correct. Double-check the letter O and the number 0 (zero) > press I for Insurance and L to List to
screen and see if the insurance code is added with the correct ID number and/or Group number. If the
insurance code is not added you will need to do so and then attach the correct provider number you need
to report. Another reason to get this edit is an invalid SOP (source of pay) for the Payer/Payor ID number
reported. Check the financial code that was used on the claim. From Main menu > 2 Patient File > Enter
patient name or account number > Press 2 Policy Holder Info > check the correct insurance policies for
the correct financial code and insurance code. Then go to I for Insurance Claims > Find the claim number
> Check the Financial Codes 1 and 2 and the Insurance Codes 1 and 2 for accuracy > C to Change if
they are not correct > Enter over to the Financial Codes and correct > Press Page Down > X to Exit
2. A3,153,IN,Y P017, Commercial Payer/Payor number ID and or claim office number invalid. There is not a
proper Payer/Payor ID number on the insurance code. Add Payer/Payor ID, and if applicable, Claim
Office number to the insurance code. To correct:
From Main Menu > 4 Code File > 6 Insurance Companies > Find the insurance > Check the ANSI
Payer/Payor ID and ANSI Clm-Off number fields for accuracy. If they are incorrect choose C to Change
and add the Payer/Payor number from EDI’s most current Payer/Payor ID list. Pay close attention to the
letter O and the number 0 and the number 1 and the letter I > Press Page Down > X to Exit
3. A3,162,P2,P052 – BCBSM Supplemental claims and HIC number missing. Usually this is an Invalid HIC
number. Medicare contract number does not match what Medicare has on file. To correct the contract
number:
From Main Menu > 2 Patient File > Search for patient or use patient account number > Press Enter > 2
Policy Holder Info > Find Medicare > C to Change > arrow down to the Contract No. > add the
alpha/numeric character to the end of the contract number > Press Page Down > X to Exit
4. A3,164,IL,A520 – Sub contract number invalid or missing. You will need to add or correct subscriber
contract number. To correct:
Policy Holder Info > Check insurance policy for accuracy and if incorrect > C to Change > Enter down to
the Contract No. > add the contract number > Press Page Down > Yes to Save > X to Exit
5. A3,255,P145,P145 Diagnosis pointer number > diagnosis codes present. The transaction line is pointing
to the wrong diagnosis. To correct:
This edit states there is something wrong with the diagnosis either in the DX Data field in the header or on
the claim transaction line. Examples are; there is a wrong pointer code in the header. For instance the
wrong set of diagnosis was being used or a new set should have been created to use. It could also mean
that the diagnosis are not loaded correctly according the proper Payer/Payor (top or bottom fields) in the
DX Data field. Another example would be that the top or bottom fields might have been left empty. You
may check the claim header to see if there is anything there and then check the transaction claim line
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itself. If there is a DX Data pointer loaded into the header but left blank it will override the transaction
claim line. Correcting the DX Data From Main Menu > 2 Patient File > Search for patient or use patient
account number > Press Enter > Press I for Insurance Claims > Press Z to Zoom to claim header. C to
Change and enter down to the Diagnosis field > Press F1 > review/add or change the DX Data codes and
select the proper one > Press Page Down > Yes to correct > X to Exit. Correcting from the claim
transaction line; from Main Menu > 2 Patient File > Search for patient name or use patient account
number > Press Enter > 5 for Transaction Ledger > M for Maintenance > Find the correct claim number
for date of service and procedure > Enter > C to Change > Press Enter to the diagnosis field and key in
correct diagnosis > Press Page Down > X to Exit. Remember that if there are multiple transaction lines
they may all need to be corrected.
6. A3,479,04,P212 The Payer/Payor ID at the claim level must be the same as the SVC (service) Level.
This edit indicates that an error was made at the time the insurance payment was posted. This happens
most frequently with statusing, chiro xray, HIT and secondary claims. Genius Solutions Technical Support
has asked that you call them and let them determine the error and how it needs to be corrected.
7. A3,249,P050 – POS invalid. The Place of Service is invalid on the transaction line. To correct:
Transaction Ledger > M for Maintenance > Choose the correct claim by date of service and procedure
code > Press Enter > C to Change > Enter over to the POS field and indicate the correct Place of Service
> Press Page Down > Press X for Exit
8. A3,126,IL CDA204 (address), 208 (zip code), 206 (City), 207 (State). Invalid insured address, city, state
and zip code. ANSI requires that the subscriber’s insurance policy have an address, city, state and zip
code. This is an issue if the policyholder is not marked Self. When it is Self THOMAS will pull the
information from the patient information screen. If the policyholder is not the patient then:
Policy Holder Info > Find the Policy > C to Change > arrow down to the subscriber address and add or
correct > Press Page Down > X to Exit
9. A3,400,P179. Sum of Primary Payer/Payor SVC (service) paid amts do not = claim paid. This edit
indicates that an error was made at the time the insurance payment was posted. Genius Solutions
Technical Support has asked that you call them and let them determine the error and how it needs to be
corrected
10. Missing or Invalid; Billing, Rendering, Referring, Provider ID, Attending etc. There are many front-end
edits for these errors. All of these edits indicate that something is wrong inside the Code Files for the
provider that was used on the claim. Also, make sure the UPIN is loaded in the front screen for the
referring code, to review this information:
From Main Menu > 4 Code File > 4 Doctor Codes > Press I for Insurance and L to List to screen and see
if the insurance code is added with the correct ID number and Group number > Press Exit > Press 5 for
Referral Codes > Find the provider and check all fields for missing or wrong numbers > If numbers are
missing or wrong press C to change > Enter down to the correct field and add or correct ID numbers.
Double-check the O’s and the 0’s (zero) > Page Down > Press I for Insurance and any other insurance
codes are loaded for the provider ID’s that would not be listed on the Referring Doctor screen, such as
BCN, HAP etc > If the insurance code is not added here you will need to press A to Add > enter the
insurance code > Press Enter > Enter the ID No number > Make sure that field 17A has a Y entered >
Press Enter > Press Yes to Save > Press X to Exit.
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5. WPS MEDB Report
In the event you submitted Medicare claims the following day, you should receive a WPS Medicare
confirmation report indicating the number of claims and total dollar amount of those claims that were received.
This report is supplied by WPS Medicare and confirms their receipt of your claims. This information can be
referenced in the EDI User Guide.
) TIP: If you have claims that have “errors or deleted”, you need to correct and rebill them before WPS can
process. Claims “deleted” or claims “with errors” should be detailed within this report.
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6. 835 Report
The 835 reports reflect payment advice and insurance check information. This information can be referenced
in the EDI User Guide. To locate the 835 reports that your office has received, go to your EDI Client Print
Reports area. Not all offices print the 835 Report and instead they wait for the paper vouchers.
Please read the following carefully:
1. If you are currently receiving the 835 reports you do nothing.
2. If you are not currently auto posting and not receiving this report you may fill out the WPS input sheet for the
835 activation of this report and fax the form to WPS Illinois/Michigan/Wisconsin office. (See the WPS Input
Sheet for ERA Providers Electronic Data Services on the next page).
3. If you are currently auto posting in the UBPC format and want to continue until the cutoff date, DO NOT fill out
the WPS Input Sheet for ERA Providers Electronic Data Services on the next page. If you do, Medicare will
turn off the UBPC report and only give you the new 835 reports. This means you will no longer be able to
auto post in the UBPC format. If you need further clarification on this please call Genius Solutions Technical
Support.
4. If you do decide to auto post in the 835 format, fill out the WPS form and fax it to WPS. You will then need to
call Genius Solutions, Inc. to proceed with set-up for the 835 auto posting.
NOTE: As of today you are able to auto post Medicare and BCBS claims as long as they are electronically
transmitted to EDI using the THOMAS program. Claims that are printed to paper cannot be auto posted.
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7. PRPRV Provider Authorization Report
BCBSM EDI has the capability of reporting back when Provider numbers that are authorized for your BCBSM
Submitter Code (Billing Location Code) have changed. This report is from BCBSM EDI shows the TPA
provider authorizations that have been loaded to the HIPAA EDI provider database for each submitter.
BCBSM EDI may give you this report whenever a provider number or authorization changes on a particular
BCBSM submitter code.
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8. Trouble Shooting Ideas To Try Before Calling Genius Solutions Technical Support Department.
Listed below are some helpful hints for troubleshooting EDI Client.
A. To access the different options within EDI Client, Type, “Help”, in the field that states “Enter file name to
send”. This will give you a list of commands that may be used in EDI Client. These commands may be used
one at a time. Type the command in the field that states “Enter file name to send”. If you do not feel
comfortable accessing this area, then do not proceed; contact Genius Solutions Technical Support
Department for assistance.
B. Disconnected VT
EDI Client cannot use the COM port assigned.
1. Close all programs and power down the computer, unless your network administrator advises otherwise.
Power the computer back up and try to send the file.
2. Something else could be holding the modem open.
a. If you share the modem line, verify that someone is not using that line or that you are not sending or
receiving a fax.
3. Check to make sure EDI Client is using the correct COM port.
Verify the COM port to be used:
Windows 2000 Professional, select My Computer, Control Panel, Phones & Modems Options, Modems
tab. The modems installed on the computer will be displayed with the COM port designated.
Windows XP Professional, select Start, Control Panel, Phones & Modems, Modems tab. The modems
installed on the computer will be displayed with the COM port designated.
a. Type “Show” when it asks for the file name to send, you will see the configuration of the EDI Client.
On the third line you will see a number, this is what the EDI Client is currently using as your COM
port. If the number listed is different than the number listed as your COM port within your modem,
then it will need to be changed.
Before proceeding you must know your BCBS submitter code.
b. To change the COM port, open up EDI Client. Pick Blue Cross, at “Enter file name to send” type
configure, click ok. Follow the prompts. When you are prompted for the COM port, only type a single
digit, in other words COM1 = 1, just type 1.
4. If you are still having a problem call Genius Solutions Technical Support Department.
C. No Response From Modem
When EDI tries to access modem and it is not responding.
1. Make sure your modem is on. If you have an external modem, turn off then back on.
2. If you have an internal modem, close all programs and power down the computer unless your network
administrator advises otherwise. Power the computer back up and try to send the file.
3. If your modem is on:
a. Close all programs and power down the computer unless your network administrator advises
otherwise. Power the computer back up and try to send the file.
4. If problem persists call Genius Solutions Technical Support Department.
D. No Carrier
Your call has dropped.
1. Try again.
2. If problem continues, call Genius Solutions Technical Support Department.
E. No Dial Tone
Your modem has reported no dial tone.
1. Verify the phone line is connected properly. Verify that the phone cable is properly inserted in the
connection to the modem/computer as well as the connection to the phone jack.
2. Make sure no one is on the line that the modem is using.
3. If you have voice mail on your modem line, check your voice message.
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F. No Answer Or Dialing Error
There was a problem with the connection to BCBSM EDI
1. Turn off the modem.
2. Close any programs that may be open. Properly shutdown the computer, unless your network
administrator advises otherwise. Wait 10 seconds. Turn the modem on. Turn the computer back on. Try
again.
G. Busy! Try again?
The line is busy…
1. Cancel and try again.
2. If you receive a busy signal again, try later the same day.
3. If you receive a busy signal when you have tried again, try the next morning.
4. If still busy contact BCBSM EDI or Genius Solutions Technical Support Department.
H. No Password Response
The problem is waiting for password prompts, not an actual password problem.
1. Wait a few minutes and try again.
2. Try raising or lowering your baud rate. Within EDI Client, at “Enter file name to send”, type 9600, click ok.
Then enter file name to send.
3. If you are still having problems call Genius Solutions Technical Support Department.
I. Broadcast Not Received
Problem waiting for Broadcast Message prompts.
J. Upload Error
The file did not get sent to EDI. The transmission failed.
1. When you typed the file name for transmission, verify that a . (dot) or a / (slash) was not typed in front of
your file name. Try sending the file again.
K. “MS-DOS 16 Bit Subsystem”
Please call Genius Solutions Technical Support Department for assistance.
L. Error looking for 1 responses
Problem with retrieving the response files.
M. Variable B Not Found
N. Variable Original Not Found
O. If You Are Receiving “Hieroglyphics” Or “Strange Looking” Characters On The Screen After
Connecting To EDI
P. If you go straight to the status screen when clicking “Pick” next to Blue Cross-Call Genius Solutions
Technical Support Department.
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Q. End of File Unexpected ANSI – This error appears on Status of Last Transmission.
1. Re-prepare and resend the file. It is important that the original file that received this message is recreated.
Do not resend the original file. You may use the option of Billed but Unpaid to quickly re-prepare the file.
Once the file is prepared, close out of THOMAS, then send file. If you need assistance using the Billed
but Unpaid option, contact Genius Solutions Technical Support Department.
2. Make sure the computer that has prepared the file has closed out of THOMAS Billing Menu before the file
is sent.
3. If still receiving the message, try lowering your baud rate. Within EDI Client, at “Enter file name to send”,
type 9600, click ok. Then enter file name to send.
If any of these problems persist, contact the Genius Solutions Technical Support Department.
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Chapter 8:
Claim Preparation Tips
A. Other Status Claims
Prior to preparing or printing claims, double-check, “O. Other Status Claim” for any claims you may have set
aside. (Main Menu, option 5. Insurance Billing, option 1. Paper Claims, option O. Other Claim Status).
B. Electronic Billing First
Always do electronic billing prior to paper billing. THOMAS will always pull claims that can be sent
electronically leaving only claims that can be submitted on paper behind.
C. Run a Pre-billing Report
The pre-billing report checks the claims you are preparing to process for any obvious errors. If a claim is
determined to have an error, THOMAS will not prepare or print the claim. If you fail to run the pre-billing
report, THOMAS will not realize a problem may exist and allow you to prepare or print the bad claim.
D. Hard-Copy Claims
Prepare the unbilled claims separate from your secondary claims. By printing them separately, you will
produce a stack of unbilled claims that can be mailed “as is” in most cases, where as the secondary claims
will need their attachments. Preparing them separately keeps you from having to sort through all of the
claims just to find secondary claims that need the attachments.
E. Billed But Un-Paid Claims
The option to run Billed But Unpaid claims, for old claims, should be run periodically. THOMAS will give you
a list of all claims in a billed status within a specified period. Anyone that works the accounts receivables will
find this is a quick and easy way to re-bill all your claims in the system back to the insurance company
whether electronic or paper.
F. Individual Claim Rebilling
When the need arises to re-bill a small amount of claims individually, individual claim rebilling provides this
easy method.
G. Patient Insurance Policies dTHOMAS
The position of 1, 2 inside of the patient account allow those policies to default onto the insurance claim when
posting charges. Patient insurance policies that are in positions 3, 4, 5, 6, 7, 8 will not automatically default
onto the claim yet still can be used if necessary. Position 9 is automatically utilized by the system for cash
and/or guarantors. When claims are generated, the information that is used on the claims is pulled according
to which policies are indicated on the claim and the information indicated within the patients’ insurance
policies, regardless of the position of the insurance policy.
• If you change information on an existing policy then the new information will be reported when billing/rebilling any claims attached to that policy.
• If you change the position of the policy by changing the number (1-8), then when claims are generated
the original insurance policy information will still be indicated.
The Financial Codes and Insurance Codes that are used in the examples in this document are for sample
purposes. The codes that are used in your office may be different.
Example: The patient has Primary insurance through PPOM. Beginning June 1, 2005 the patient has a new
employer and now has Blue Cross Blue Shield. You have been billing out claims for this patient to PPOM until
May 31, 2005. Based on the new insurance information from the patient, you should change the insurance
policy 1) PP/PPOM to 4) PP/PPOM. Then add a new primary policy of 1) BC/BC. This allows any claims that
were originally billed to PPOM to be re-billed to PPOM if necessary and any new charges posted into the
system will be billed to the new BC. You may also indicate “Start” or “End” dates within the Status screen,
found inside of the Patient Insurance Policy screen.
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Scenario: The date is June 5, 2005, and the provider has given you a billing slip for services rendered on May
28, 2005. Since the patients’ insurance in May was PPOM you will need to indicate PPOM on the claim. To
do so, set up the patient account as described in the previous paragraph. Proceed with Posting the Charges
for May, when the Header appears for Posting Charges and it asks “Correct?” select “No”. Place the cursor in
the field for FC1) (the primary financial code), press the F1 key. The list of policies for this patient will be
listed. Use your arrow keys to select the proper insurance policy, ( 4) PP/PPOM). Proceed with posting
charges as usual.
) TIP: When moving a policy, it is important that within each patient account, each policy has a unique Financial
Code indicated on each policy. It is acceptable to have the same Insurance Code.
Example: The patient has Primary BC insurance, (Financial Code BC and Insurance Code BC) and their
group number changes, effective April 1, 2005. To maintain the original claims being billed out with the
original group number you would need to move the policy from 1, to 4 or higher, then add a new policy 1)
BC/BC) with the new information so the new claims from April 1, 2005 and forward will pull the new contract
information. When you move the original BC policy to the fourth position you should change the Financial
Code to a unique Financial Code within the patients account, such as BS, B2 or B3.
Another example might be that the patient has Medicare as the primary policy and Aetna as their secondary
policy. The policies are set up as 1) MR/MR 2) OT/AETNA. The patient has terminated their Aetna policy and
has a new secondary policy of AFLAC. Move the Aetna policy to the fourth position, change the financial code
from OT, SI or O2. (4) OT/Aetna). Add a new secondary policy for AFLAC, (2) SI/AFLAC).
If you do not have additional Financial Codes for the same type of insurance you may contact the person in
charge within your office to set up a new Financial Code or contact Genius Solutions Technical Support
Department for assistance.
H. Patient Insurance Policies THOMAS-Lite
THOMAS-Lite may have up to two policies per patient account. Therefore if a patient obtains a new
insurance policy but you would like to maintain the current information, you may add a new account for the
patient with the new insurance information. If you would like to have more features, please contact Genius
Solutions Sales Department to upgrade to the full dTHOMAS or eTHOMAS.
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Chapter 9:
Status Inquiry
A. When may I use Status Inquiry?
According to BCBSM EDI User Guide, Submission of BCBSM Professional Status Inquiry Claims:
Electronic BCBSM status inquiry claims should be submitted when the provider disagrees with the initial
determination for a claim, or for a particular service within a claim. In order for a status inquiry claim to be
properly adjudicated, the following information must be included in your electronic claim (837 transaction) in
addition to all regularly required fields. When submitting a status inquiry on a supplemental or COB claim, all
required fields for those types of claims must be submitted in addition to the fields required for submission of
a status inquiry claim.
If the provider previously received a payment or denial that they disagree with, a status inquiry claim (837
transaction) can be submitted by selecting one of the following values for CLM05-3 (if applicable):
• Use code value of 7 to indicate payment other than anticipated (POTA)
• Use code value of 7 for corrected claims.
• Use code value of 8 to indicate replacement of a previously rejected claim.
• Use code value of 1 to indicate COMP NPR and submit as an original claim.
If a code value of 7 or 8 is submitted, the original claim reference number ICN/DCN must be reported. If
the claim does not fall into the one of the examples, above, do not submit as a status inquiry. Simply
correct the claim and resubmit electronically.
Status Inquiry should be sent on claims that you have received a payment or nonpayment from BCBSM. If
you do not know the status of your claim, providers who have access to web DENIS can verify the status of
their claims using the Claims Tracking Feature or you may also contact Provider Inquiry. See the correct
phone numbers on the “Who to Call List” provided. Provider Inquiry can tell you if you should use a Status
Inquiry.
1. When may I use POTA (Payment Other Than Anticipated)?
The claim must have received payment of $0.01 or higher. Perhaps the original claim was processed for
the wrong quantity or units, resulting in a lesser payment than anticipated. Example the original claim
was for a quantity of 2, but was processed and paid as a quantity of 1. Complete all fields within the
Status Inquiry, including the Document Control number (ICN), (Claim Control number). A code value of 7
is reported within the ANSI file in the CLM05-3 position.
2. When may I use Rejected (replacement of a previously rejected claim) Status Inquiry?
If the claim has been processed, but nothing was paid towards it ($0.00). Example an office visit was
rejected and you know that the patient has coverage or perhaps rejected duplicate claim. If no corrections
are necessary to the claim you may want to just re-bill the claim. If you proceed with the Status Inquiry,
complete all fields within the Status Inquiry, including the Document Control number (ICN), (Claim Control
number). A code value of 8 is reported within the ANSI file in the CLM05-3 position.
3. When may I use Corrected Status Inquiry?
If the claim has been processed but the original claim included wrong information or the claim was
missing information. Example; a claim for pre-determination and the admit date was not included on the
original claim). Complete all fields within the Status Inquiry, including the Document Control number
(ICN), (Claim Control number). A code value of 7 is reported within the ANSI file in the CLM05-3 position.
According to The Record, March 2001, page A-24 you should send a corrected CMS 1500/CMS-1500
claim instead of a status inquiry if you are changing or adding any of the following information: Patient or
subscriber data, diagnosis code, procedure code, location-of-service or type-of-service. You may also rebill the claim electronically in the original format.
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4. When may I use COMP NPR (No Payment Received)?
If Medicare is primary and BCBSM is secondary, usually Medicare will forward the claim to BCBSM. If no
payment has been received then you have multiple options within the THOMAS system. Be certain that
you have posted the Medicare response within the system.
• You may submit the claim electronically as Secondary. A code value of 1 is reported within the ANSI
file in the CLM05-3 position.
• You may submit the claim as a Status Inquiry of COMP NPR. Complete all fields within the Status
Inquiry. The Document Control number (ICN), (Claim Control number) is not required. A code value of
1 is reported within the ANSI file in the CLM05-3 position.
Note: Within the THOMAS system, within the ANSI file, the code value is the same for Secondary and Comp
NPR.
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B. Creating a Status Inquiry Claim for BCBSM
The Status Inquiry portion of the system is only accepted by BCBSM.
Verify that in your Financial Code files that ST is set up as a code of ST, Form 5, Description: Status Inquiry,
Insurance Type 1.
You may access the Status Inquiry features from two areas, as you are Posting Insurance Payments or from
the Patient Menu under the Insurance claims.
1. To create a Status Inquiry while Posting Insurance Payments:
• Post the BC explanation of benefit as desired. You will need to designate which transaction lines will
be included in the Inquiry by placing an “I” in the Status field to the far right. Place an “N” on the
transaction lines that should be suppressed from the Inquiry. Place the cursor in the field, type the
correct letter in the field or use your space bar to toggle to the correct option.
• Select “Done”, then select “Inquiry”.
• The inquiry information screen will appear.
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Date of Request:
Claim Control
number:
Non-payment
Code:
Status Type:
POTA:
Rejection:
Correction:
Comp NPR:
Check Date:
Payment Amount
number:
Check No:
Reason:
Service Lines:
This date defaults to today’s date.
Enter the Document Control number (Doc#). This goes into item 29 of the Michigan
Health Benefits Claim Review form if you submit by paper.
Enter the Non-payment Code from the BCBS voucher. This goes in item 28 of the
Claim Review form.
Select the status type of this claim from the following:
Payment Other Than Anticipated.
When questioning a rejection.
Correction to original claim.
Complementary Coverage and a payment or rejection was not received.
Enter the Check Date, if applicable, from the remittance report. This goes in item 26 of
the Michigan Health Benefits Claim Review form.
Enter the insurance payment amount, if applicable. This goes in item 25 of the
Michigan Health Benefits Claim Review form.
Enter the insurance check number, if applicable. This goes in item 27 of the Michigan
Health Benefits Claim Review form.
Enter the diagnosis or additional information in this area. This goes in item 30 of the
Michigan Health Benefits Claim Review form.
Each of the claim’s lines of services will list on the bottom of the window. Place a
check mark within the box under the Inquiry column heading to select a given line(s)
that you wish to submit in for review.
2. To access or create the Status Inquiry from the Patient Menu:
• Select “Insurance Claim” from the Patient Menu
• Locate the correct claim (look for correct dates of service and procedure codes).
• You will need to designate which transaction lines will be included in the Inquiry and suppress any
other transactions. Choose “Trans” from the menu options across the bottom. Use your space bar to
toggle to the correct status for each line. “I” for transaction lines to be included on the Status Inquiry.
Place an “N” on the transaction lines that should be suppressed from the Inquiry.
• Select “Inq” from the menu options across the bottom. Complete the Inquiry Information screen as
described in the previous example.
• Indicate “I” for Inquiry within the Status field.
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C. Transmitting Status Inquiry
When transmitting BCBSM electronic Status Inquiry claims, you must select them when preparing claims.
From the Main Menu, option 5. Insurance Billing, option A. ANSI 837, option 1. BCBSM, option 1. Prepare
Claims. Select option S. Status Inquiry.
You may also locate Status Inquiry that have been created in your system but not billed out by selecting:
From the Main Menu, option 5. Insurance Billing, option 1. Paper Claims, option O. Other Status Claim List.
Select Inquiry and a list of claims will appear.
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Chapter 10:
Chiropractic Billing Of X-Rays Within The dTHOMAS System With ANSI
BCBSM accepts Chiropractic billing of x-rays directly to BCBSM, when BC is secondary to Medicare. The
scenarios detailed below are not effective when dealing with any other insurance carriers.
A. Set up
From the main menu across the bottom middle it should state, THOMAS CHIROPRACTIC SYSTEM LITE.
Financial Code ST should be set up as Form 5 and Type 1. (From the Main Menu, option 4. Code Files,
option 1. Financial Codes).
Insurance Codes for BCBSM must be BC. (From the Main Menu, option 4. Code Files, option 6. Insurance
Companies). If the insurance code that the practice uses for BCBSM is NOT BC, do not change it. If you
change an existing insurance code to something else it may adversely affect any outstanding claims.
Any Procedure Codes that are x-ray codes must be indicated as x-ray “Y”. (From the Main Menu, option 4.
Code Files, option 2. Procedure Codes).
dTHOMAS Example 1:
When the patients’ primary policy is Medicare and their secondary policy is BCBSM that has full benefits
(adjustments, office visits and x-ray benefits), then set the patient policies up as, 1)MR/MR 2)BC/BC. By utilizing
this pattern the system will allow you to post charges such as an adjustment and an x-ray at the same time, have
the system automatically separate the x-rays from the rest of the procedure codes and create a claim that will bypass Medicare and be billed directly to BCBSM.
dTHOMAS
dTHOMAS
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dTHOMAS Example 2:
When the patients’ primary policy is Medicare and they have a BCBSM policy that only covers x-rays, then set
the patient policies up as, 1) MR/MR 3) ST/BC. By utilizing this pattern the system will allow you to post charges
such as an adjustment and an x-ray at the same time and have the system automatically separate the x-ray
claims from the rest of the procedure codes. The purpose of the ST/BC policy being in position 3 is so that any
co-pays or deductibles from MR will NOT get billed to the BC policy. You will be able to transfer any balances that
are patient responsibility directly to the patient.
dTHOMAS
dTHOMAS
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dTHOMAS Example 3:
When the patient does not have Medicare primary insurance but does have a BCBSM policy that only covers xrays, then set the BC policy as 3) BC/BC. Policy 1 and Policy 2 must be empty. You will need to enter the x-ray
procedure codes separately from other procedure codes that should be posted as cash, (adjustments, office visits
etc.)
dTHOMAS
When you post charges for x-rays, do the following:
• If you do not want to charge the patient for the x-ray then clear the CHRG_PAT field.
• Indicate BC as the policy in the field labeled INSUR.
• To access the Header, if necessary, select the menu option “Header” from the bottom of the Post
Charges screen.
dTHOMAS
For all other charges for this patient it will then be treated as cash (no insurance) with all charge balances
immediately charged to the patient, allowing you to mark the claim “C” for complete.
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Chapter 11:
Chiropractic Billing of X-Rays within the THOMAS-Lite system with ANSI
BCBSM accepts Chiropractic billing of x-rays directly to BCBSM, when BC is secondary to Medicare. The
scenarios detailed below are not effective when dealing with any other insurance carriers.
A. Set up
From the main menu across the bottom middle it should state, THOMAS CHIROPRACTIC SYSTEM.
Financial Code ST should be set up as Form 5 and Type 1. (From the Main Menu, option 4. Code Files,
option 1. Financial Codes).
Insurance Codes for BCBSM must be BC. (From the Main Menu, option 4. Code Files, option 6. Insurance
Companies). If the insurance code that the practice uses for BCBSM is NOT BC, do not change it. If you
change an existing insurance code to something else it may adversely affect any outstanding claims.
Any Procedure Codes that are x-ray codes must be indicated as x-ray “Y”. (From the Main Menu, option 4.
Code Files, option 2. Procedure Codes).
THOMAS-Lite example 1:
When the patients’ primary policy is Medicare and their secondary policy is BCBSM that has full benefits
(adjustments, office visits and x-ray benefits), set the patient policies up as, 1) MR/MR 2) BC/BC. By utilizing this
pattern the system will allow you to post charges such as an adjustment and an x-ray at the time of entry and still
create a separate claim for the x-rays and a separate claim for the rest of the procedure codes. The claim with the
x-ray codes will by-pass Medicare and be billed directly to BCBSM. Follow the directions below to activate this
process.
Prior to posting charges the header will come up. Do not make any changes to the Financial or Insurance Codes.
Complete any necessary fields within the Header that you need to support the charges that you are about to post
for the patient. Once the Header is correct, proceed to the next screen.
THOMAS-Lite
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On the Posting Charges screen, when you post a charge that is an x-ray, you must remove the MR from the first
insurance position and replace it with ST. You then need to remove the BC from the second insurance position. If
you are billing charges other than x-ray, (adjustments) you will leave the insurance information as is.
THOMAS-Lite
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When the patients’ primary policy is Medicare and they have a BCBSM policy that only covers x-rays, then
create two separate accounts for the patient. The first account will be for their Medicare, 1) MR/MR. You will post
all charges other than x-rays to this account. Then when you post the response from the Medicare voucher, any
balance that is the patients’ responsibility will be transferred to the patient. The second account will be for their
BCBS x-ray only policy, 1) BC/BC. You will post all x-ray charges to this account. Then when you post the
response from the BC voucher, any balance that is the patients’ responsibility will be transferred to the patient.
THOMAS-Lite
THOMAS-Lite
When the patient has BCBS x-ray only coverage and no other insurance policies, then create two separate
accounts for the patient. The first account will be for their non-insurance (cash) procedures. Complete the patient
information screen. As you save the patient information screen, the policy screen appears, press escape. You will
post all charges other than x-rays to this account; this will allow all charges entered to be billed directly to the
patient. The second account will be for their BCBS x-ray only policy, 1) BC/BC. You will post all x-ray charges to
this account. Then when you post the response from the BC voucher, any balance that is the patient’s
responsibility will be transferred to the patient.
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Chapter 12:
Current Events
A. Railroad Medicare
Genius Solutions is an approved software vendor with Palmetto GBA (Medicare Railroad Retirement Board).
Our clients can submit ANSI 837 Professional electronic claims directly to Palmetto GBA without paying
clearinghouse fees. To submit electronic claims directly to Palmetto GBA, you must have a Palmetto GBA
Electronic Submitter ID and Provider Number. You may find Palmetto GBA EDI Enrollment forms at
www.palmettogba.com or call them directly at 1-866-749-4301 for assistance. Once you have received your
Submitter ID number, you may contact Genius Solutions Technical Support for set-up.
B. What Do You Do When You Have A Change Of Provider Numbers, Tax ID Numbers Or A New Doctor?
Please contact Genius Solutions. There maybe serious consequences if you just change information. We can
add a new doctor code to take on the new numbers or for a new Tax ID number. Let us help you find the best
solution.
C. Blue Care Network Provider Number Changes
As you may have read in the May-June 2005 Network News, starting on July 1, 2005 Blue Care Network
(BCN) will allow providers to begin reporting the BCBSM Bill PIN (BCBSM 10 digit provider ID number)
instead of the BCN P, G, and S codes. Providers have until October 1, 2005 to implement this change. These
changes will occur over a three-month period to give providers and their software vendor's time to make their
changes. According to The Record, June 2005 on page 13, “Effective Oct. 1, 2005, paper and electronic BCN
claims will be rejected if they are not submitted with the correct BCBSM Bill PIN and BCBSM license number
(when applicable)”.
Genius Solutions, Inc. has begun testing ANSI claims with the 10 digit Individual and Group BCBSM Bill PIN,
State License number, and the 1B and 0B qualifiers that ANSI requires. We are confident that our clients will
be able to make an easy transition to the new requirements.
To help prevent payment delay, as of July 1st we will be transmitting live claims with these changes in place
with just a few of our clients. We will then verify proper payment of these claims before we release the new
version to everyone via the AutoUpdate Client. Then all of our clients may start updating their THOMAS
software to accommodate these changes.
We anticipate the BCN update for THOMAS will be available by August 1, 2005. Once we release the update
and you have updated your THOMAS, you will be required to change your Doctor Code File numbers into the
new format. BCN Providers will want to do this before October 1, 2005 but are not required to do it on July 1,
2005. We are currently recommending clients check for updates after August 1, 2005 and check the Genius
News, option N on the Main Menu, for any last minute instructions.
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Individual Practices
Within the Doctor Code file, use the (I)ns screen for BCN Insurance Code to complete the BCBSM 10-digit
Bill PIN number as indicated in the following example.
This number will report in box 33. of the CMS 1500 claim form.
Note: You are using a different Doctor Insurance ID for BCN; you are not using the BCBSM screen. Also, you
are using the BCBSM 10-digit number as supplied by BCN. You cannot create just one code file for BCBSM and
expect it to work for both BCBSM & BCN. Create both codes as shown above (in this case the BCN code file).
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Group Practice
Complete the (I)ns screen for group information as indicated in the following example.
Enter the provider’s BCBSM License Number in the ID NO# field and the 10-digit BCBSM Bill Pin Group ID
Number in the GR NO# field. In a group practice, this group number will be the same for all providers within
the group classification.
The content of the ID NO# field will report in 24k of a CMS 1500 claim form. The content of the GR NO# field
will report in box 33. of the CMS 1500 claim form.
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Appendix A: How To Start Sending Claims Electronically to Palmetto GBA
(Medicare Railroad Retirement Board)
For information on how Medicare contractors are starting to notify providers of enforcement of electronic claim
requirements effective July 1, 2005, please visit:
http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/mm3440.pdf
For information on procedures and deadlines set forth by CMS for Medicare contractors to follow, please visit:
http://www.cms.hhs.gov/manuals/pm_trans/r450cp.pdf
Note: Not all providers are required to submit Palmetto GBA claims electronically. For a list of
exclusions, visit the above websites.
To visit the Palmetto GBA website: www.palmettogba.com
A. Complete The Palmetto GBA paperwork
You must obtain a Palmetto GBA Submitter ID and Password in order to start sending Railroad Medicare
claims electronically. For the application form please visit the Palmetto GBA website listed above, or call the
Palmetto GBA Tech Support Center at (866) 749-4301. If you choose to obtain the application via their
website, once at the home page click on Electronic Data Interchange (EDI) under the PROVIDERS section.
Click on Railroad Medicare to the left. Click on EDI Enrollment to the left. Click on Railroad EDI Enrollment
Packet – 2004. At the top of the page click on View Attachments. This will open up a window for you to open
up the application as a PDF document.
Read and complete the application. The forms MUST be mailed to Palmetto GBA because they require an
original signature. The PART B – EDI SOFTWARE VENDOR DATA of page 7 should be filled out as follows:
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B. Get The Latest Version Of Thomas
Update to at least version 7.67. If you need help with the Thomas AutoUpdate, contact the
Genius Solutions Technical Support Department for help.
C. Setting Up Thomas
Verify the ANSI configuration screen is correct for Palmetto GBA
1. From the Main Menu select 5, Insurance Billing.
2. Select A, ANSI.
3. Select A, Palmetto Railroad.
4. Select 2, Configuration.
The following is an example of what the configuration screen should look like. The provider’s Palmetto GBA
Submitter ID should be populated in place of “SUBMITTER ID” in all three places.
Add the ANSI Payer ID for Palmetto GBA
1. From the Main Menu select 4, Code Files.
2. Select 6, Insurance Companies.
If you already have an existing Railroad Medicare Insurance Code you may use it. Add the ANSI Payer ID of
C00882 and leave the Claim Office Number blank. If you do not have an existing Insurance Code, create one
and fill in the appropriate address information. The following is an example of what the Insurance Code
screen could look like.
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Verify the Financial Code is set up
2. Select 1, Financial Codes.
If you already have an existing Financial Code you may continue to use it. The important thing is that the
Form is 2 and the Insurance Type is C. The following is an example of what the Financial Code screen will
look like.
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Verify Doctor Code is loaded
2. Select 4, Doctor Codes.
3. Select Ins at the bottom menu bar.
4. Add your Insurance Code.
5. Load the Palmetto Provider ID’s accordingly depending on whether you are an individual or a group.
Individual Provider
The following is an example of what the Doctor Insurance ID file will look like:
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Group Provider
The following is an example of what the Doctor Insurance ID file will look like:
D. Preparing Claims
1. From the Main Menu select 5, Insurance Billing.
2. Select A, ANSI.
3. Select A, Palmetto Railroad.
4. Select 1, Prepare Claims.
5. Choose your method of preparation.
6. Enter your Palmetto GBA Financial Code.
7. Prepare your claims as usual. Be sure to make note of your file number. Your filename will contain a47instead of the a01- you are accustomed to seeing. This is a signal that this is a batch of claims for
Palmetto GBA instead of BCBSM.
8. Exit out of Thomas.
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E. Configuring the EDI Client
1. Double click on the EDI Client icon on your desktop to open the EDI Client.
2. Click on Send and Receive.
3. Click ADD at the bottom of the pick receiver list.
4. Click on the box to the left of Palmetto GBA so that there is a check mark in it.
5. Click SAVE at the bottom.
6. You will now be back to the pick receiver list. Scroll down to the Palmetto GBA option and click on pick
next to it. You will now need to configure the EDI Client for Palmetto GBA. Configuring is UPPER case
sensitive. Enter your Submitter ID and click OK. Enter the EDI phone number, 1-803-788-9860 and
click OK. Enter your modem COM port. If you have problems obtaining your COM port contact Genius
Solutions Tech Support. Enter your password for Palmetto GBA submissions. Enter the file name to
send (it is only necessary to enter the a47-XXXX) and click OK.
7. When the file has been sent successfully the EDI Client will pop up a box that says claims sent and you
will have the option to click OK. If you do not get this box you can assume your file did not go and you
should try to resend it.
8. Unlike claims to BCBSM EDI you will NOT receive a Status of Last Transmission.
9. The following day you can dial in leaving the file name blank to obtain your 997 and/or Claim Acceptance
Response Reports.
NOTE: IF YOU NEED HELP
Palmetto GBA Tech Support Center – (866) 749-4301
www.palmettogba.com
Genius Solutions Technical Support Department - (586) 751-9080
Support23@geniussolutions.com
47
06/07/2005
Appendix B: Contacting Genius Solutions, Inc.
There are several ways to contact our office. Please take advantage of the method you find most useful to your
office.
586-751-9080
Telephone:
Option: 3
Sales
Option: 4
Accounting
Option: 5
Administrative Assistance/Forms
Option: 6
Technical Support Department
Option: 0
Attendants during normal business hours
If an employee has a specified a call back
extension, you may dial it at any time
ext.
Fax:
Internet:
Main Phone Number
586-558-9443
Training
586-751-9230
Administration/Forms Ordering
586-751-3016
586-751-7545
Sales
http://www.geniussolutions.com
sales@geniussolutions.com
support23@geniussolutions.com
E-Mail:
http://www.geniussolutions.com
Company web site
Sales Department
Forms Ordering over the Internet
Enter the Genius Solutions Products ►
Products ► Forms ►Forms Order Form.
Complete the form and left click Submit one
time. Your order will be emailed and
processed within one business day.
Mailing Address:
5504 E 12 Mile Rd Ste. B
Warren, MI 48092-4637
Business Hours:
9:00 a.m. – 6:00 p.m. Eastern Time
Monday through Friday except Holidays
48
06/07/2005
Seminar Questions
Genius Solutions Support Department
Fax: 586-751-3016
Date:
Practice Name:
Client ID:
Contact Name:
Alt. Contact:
Best time to reach:
Phone:
Fax:
Email:
Question:
Response:
GS Support Tech:
Date:
Genius Solutions, Inc. 5504 E 12 Mile Rd. Warren, MI 48092 Phone: (586) 751-9080
49
06/07/2005

dTHOMAS/THOMAS-Lite Blue Cross Blue Shield of Michigan-EDI and

Transcription

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