New Flexible Grids for Claim Generation


NOTE: Before sending claims, you will need to finalize your practice and provider setup information on the IDs grids. If you are upgrading to Medisoft 16, you will also need to finalize your IDs grid information. To provide the highest level of data integrity and accuracy, the conversion process for Medisoft 16 provider/practice setup, does not delete information while creating grid entries that might still be needed, such as legacy information (Blue Cross provider numbers, Medicare provider numbers, etc.) but converts this data to a grid entry in Medisoft 16. Before filing claims, you will also need to finalize your grid entries making sure to remove unnecessary data such as out-of-date legacy numbers. For more information, see Medisoft Claim Generation FAQ .

Medisoft 16 introduces new user interface windows to better address different insurance filing requirements. This new layout gives you the flexibility to easily configure your setup to address various requirements when generating both print and electronic claims.

The new implementation provides a flexible environment that you can quickly customize to reflect your claim processing needs by setting up different grid entries for insurance carriers, providers, your practice, or your data requirements (NPI, legacy, etc.) that you can apply and, if needed, quickly modify. These changes support creating as many custom scenarios that you need to successfully file claims.

This new method streamlines and consolidates tabs on key windows such as the Insurance Carrier, Provider, and Referring Provider and moves labs and facilities from the Address tab to the Facility tab. Also, the Practice Information window features a new tab, Statement Pay-To, which is used for Bill Flash reports.

The key element of this improvement is the implementation of Practice, Provider, Referring Provider, and Facility IDs grids. The settings and selections that you make on these grids, along with settings on the Insurance Carrier window, are used for claim generation.  These settings are highly flexible, providing greater breadth and depth to address your particular office’s billing needs.  The inherent flexibility in this implementation means that you can enter limitless scenarios for any combination of insurance carriers, insurance classes, facilities, referring providers, providers, and your practice to address different carrier filing requirements.

Another important change for electronic claims involves the logic of group and individual filing moving from the EDI Receivers window to the Provider window. You now bundle claims by creating provider filing rules using the Group or Individual buttons on the Provider IDs grid instead of sending via a group EDI receiver or an individual EDI receiver; however, if a carrier requires further refinement, you can create/use multiple submitter IDs to separately batch by submitter ID.

NOTE: Any custom report, either created or modified, in a version of Medisoft prior to 16, such as the CMS 1500, will not pull some data if the field in question was impacted by the new fields on the various IDs grids. The level of customization that went into creating the original report will determine if you should modify the report to reflect the new fields in Medisoft 16 or re-create your custom CMS 1500 form using the CMS 1500 form included with Medisoft 16. For more information on where fields now pull for printed claims using the CMS 1500 form, see Clickable CMS 1500 . For more information on the new logic for the changed fields in the CMS 1500 reports, see the topic CMS 1500 Report Changes with Medisoft 16 . The UB-04 form was also modified. For more information on where fields now pull for printed claims using the CMS 1500, see Clickable UB-04 Form .

NOTE: Statements in Medisoft 16 do not pull data from the EDI PINS table. If you customize these reports, you cannot add this data to a statement. This data, however, is available when customizing claims, such as the CMS 1500 form, and all other reports. If you have statements from pre-Medisoft 16 that you added these fields to, the statements when used in Medisoft 16 will leave the fields blank.

New Electronic Claims, Eligibility Verification, and ERA Processing

Medisoft 16 introduces a new, integrated electronic claims solution, the Revenue Management feature. This solution is offered in two forms: Revenue Management Advanced and Revenue Management Direct.  

Revenue Management Advanced uses the RelayHealth clearinghouse for electronic claims processing and eligibility verification. With Medisoft 16, there is no cost for this software option though there are clearinghouse charges. For more information on pricing, contact your local value added reseller or Medisoft sales at 800-333-4747.

Revenue Management Direct provides pre-configured connectivity to the most popular direct payers and also supports adding connections to other payers or clearinghouses. This solution is available as an annual subscription with additional fees per direct connection. For more information on pricing, contact your local value added reseller or Medisoft sales at 800-333-4747.

With either option, Revenue Management provides a flexible tool that lets you manage your claims processing environment and, if necessary, make changes without completely replacing your EDI software.  

Revenue Management differs from other EDI solutions by virtue of its design; it is an integrated component of Medisoft which means that the company that produces your practice management solution also produces your EDI solution—a complete revenue management solution that seamlessly updates claim status and date sent while also providing ERA (electronic remittance advice) posting and eligibility verification.

Revenue Management provides value and robust support by offering claims submissions for many types of providers and facilities including physicians, therapists, surgery centers, rural health, imaging centers, DME providers, dialysis centers, etc. You can send Part B claims to virtually any payer via the RelayHealth clearinghouse or direct connections. It even supports Part A along with ERA and eligibility verification.

Additional System Requirements

The Revenue Management feature is engineered to run on the same platform as Medisoft and does not require additional memory or a different CPU. Depending on the types of payers/clearinghouses that you connect to, you will need a modem and phone line, an internet connection, broadband, a web browser, etc. Review your clearinghouse/payer’s requirements.

What Does Revenue Management Replace

When you complete the Medisoft 16 installation,  Revenue Management will replace several Medisoft components including the Claims Manager EDI module, all other existing EDI direct modules (can be converted to Revenue Management), the ERA application, and the Eligibility Verification engine.  After installation, you will complete an online registration before your 30 day trial expires and, if necessary, complete any annual subscription agreements.

What EDI Migrations Path Are Available

 

If you currently use a direct module

Convert to Revenue Management Advanced with enrollment in RelayHealth.

--OR--

Convert to Revenue Management Direct to continue to connect directly to payer(s).

 

If you currently use Claims Manager

Convert to Revenue Management Advanced with enrollment in RelayHealth.

 

If you currently use a competitive clearinghouse such as Phoenix

Convert to Revenue Management Advanced with enrollment in RelayHealth.

--OR--

Work with your value added reseller to create direct connection to competitive clearinghouse.

 

If you currently use RelayHealth

Convert to Revenue Management Advanced—easy choice since you are already enrolled with RelayHealth.

 

How Do I Install Revenue Management

Installing Revenue Management is simple and is part of the Medisoft 16 installation. It does not require any separate installation activities.  

How do I Launch Revenue Management

Launch Revenue Management from the Activities menu, Revenue Management menu, Revenue Management command. Launch Revenue Management reports from the same menu. You can verify eligibility using mostly the same process as earlier releases (you will need to apply security to your practice and create at least one user)—the verification engine now uses Revenue Management.

Menu items for obsolete features available in Medisoft 15, such as options on the Services menu (Claims Manager and Eligibility Verification) and on the Activities or Tools menu (Electronic Remittance and Claims Manager), no longer appear on the menus.  Electronic Claims are now generated from the Revenue Management menu on the Activities menu.

Does Revenue Management Offer Any Additional Features or Solutions

Both versions of Revenue Management provide (on an additional yearly subscription basis) claim editing and ANSI validation.  Reducing your rejections before they are sent by checking for pre-existing errors means that your business will be paid faster for the services it renders, and your claims processing staff will save time not having to rework and re-file rejected claims.

Before sending and receiving notice of a rejected claim, validate the claim’s data formatting and validity using system rules. These rules include Medicare requirements along with common billing scenarios. You can also, based on your own business environment, define and apply your own claim check rules using a drag-and-drop rules editor.

An important part of the claim editing feature is the speed and ease in which claims are corrected in Medisoft. The claims analysis quickly guides you in correcting claim issues, and with a few simple steps you can avoid having a claim rejected.

Depending on your practice needs, you can add several other features to Revenue Management including additional software plug-ins that add custom data fields for:

  • Part A Rehab (CORF / ORF)

  • Dialysis

  • KidMed (Medicaid EPSDT)

  • Medicare DME with CMN’s

  • Rural Health

  • General Purpose UB-04

  • Medicaid Programs

  • Ambulance

For more information on pricing for these additional features, contact your local value added reseller or Medisoft sales at 800-333-4747.

How Does It Work?

Revenue Management seamlessly fits your established workflow. After you enter charges and create claims, the Revenue Management feature retrieves the claim data that you plan on submitting from the Medisoft database and creates electronic claim files and transmits the files to the payers. You can also receive and view reports and complete ERA activities such as posting primary, secondary, or tertiary payments along with updating claim status for crossover claims.

An important feature of Revenue Management is claim tracking and history. The feature supports sending and receiving claim status transactions which gives you insight into your claim processing payment timeline. Revenue Management also saves claim information including when it was edited or sent and acknowledgments/payments received.

You can also quickly view and print reports associated with the claim and, if needed, quickly send a claim status inquiry.

When the Revenue Management feature receives an ERA 835 file, you have several options. The application translates the file before posting it, allowing you to review the report and print or export it. Then you can quickly post the file and select a posting date along with a payment code. And if needed at a later date, you can review the posting report that details the specific posting data.

When you receive an 835 remittance payment file from a payer or clearinghouse, the Revenue Management feature interprets the file and prepares it for posting in Medisoft. A preview of the remittance is displayed so you can review the payment information and print or export a copy. When you are ready to post the payment, just choose the posting date and payment code (use the payer’s code or assign your own), and the payments and adjustments are posted in seconds. After posting is complete, a posting report is generated to show exactly what was entered in your system.

Eligibility verification is a simple process and uses mostly the same established methods in Medisoft to check a patient’s status. The Revenue Management feature then checks with the payer’s records to check the patient’s coverage.

The Revenue Management feature manages the connection to payers by selecting the appropriate connection method to a clearinghouse/payer. Most require claims to be submitted using a defined method such as a broadband connection, a dial-up connection, a web site, ftp, etc., and the feature calls the needed tool such as hyperterminal, web browser, ftp application, etc.) for each payer.  In some cases, you would still login to your payer’s web site and perform the file transfer. But in some cases for certain payers, Revenue Management can completely automate the claims submittal process.  For each claim file, the Revenue Management feature creates an ANSI 4010A1 native format file, configured to the payer’s specifications.

Along with sending claims, the feature also processes all received reports. You can quickly preview, print, and post to Medisoft.

What Do I Need to Complete Before Sending Claims

Before using the Revenue Management feature for new connections, you must enroll with the clearinghouse or direct payer and receive submitter numbers for the RelayHealth clearinghouse (Revenue Management Advanced) or direct payers (Revenue Management Direct).  You will also need to set up the RelayHealth clearinghouse or direct payers in Revenue Management; the software includes preconfigured support for many popular clearinghouses and direct payers.

You will also need to register your software and, if necessary, complete your annual subscription once your trial period ends.

NOTE: Revenue Management supports payers that accept a
HIPAA-compliant ANSI 837 claim file.

For More Information

After installing Revenue Management, view the online help located in the Program Files\Medisoft\Bin\RCM folder. Double-click help.exe to launch the system and view the help videos.

Eligibility

Medisoft 16 introduces new eligibility data entry and processing logic that gives you greater control and the ability to manage you Payers IDs (the enhanced payer ID management also applies to insurance payer IDs, not just those used for eligibility verification). The flexible implementation lets you define when you check for updates and gives you the ability to update a Payer ID, which reduces potential downtime and increases your ability to address eligibility verification issues.

A key element of this change is enhanced system performance--eligibility does not automatically check for updates, avoiding kicking off an unintentional update cycle. Also when you installed Medisoft 16, the application included an initial payer ID data set which also avoided a longer delay between the time you install the software and the time you use it. And when you do check for updates, the new logic only pulls updated/changed information, saving you more time.

Adding to the performance enhancement is the new Payer ID lookup window which deploys enhanced search filters with the ability to add, edit, and delete a record (user-supplied Payer IDs) with no template editing required.

Payer IDs supplied by initial installation of Medisoft and subsequent updates are now labeled as System, which in turns provides a simple way to filter the Payer ID window. Payer IDs that you enter are labeled User which also provides a quick filter option.

System supplied payer IDs are read only—you cannot edit or delete them. You can, however, edit and delete entries you create (user), and the new logic will deploy a user-defined payer ID before a system ID. The new logic does not allow duplication of user-supplied Payer IDs; however, you create a duplicate of a system supplied payer ID as a user-supplied ID, which means you can edit it on the fly and make timely updates if needed.

Medisoft 16 also streamlines eligibility security and access by making eligibility security assignments part of insurance—that means that the rights you assign (add, edit, delete) for insurance are the same for eligibility.

With the new security addition, your settings/available records match the logged in user.