TDHconnect 3.0 NHIC. an EDS company

Transcription

1 TDHconnect 3.0 NHIC an EDS company

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3 Table of Contents TDHconnect 3.0 Hardware and Software Requirements... 1 Functions of TDHconnect Support... 2 Installation... 4 Software Updates (Service Packs)... 8 TDHconnect Log On Set Up Communications Set Up Reference Files TDHconnect System Maintenance System Totals Window Medicaid Eligibility Medicaid Claims Medicaid Claim Status Inquiry (CSI) Medicaid Electronic Remittance and Status (ER&S) Medicaid Appeals TDHconnect Log On Error Messages Terminology Shortcut Keys Function Keys TDHconnect Order Form National Heritage Insurance Company Electronic Remittance and Status (ER&S) Agreement Instructions National Heritage Insurance Company Electronic Remittance and Status (ER&S) Request Agreement Request for Electronic Funds Transfer Claim Status Inquiry Authorization Texas Medicaid TDHconnect 3.0 Workshop Evaluation

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5 TDHconnect 3.0 Hardware and Software Requirements PC with a Pentium II (2) class processor, 400 Mhz 128 MB of RAM MINIMUM PC REQUIREMENTS 100MB hard disk space for installation, plus 3 times the size of the database CD-ROM drive for installation 800 x 600 VGA (monitor resolution), 256 colors Microsoft Windows 95 or later operating system or Microsoft Windows NT operating system version 4.0 with Service Pack 6 or later. Note: Windows XP is not supported at this time bps modem Adobe Acrobat Reader 4.05 or higher (4.05 is included on the installation CD) Microsoft Internet Explorer (I.E.) 4.01 with Service Pack 2 (Microsoft Internet Explorer 5.0 will be included on the TDHconnect installation CD.) Important: Providers in rotary dial areas cannot use TDHconnect 3.0. TDHconnect does not work with T1 or cable modem transmission lines. It does work with a standard telephone line or the slower port of a DSL connection that a telephone could connect to. A basic knowledge of Windows is required. The section titled Log On provides basic information on how to log in after TDHconnect 3.0 software installation. Functions of TDHconnect 3.0 With TDHconnect 3.0 you can: Administer billing for Family Planning, Long Term Care, Medicaid, and CSHCN clients (see HIPAA table below) Support the submission of Blue Cross and Medicare claims Access the same database simultaneously for up to ten concurrent users per database HIPAA Compliant Transaction Types Eligibility Request 270 Eligibility Response 271 Professional Claims 837P Institutional Claims 837I Dental Claims 837D Claim Status Inquiry 276 Claim Status Inquiry Response 277 Electronic Remittance and Status Report 835 Page 1

6 Support In no event will NHIC be liable to you for damages, including any loss of profits, lost savings, or other incidental or consequential damages arising out of your use, inability to use, or interpretation of these instructions. Documentation In addition to the instructions contained in this manual, the installation and setup instructions are also contained in the booklet TDHconnect 3.0 Service Quick Start Guide shipped with the software. The guide is also available in TDHconnect (after installation) by clicking Help Online Manuals Quick Start Guide. Technical Assistance The Electronic Data Interchange (EDI) Technical Helpdesk provides technical assistance only by troubleshooting TDHconnect 3.0 and Texas Medicaid Network (TexMedNet) system problems. Contact your system administrator for assistance with modem, hardware, or phone line issues. To reach the EDI Technical Helpdesk, select one of the following methods available Monday through Friday, 8 a.m. to 5:30 p.m. Central Standard Time: Fax or (Expect a response within 24 hours) nhictexmed@eds.com For Medicaid, CSHCN and Family Planning technical issues, call (or in Austin, call ) For Long Term Care technical issues, call (Select option 2) (or in Austin, call ) (Providers in rotary dial areas cannot use TDHconnect 3.0) Training Assistance The EDI Technical Helpdesk does NOT provide training. Call your NHIC Provider Relations training specialist or attend one of the training workshops provided by NHIC Provider Relations. For training specialist contact information, call NHIC Customer Service at (select option 5) or visit our website at For CSHCN Customer Service, call For Long Term Care (LTC), call NHIC LTC Helpdesk at (in Austin dial ). For Medicaid and Family Planning information, call NHIC Customer Service at (select option 5). For workshop and other information, visit For other Medicaid customer service numbers, refer to the 2003 Texas Medicaid Provider Procedures Manual, Telephone and Addresses Guide, pages v through x. Claim Assistance Following is contact information for questions regarding electronic or paper claims: For Medicaid, Family Planning, and CSHCN claims assistance, call NHIC Customer Service at (Select option 5 to speak to a Customer Service Representative) or refer to the NHIC web page, and link to Medicaid workshop schedules and FAQs. For Long Term Care (LTC), call NHIC LTC Operations at (in Austin, call ), select option 1, or refer to the NHIC web page, and link to the LTC home page. For other customer service numbers, refer to the 2003 Texas Medicaid Provider Procedures Manual, Telephone and Addresses Guide, pages v through x. Page 2

7 TDHconnect 3.0 Online Help (after installation) The help topics provide instructions for using TDHconnect 3.0. To access help from the menu, click Help, and then click Contents and Index or click the help book icon on the toolbar. Press F1 to open related help topics for each window. Contents, Index, Search, and Favorites tabs appear on the left side of your browser window to access help topics. The right side displays the selected help information and instructional steps. Important: To run TDHconnect 3.0 help, Internet Explorer 4.01 Service Pack 2 or higher must be installed on your PC. The Contents tab contains a multi-tiered list of help topics in TDHconnect 3.0 help. The Index tab contains an index for TDHconnect 3.0 help. Information is organized alphabetically. The Search tab works like most Internet search engines. In the "Type in the keyword to find" field, type the word or words you want to find, and then click List Topics. The help system returns a list of the help topics that contain the word you typed. The Favorites tab allows you to mark the address of a help topic you use regularly. Open the help topic and click Add in the Favorites tab. The current topic is added to the tab as a link. Display the TDHconnect 3.0 User Manual Adobe Acrobat Reader 4.01 with Service Pack 2 or higher is required in order to open, display, and print the online TDHconnect 3.0 User Manual. When using a printed copy, remember that the flow of information is intended for online viewing, not hard copy reading. Print the TDHconnect 3.0 User Manual 1. On the main menu, click Help Online Manuals User Manual. 2. On the Acrobat Reader main menu, select File and click Print. 3. Select the printer and printer settings. 4. Click OK. NHIC Web Site Publications and forms can be downloaded from the site, by clicking either TDH-NHIC 2003 Publications or Downloadable Forms and Manuals. Publications include the 2003 Texas Medicaid Provider Procedures Manual and bulletins. TexMedNet TexMedNet is available through either an Internet Service Provider (ISP) or through a dial-up connection. The simplest method of connecting to TexMedNet is through For instructions on establishing a dial-up connection, see the section Software Updates (Service Packs) in this manual. To access file libraries in TexMedNet: From the TexMedNet home page, click File Libraries. The Enter Network Password window displays. Enter the user ID in the User Name field. For most users it will begin with "P." The default ID is guest (in lower case). Enter the Password in the password field. For most users the password will be temp1 (in lower case). The default password is state (in lower case). Some of the libraries are: 03manual Contains 2003 manuals such as the 2003 Texas Medicaid Provider Procedures Manual. BNPG Contains banner pages. Bulletin Contains bulletins. Feesched Contains fee schedules. TDHUPDT Contains service packs (software updates). Page 3

8 Installation Helpful Hints If installing TDHconnect on a local area network (LAN): The system administrator must install TDHconnect 3.0 on each PC and install the databases in a common LAN location. The system administrator must map the individual PCs to the database location on the LAN. Since there is only one database (located on the server), only one Compass 21 user ID and password is needed. The most current TDHconnect service pack must be installed on each PC that has TDHconnect 3.0. If you need to submit CSI requests or download the Electronic Remittance and Status report, you need to obtain the appropriate form from or from the EDI Technical Helpdesk. On the TDHconnect main menu (Systems Totals window), select Communications, then click System Settings. Verify you have a production user ID in the Compass21 and/or CMS user ID fields. TDHconnect 3.0 does not support modem pools. Administrative rights are required when installing to a network. "How to" documents explaining how to transmit transactions are located at under the Electronic Data Interchange link. To learn more about current TDHconnect 3.0 issues, visit Click the Electronic Data Interchange link or the Long Term Care link for more information. Copyright ( ) Electronic Data Systems Corporation. All rights reserved. Acrobat ( ) Reader ( ) Adobe Systems Incorporated. All rights reserved. Internet Explorer ( ) Microsoft Corp. All rights reserved. Before installing TDHconnect 3.0, carefully read and follow the sequence of installation tasks listed below. If the installation sequence is interrupted TDHconnect 3.0 will not install correctly. Pre-Installation Steps 1. Determine that the computer(s) meet the hardware and software requirements, previously mentioned. 2. Verify that Internet Explorer (IE) 4.01 Service Pack (SP) 2 or higher is installed. To determine the version of Internet Explorer installed on your system, start Internet Explorer and select About Internet Explorer. Internet Explorer (IE) 5.0 is included in the TDHconnect 3.0 Installation CD-ROM. If an earlier version of Internet Explorer is installed, uninstall it and install Internet Explorer 5.0 from the CD-ROM. If no version of Internet Explorer is installed, then install Internet Explorer 5.0 from the CD-ROM. To uninstall a program, go to the Start menu (in lower left corner of screen) and click Settings, then Control Panel. Double-click Add/Remove Programs. In the Install/Uninstall tab, click the program to be removed and then click the Add/Remove button. To install a program, go to the Start menu (in lower left corner of screen) and click Settings, then Control Panel. Double-click Add/Remove Programs and in the Install/Uninstall tab click Install. Insert the CD-ROM containing the program to be installed and click Next. 3. If Acrobat Reader 3.0 is installed, it must be uninstalled. (See above to uninstall a program or contact your system administrator for assistance. If you do not have a system administrator, please contact the appropriate technical assistance group.) 4. Create and save an external backup of TDHconnect 3.0 onto tape, CD-ROM, or a separate machine if available. 5. Purge old records from TDHconnect if this has not been done. From the TDHconnect Explorer, click the plus sign (+) next to System and the double-click Database Utilities. Select the Purge tab and select the program to be purged. In the Age in days box, enter or select the number of days. Only records older than the number of days defined in this box will be purged. Click Purge to purge the records for the selected programs. Page 4

9 6. Compress the database by clicking the plus sign (+) next to System (on the left side of the screen) and then doubleclick Database Utilities. Select the Compress tab and select the program to be purged. Only one database at a time can be compressed. Click Compress. 7. Close all open applications on the desktop. Installation Steps Important: Administrative rights are required when installing TDHconnect 3.0 in a Windows network environment. 1. Close all open programs on your desktop. 2. On the Start menu, select Settings, and then click Control Panel. 3. Double-click Add/Remove Programs. 4. In the Install/Uninstall tab, click Install. 5. Insert the installation CD into your CD-ROM drive. Click Next. 6. Click Browse. 7. In the Look in field, select the location of your CD-ROM drive. 8. Select "Setup.exe" from the list of files, and then click Open. 9. Click Finish. The TDHconnect 3.0 installation window opens. 10. Read the TDHconnect Welcome screen, and click Next, and Next again to confirm that you are about to install TDHconnect. 11. When the Choose Destination Location window opens, click Next to install the default installation location, or click Browse to select a new location. 12. In the Start Copying Files window, click Next. 13. When the Acrobat Reader 4.05 Setup window opens, click Next. If you have Acrobat Reader 4.05 or higher already installed on your system, click Cancel, then Yes, and skip to step When the Choose Destination Location Window opens, click Next to install to the default location, or click Browse to select a new location. A message appears: Copying program files. 15. When the Information window displays Thank you for choosing Acrobat Reader!, click OK. 16. The following message appears: Do you wish to backup your databases This will overwrite databases that are in the Backup folder. Click Yes to backup the existing databases, or No to avoid backing up the databases. 17. The Setup Complete window opens. Select either Yes, I want to restart my computer now. or No, I will restart my computer later, and click Finish to close the window. NOTE: TDHconnect 3.0 will not finish installing until after you have restarted your computer. Page 5

10 Set Up the Dialing Properties in a Windows Operating System Important: This setup does not apply to Windows For all providers, before you can send requests and retrieve responses, you must set up your dialing properties and communications settings in TDHconnect From the Start menu, select Settings, then click Control Panel. 2. Double-click the Modems icon. If you have more than one modem installed or listed in the Modems Properties dialog box, select the modem that was setup during installation. 3. On the Modem Properties dialog box, click Dial Properties. 4. If you must dial a number to access an outside line, proceed to steps 5 and 6. (If not, skip to step 7.) 5. In the "To access outside lines for local calls, dial" field, type 9. (You may substitute another number instead of 9 if your service requires it.) Important: If using Windows 95 and 10-digit dialing is required, also enter your area code. 6. In the "To access outside lines for long distance calls, dial" field, type 9. (You may substitute another number instead of 9 if your service requires it.) 7. In the Dialing Properties window, click Apply, then click OK. 8. In the Modem Properties window, click Close. Exit the Control Panel window. Finish Installation 1. If TDHconnect 3.0 is still open, exit the program. 2. If other applications are added after installing TDHconnect 3.0, the system administrator (or appropriate technical assistance group) should test TDHconnect 3.0 to ensure that the other applications did not disable it. Important: After installation, download the most recent Service Pack (see next section) to get critical software updates! Check with or for the most recent Service Pack release. Data Conversion EDS/NHIC is not liable for any data lost during the conversion process. It is your responsibility to take the appropriate steps to back up and save your data before beginning the data conversion process. Installation converts eligibility, claims, claim status inquiry and electronic remittance and status reports data to TDHconnect 3.0 automatically. All acute care completed claims are converted with the status of Incomplete. As a result, you have to open all converted claims and save them. If the claim passes TDHconnect 3.0 edits, the claim saves as Complete; however, the word Complete should not be confused with a claim being processed and finalized by NHIC, rather, a completed claim is stored on your hard drive and is ready to be submitted to NHIC. Note to providers who file eyeglass appeals: If you convert data from TDHconnect 2.0 to TDHconnect 3.0, any rejected eyeglass appeals that were stored in TDHconnect 2.0 will have to be manually re-entered in TDHconnect 3.0 before resubmitting the eyeglass appeal. Page 6

11 Convert Existing Appeals to TDHconnect 3.0 The Data Conversion process converts appeals information. If the data conversion process stalls or stops during processing and does not complete correctly, it is possible that your old database might be corrupted or you might lose old data. 1. Back up and save your TDHconnect 2.0 data prior to conversion. 2. Exit all versions of TDHconnect, including TDHconnect From the Start menu, select Programs, then TDHconnect. 4. Click ConvertAppeals. 5. The TDHconnect Appeals Conversion window opens. Click the type of appeals to be converted, such as Convert Medicaid Appeals for Medicaid appeals. The totals in the windows change to reflect the conversion changes. Page 7

12 Software Updates (Service Packs) The TexMedNet Web site contains information such as bulletins, banner pages, the Provider Procedures Manual(s), as well as TDHconnect updates (service packs). There are two ways to connect to the Texas Medicaid Network (TexMedNet) Web site (formerly known as TexMedNet BBS): 1) through an internet service provider (ISP) or 2) through Windows Dial-up Networking. Important: Administrative rights are required when installing updates to TDHconnect 3.0 in a Windows NT or Windows 2000 environment. Staying current with the most recent service pack for TDHconnect software is very important as the updates may contain critical changes which affect billing. Routinely check the web sites as described below to see if new service packs have been released and if so, be sure to download and install them. Service packs are comprehensive, so that the most recent service pack contains the changes made in prior service packs and service releases. The two main methods of downloading service packs are through a web site or through a dial-up connection. Downloading from a web site incurs the cost of having an Internet service provider whereas the dial-up connection incurs long distance telephone charges. NOTE: It is not necessary to be connected to the TexMedNet web site or to have an Internet service provider to submit claims, eligibility requests, appeals, or claim status inquiries through TDHconnect. Connect to TexMedNet (choose one of the following, although the first option is recommended): Downloading through an Internet Service Provider (ISP) Open Internet Explorer. (If not connected, first connect to your ISP.) In the address line, type The TexMedNet Web site should open and display "Welcome to TexMedNet!". Follow the instructions Log on to TexMedNet listed below. Downloading through a dial-up connection Create a dial-up Connection profile called "TexMedNet." (See the "Access TexMedNet" topics in the TDHconnect 3.0 User Manual.) Remember to use as the phone number, bbsguest as the user ID, and state as the password. Dial the TexMedNet dial-up connection profile previously created. When the connection has been established, open Internet Explorer. Type in the address line. The TexMedNet Web site should open and display "Welcome to TexMedNet!" Log on to TexMedNet From the TexMedNet home page, click File Libraries. The Enter Network Password window displays. Type the user ID in the User Name field. For most users it will begin with "P." The default ID is guest (in lower case). Type the password in the Password field. For most users the password will be temp1. The default password is state (in lower case). Click OK. The area of the Web site you selected will appear. Download the most current TDHconnect 3.0 Service Pack 1. Click once on the TDHUPDT library in the lower left-hand pane. 2. Click once on the filename of the readme file for the Service Pack (e.g. TDHSP1.TXT) from the list of files in the right-hand pane. This readme file contains important and helpful information on the following topics: Information on the improvements included in the service pack. Page 8

13 Downloading a TDHconnect 3.0 Service Pack Installing a TDHconnect 3.0 Service Pack To read this file online, use the PAGE DOWN and PAGE UP keys. Print the file by clicking Print on the File menu in the Windows-based editor or viewer. 3. Click once on the filename of the Service Pack (e.g. TDHSP1.EXE) from the list of files in the right-hand pane. You will be prompted to: "Run this program from its current location" or "Save this program to disk". 4. Select "Save this program to disk", and then click OK. A dialog box will open. 5. Download the file to the desktop by clicking on the black arrow to the right of "Save in" for the drop down menu. Click once on Desktop from the drop down menu, and then click Save. The file downloads to the desktop. 6. After the file downloads, click Close and exit TexMedNet. Note: The download can also be made from the Downloads and Updates <./downloads.html>sections of the TDHconnect Online Helpdesk. Install the TDHconnect 3.0 Service Pack 1. From the desktop, double click on the icon added by the completed download (The file can be moved to a location on a LAN to share with other TDHconnect 3.0 users.) 2. A message box opens with the following message: "This will install TDHconnect 3.0 Service Pack #. Do you want to continue?" Click Yes to install the TDHconnect 3.0 Service Pack. 3. The TDHconnect Service Update Installation Utility window appears then the TDHconnect 3.0 Service Pack wizard opens. 4. Several informational messages appear. Click Next with each message. 5. A message box opens with the following message "Do you wish to backup your databases? This will overwrite databases that are in the Backup folder." Click "Yes" if you want to backup your databases before installing any database updates. Click "No" if you want to continue with the installation with out making backups. 6. Several additional informational messages appear. This process may take several minutes as database updates are being made. 7. Installation of the TDHconnect 3.0 Service Pack is complete. To view the readme file, check the box then click Finish. The readme document opens. 8. After reading the document, close it by clicking the X in the upper right hand corner, then uncheck the box and click Finish. 9. When prompted to restart the computer, choose Yes, I want to Restart my computer, then click Finish. 10. The next time TDHconnect is opened, the version of the service pack will be displayed along with the name TDHconnect 3.0. Alternative Method of Downloading: Using the eds-nhic web site This is the simplest way to download service packs but requires an Internet Service Provider and may be slower than connecting to TexMedNet described below. To download from the eds-nhic web site: Open Internet Explorer. In the address line, type Click Electronic Data Interchange, click Downloads and Updates and follow the online instructions. Page 9

14 TDHconnect Log On Important: Each user must have a unique TDHconnect user ID and password. Additional user IDs can be created in TDHconnect using the security function. 1. Double-click the TDHconnect 3.0 icon on your desktop. 2. In the User ID field, type the word "admin" in lowercase letters, and then press the TAB key. 3. In the Password field, type the word "password" in lowercase letters. This password field is always case sensitive. 4. Click OK. When logging on, error messages may be displayed such as: admin is currently logged on to TDHconnect, or TDHconnect is already running. Please open Task Manager and End Task for the Shell and Hints tasks that are running. To resolve these errors, see the section TDHconnect Log On Error Messages on page 79 of this manual. Page 10

15 Set Up Communications Set Up Communications System Settings Important: An ECMS production user ID and password must be requested from the EDI Technical Helpdesk. After logging in, the System Totals screen is displayed. This is the main screen in TDHconnect. From the main menu, select Communications, and then click System Settings. In the User ID field in the Compass 21 section, enter the Compass21 User ID (not the logon ID) that the EDI Technical Helpdesk issued, in lower case. In the Password field to the right, enter the Compass21 password that the EDI Technical Helpdesk issued in lower case. Also enter the Organization Name, or if the name has a last name and a first name, enter those. In the ECMS field, type the ECMS telephone number (866) Page 11

16 Set Up Communications System Settings (continued) Next, click the Contact Information tab. Enter the last name, first name and phone number of a contact person at the company. Click Apply, and then click OK. Set Up Communications - Modem From the TDHconnect 3.0 main menu, select Communications, and then click Modems. Page 12

17 Set Up Communications Modem (continued) In the Connect using drop-down menu, select the modem name. In the From location drop-down menu, select the location, such as new location. Click OK. Page 13

18 Set Up Reference Files The client and provider reference files are not required to file claims and appeals. However, they are recommended and can be time saving when filling out forms and can reduce the chance of keying errors. The tree view on the left side of the Systems Totals screen that contains yellow folders is referred to as the TDHconnect explorer. To expand a folder within the tree click on the + sign and to close the folder click on the sign. Reference Files Add Clients Note: New clients can also be added through eligibility or MESAV responses. Click the + sign next to Reference Files and then double-click Client. The existing clients are displayed. To add clients manually, click Add. Page 14

19 Fields with bold headings are required. Click the Client Status box located next to the appropriate program name. Click the program in the Launch Program for Client menu (this example chose Medicaid). The tabs for a Medicaid client are Client Detail, Associated Provider, Authorization, Diagnosis, Other Insurance, and Miscellaneous. Although the fields in these tabs may be manually completed at this time, a faster method is to only enter the Account No. and the Medicaid No. at this time and use the Eligibility request to fill out the other fields (see the Eligibility section). The Account No. is a 1 to 20 character alphanumeric field assigned by the provider (not NHIC) to track the client. The Medicaid No. is the 9-digit client/medicaid No. After entering this data, click OK. Page 15

20 Reference Files Add Clients (continued) The screen automatically returns to the client setup screen. Enter another client or click cancel to close. Reference Files Add a Provider To add a provider record to the database double click on Provider. Click Add. Page 16

21 Reference Files Add a Provider (continued) Complete the provider information fields. Fields with bold headings are required. Click the provider status box next to the appropriate program. Click the program in the "Launch Program for Provider" menu to continue to the next screen. This example shows Medicaid selected. Enter the nine-digit Texas Provider Number (TPI), which is required. The other fields are optional. Click OK. Page 17

22 Reference Files Reference Codes Double-click Reference Codes to view procedure codes, diagnostic codes, billing codes, EOB codes, etc. These codes are included with TDHconnect. To view more than the first 50 entries, use the Filter function. The Autofind Column window displays the code that was selected in the Codes window. Enter a code in the Autofind Text window, and as the code is entered, the Description window above lists entries matching the Autofind Text. To see different types of codes, scroll up or down the Codes window and select the desired code (e.g. Procedures, Diagnosis, EOB, EOPS, etc). When in claims or appeals, and the cursor is in a code field, the F2 key can be pressed to access these codes which can be used to auto-populate the forms. Modifiers and billed amounts can be added to procedure codes and used later to auto-populate claim forms. To add modifiers or billed amounts to procedure codes, click the procedure code (using Filter if necessary to locate it) then click the modifier field or billed amount field and enter the desired data. Repeat for each modifier or billed amount to be added. When finished, click OK. To exit click Cancel. Page 18

23 Reference Files (Retrieve Other) Download Reference Codes Although TDHconnect includes reference codes, these codes change and need to be periodically downloaded. Be sure to compress the database (see the database functions in the System section) after downloading codes. To download Compass 21 (C21) reference codes: From the System Totals screen click the Retrieve Other tab. Scroll down to the C21 Reference Codes. Click the appropriate boxes for codes to be downloaded. Click the Download button. After the download is complete, go to the System database functions and compress the database. Page 19

24 TDHconnect System Maintenance System System Functions To view system functions click the + sign next to System. This opens the system folder. System Database Utilities The maintenance features of backing up files, purging files and compressing the database are important to keeping TDHconnect to a reasonable file size. After sending and receiving requests, the database becomes larger and response time may eventually become slower. These database utilities help maintain the response time. Double-click Database Utilities to display the Database Utilities window. System Database Utilities Compress Click Compress to compress the database into a smaller area of the hard drive. To improve the performance of the computer, this feature should be used once per month and after purging data. Page 20

25 System Database Utilities Purge The Purge tab is used to purge old data from TDHconnect. Scroll through the menu, click on data to be deleted, and click the Purge button. In the Age in days box, enter how old (in days) the data must be to be deleted. Any data that is as old or older than the number of days entered will be deleted. Finally, click the Purge button to delete the data. Note: It's a good idea to do a back-up before purging data, and to do a Compress after purging. Page 21

26 System Database Utilities Mapper Note: Mapper is used mainly when multiple users are sharing one TDHconnect database, although any TDHconnect user can change the location of the database. The system can support only up to 10 concurrent users. When shared, the database is located on a server and TDHconnect is installed on the computers connected to the server. The database is shared but TDHconnect itself is not. To set up concurrent users: First, create a folder on the server where the TDHconnect database is to be stored (and shared). After installing TDHconnect 3.0 on the computers that access the server (accepting the default database location), the Mapper function can be used to locate the TDHconnect database on the server. Another option is to point to the database on the server during installation of TDHconnect on each computer. Important: Administrative rights are required when installing TDHconnect 3.0 in a Windows NT or Windows 2000 environment. Page 22

27 System Database Utilities Back-up In the Back-up tab, click the Select box for the type of data to be backed-up (e.g. Medicaid), then click the Back-up button. Note: Be careful not to accidentally click the Restore button because it will write over the existing database with the backed-up database copy and any changes that occurred since the previous back-up will be lost. A back-up copy of the databases chosen is placed in the TDHconnect backup folder. This also overwrites the previous backup. To back-up the data to a different drive (in case of hard disk failure) contact your system administrator or computer support. System Password Admin To change the password of the user currently logged in, click Password Admin under System. Enter the current password, enter the new password again to confirm, then click OK. Note: If the password is changed and forgotten, NHIC s EDI technical support team will be unable to assist in getting into TDHconnect. Page 23

28 System Scheduling The scheduler is used to schedule future events such as sending requests to NHIC, getting responses from NHIC and completing database maintenance. System Scheduling - Options The Options tab is used to allow, or not allow, events to be scheduled. Note: The PC must be on and the user must be logged into TDHconnect at the time the event is scheduled! Be sure to schedule events at least 15 minutes apart. System Scheduling Send Requests To schedule to send a batch of requests to NHIC, click the Send Requests tab and then click the Add button. Click the down arrow beside the Type window to select an event. Click the down arrow beside the When window to select a date. Then enter the hour, minute, second, and AM or PM in the window below the date. Select an Interval. If Irregular is selected, enter the number of days in the window to the right. The Age box is not used to send requests. Page 24

29 System Scheduling Get Responses Click the Get Responses tab to schedule the retrieval of batch responses. If "send requests" have been scheduled then consider scheduling retrieving them the following day. The windows are similar to the Send Requests tab. Click Apply and then OK to schedule. System Scheduling Database The Database tab serves to back up, compress, or purge files from the database. These are valuable functions of the Scheduler. Compressing the database is recommended after downloading codes. Select one of the purge requests, then enter how old (in days) the files are that should be deleted in the Age window. (Refer to page 20 for complete purge instructions.) Click Apply and then OK to schedule. Page 25

30 System Scheduling History The History tab displays any scheduled events that occurred as successful or unsuccessful and should be used to verify scheduled events. If the event was unsuccessful, submit the request or response retrieval in the Program Summary window or go to Database Utilities for database maintenance. System Security Administration Security Administration is used to set up new TDHconnect users. TDHconnect is set up with a default user called Admin. Click the Add User button to bring up the Security Wizard. Page 26

31 System - Security Administration Wizard Step 1 Follow the Security Wizard step-by-step instructions to add a user. An orange square indicates the step in process. Fields with bold titles are required fields. The word "password" should be used as the password. New users will be asked to change their password the first time they login. Click Next to advance to the next step. System - Security Administration Wizard Step 2 In step two, choose the program that the new user will need access to by double clicking the program name in the Program Options menu. The program is moved to the Selections box. To deselect a program, double click on it in the Selections Box and it will be returned to the Program Options menu. This example indicates that four programs were selected. Click Next to continue. Page 27

32 System - Security Administration Wizard Step 3 Select the options that the new user will have access to use. Click the + sign by the user ID to see available programs and click the + sign next to a program (such as Medicaid) to see the options. Click any + sign to expand options such as claims, CSI, etc. Double-click any green to remove that program. The removal is indicated by a red X. To reverse this action and restore a program, double-click a red X and it becomes a green. Click Next when done. System - Security Administration Wizard Step 4 Step four summarizes the functions that the user can complete. To change a selection click Back, otherwise click Finish to add the user. Page 28

33 System TexMedNet There are two ways to enter TexMedNet: 1) Dial-Up Connection or 2) Internet Explorer. If an active Internet Explorer has not been established, a Dial-Up Connection window will be displayed after the user has double-clicked on TexMedNet. Create a dial-up connection by entering bbsguest in the User name field and state in the password field. Click Save password to avoid having to complete these steps in the future. If an active Internet Explorer has been established, a User Information window will be displayed after the user has double clicked on TexMedNet. Enter guest in the User ID field and state in the password field, then click OK. Page 29

34 System Totals Window System Totals Window Program Summary Tab The Program Summary tab displays programs (Medicaid, Long Term Care, etc.), request types (eligibility, claims, etc.) and request status (number of completed, submitted, accepted, or rejected requests). Status for Batch Requests: Completed: A request (eligibility, claim, appeal, or claim status inquiry) was entered into TDHconnect and passed all the local edits, but it has not been submitted to NHIC. Completed requests convert to submitted status after being sent to NHIC in a batch. Incomplete (displayed in claims section only): The request was entered into TDHconnect but did not pass all the local edits and is not ready to submit to NHIC. Incomplete requests convert to completed status after completion. Submitted: The request has been transmitted to NHIC for processing (see the Send Requests section later). Submitted requests convert to Processed after the response has been downloaded from NHIC. Processed (displayed in later sections): Twenty-four hours after submitting a request, download the request to see if it was accepted or rejected. Accepted: Electronically submitted requests that have passed the acceptance edits at NHIC, have been assigned an ICN (a unique claim number) and will be further processed in the NHIC system. Note: An accepted claim does not guarantee payment, only that it is accepted for further processing and will be paid or denied after it finishes processing. To see the status of accepted claims, check the Remittance and Status reports or run a Claim Status Inquiry. An agreement must be signed with NHIC to perform claim status inquiries. Call Electronic Data Interchange (EDI) at NHIC ( ) and also see the Claim Status Inquiry Authorization toward the end of this manual. Rejected: Electronically submitted requests that received a response indicating the request has been sent back for errors. The request may be corrected and resubmitted. Note: Rejected claims do not receive an ICN and will not appear on the Remittance and Status Report, nor can they be seen on a Claim Status Inquiry. It is critically important to download all submitted claims and appeals to see if any rejected and work them immediately. Page 30

35 Diagram of Batch versus Interactive Transmission A common error has been to click the OK button in claims or appeals and assume that the transaction has been sent to NHIC. Another common error has been to submit the claim or appeal to NHIC but not retrieve the response the next day to see if the claim or appeal was accepted or rejected. If all four steps of a batch transmission are not performed, any claims or appeals that were rejected may be missed, causing possible loss of reimbursement. Page 31

36 System Totals Window Send Requests The Send Requests tab allows the user to send batches or groups of appeals, claims, claim status inquiries, or eligibility requests. To send batches to NHIC click the Send box for the appropriate program and click Submit. When the transmission to NHIC ends correctly, click the Program Summary tab and the sent requests will change from completed to submitted status. System Totals Window - Retrieve Responses Approximately 24 hours after submitting requests to NHIC responses will be available. To view responses click the Retrieve Responses tab. Click the appropriate download box to retrieve the responses and click Download. If unable to retrieve a response 48 hours after submitting a request, call Electronic Data Interchange (EDI) at for technical help. To verify that responses were successfully downloaded click on the Program Summary tab. The status should be changed from "submitted" to either "accepted" or "rejected. Page 32

37 System Totals Window Retrieve Responses (continued) Important: "Rejected" claims are not kept by NHIC and are not included in Remittance & Status (R&S) reports or claims status inquiries. If the rejection is within the original 95-day deadline (one year for out of state) from the date of service, then correct and resubmit the rejected claim. If beyond the original 95-day filing deadline, the next deadline is 180 days from the date of the rejection. In this case, the rejection report would need to be printed (to prove timely filing) and sent along with a paper claim to NHIC. System Totals Window Retrieve Other The Retrieve Other tab is used to electronically download R&S reports and reference codes. Electronic R&S (ER&S) reports are available weekly at 6:00 A.M. each Monday. To retrieve Electronic R&S reports, click the Download box on the ER&S row, then click the Download button. Note: An ER&S agreement must be on file with NHIC in order to download ER&S reports. To retrieve reference codes, click the appropriate Download boxes in the Download column, then click the Download button. The Process ER&S button is used only if there is an error downloading the ER&S. Note: The Electronic R&S report cannot be seen from the Retrieve Other tab. To generate and view the Electronic R&S report after it has been downloaded, see the section Medicaid Electronic Remittance and Status (ER&S) discussed later in this manual. Page 33

38 Medicaid Eligibility The purpose of eligibility requests is to verify that the client has Texas Medicaid eligibility. An eligibility request will return very helpful information, such as if the client is in an HMO, has other insurance, no longer has Medicaid eligibility, etc. Refer to the 2003 Texas Medicaid Provider Procedures Manual, Section One, for related policy information. Changes due to HIPAA Under HIPAA, the electronic eligibility request is standard 270, and the electronic eligibility response is standard 271. What has changed: The last name and the suffix are now in separate fields on eligibility requests and responses, so separate the suffix field even if the paper 3087 shows the suffix appended to the last name. On the eligibility response, authorization information will no longer be available, so Customer Service may be contacted at (800) TPR (Third Party Resources) relationship to the insured will no longer be available on the eligibility response. Medicaid Eligibility Beginning the Request Click the + sign next to Medicaid to expand the folder. Double-click Eligibility to display the Medicaid Eligibility Request/Response Summary window. Page 34

39 Click File, and then click New to start a new eligibility request. To complete the Request information, enter the Provider ID (TPI) or click the magnifying glass to select the Provider ID. Enter the Start and End Dates. The Start and End dates can be up to three months span. The End date can be as recent as the current date. The date span can go back as far as three years. Enter any of the listed field combinations: Medicaid number; SSN and Last Name; SSN and date of birth; or last name, first name, and date of birth. Suffix is not contained in the last name field, but has its own field. Note: Enter the minimum amount of information in this section, preferably Medicaid number only, because ANY incorrect information will cause the request to fail. Page 35

40 Medicaid Eligibility Submitting and Retrieving Requests There are two ways to submit eligibility requests: interactive and batch. An interactive request is fast and done online while you wait, however it can only be done for one client at a time. A batch of requests takes 24 hours (usually overnight) but may include one or many eligibility requests. Submit/Retrieve Interactive Requests To submit and retrieve an interactive eligibility request, click the interactive button and within a few minutes the request will be either accepted or rejected and the eligibility response will be displayed. Page 36

41 Submit/Retrieve Batch Requests NOTE: Clicking the OK button does not send the request to NHIC; it stores the request in Completed status on YOUR database only. You must do all four steps listed below to send and retrieve batch requests. Submitting and retrieving a batch of eligibility requests involves four steps: 1. Fill out eligibility requests and click the 2. Go to the System Totals window; click the Send Requests OK button on each request. Requests are stored in tab Send box for Medicaid Eligibility Submit button. Completed status on your database. Cancel out Requests are changed to Submitted status and are sent to of Eligibility. NHIC. 3. Go to System Totals window 24 hours later, click the 4. Double click Eligibility under the Medicaid folder Retrieve Responses tab Download box for Eligibility (left side of window), then double click the response Download button. Requests are now changed to just downloaded to view it. Processed status. Page 37

42 Medicaid Eligibility Response The response displays client eligibility. Any tabs with shaded labels have no information to display. In this example, the client has Medicaid eligibility no Medicare, is not a lock-in client, has Managed Care, has benefit limits, but has no other insurance. NOTE: HIPAA compliant eligibility responses no longer display authorization information or Relationship to the Insured on the Other Insurance tab. NOTE ALSO: Click the Patient icon in the upper right corner of the screen to send client information to the Client Reference file, which allows the magnifying glass icons to be used later to populate client information in forms. When the Eligibility Save Patient Wizard comes up, click the fields to be sent to the client reference file, or click Select All, then click Finish. A message will state that the patient was updated. Page 38

43 Medicaid Eligibility Response (continued) Click the Managed Care tab to see the HMO or Texas Health Network (THN) information. Click the Benefit Limits tab for the latest eyeglass, hearing aid, THSteps Dental and THSteps Medical claims. Page 39

44 Medicaid Eligibility Response (continued) Click the Other Insurance tab for information on other insurers for the client. To update the client s other insurance, contact Third Party Resources at (800) See also section Third Party Resources on pages 1-17 and 1-18 of the 2003 Texas Medicaid Provider Procedures Manual. Medicaid Eligibility Printing Reports Six types of eligibility reports may be printed from the Medicaid Eligibility Request/Response Summary. Transmission Summary Click a batch eligibility response (has Transmit Type B and a Transmission ID). Click Reports and Transmission Summary to display the report. The number of accepted or rejected responses is listed. Click Print for a paper copy. Transmission Detail Click an accepted batch eligibility response (has Transmit Type B and a Transmission ID). Click Reports and Transmission Detail. A list of eligibility responses in that batch is displayed. Click Print for a paper copy. Information Request Double-click the completed row near the top of the window. At least one completed eligibility request is required. Click a completed but not submitted request. Click Reports and then Information Request. A detailed display of the request is given, but no response information is available since this request has not yet been submitted to NHIC and retrieved. Click Print for a paper copy. Information Response Click an accepted response, either batch or interactive, until the response is displayed. To print the response, click Reports, Information Response, and Print. Interactive Summary Click Reports and Interactive Summary. Enter a range of beginning and ending transmit dates and click OK. A report of eligibility responses is displayed. Click Print for a paper copy. Batch Report Click either an interactive or a batch response, click Reports and Batch Report. The report will IMMEDIATELY start printing a detailed list of ALL eligibility responses from the row you selected. Page 40

45 Medicaid Claims Note: Refer to the 2003 Texas Medicaid Provider Procedures Manual, Section 4, for related policy information. Changes due to HIPAA Under HIPAA, the electronic claim request is standard 837. Professional and eyeglass claims are standard 837P, dental claims are 837D, and inpatient and outpatient claims are 837I. Numerous changes have occurred to the main tabs (screens) for patient, provider, claim, diagnosis, details, and other insurance, and some tabs now have sub-tabs. A claim response for an accepted claim may also be used (via the save as appeal button) to generate an appeal. Important: If a claim denies with zero allowed, zero paid amounts (see R&S below), follow up with a new claim instead of an appeal, within 180 days of the R&S date. If your new claim has the same provider number, client/medicaid number, date of service, and billed amount, then the new claim can be submitted on TDHconnect. If one of these fields has changed, then the new claim must be filed as a paper claim. If a claim rejects (not denies, but rejects) and the claim is beyond the 95 day filing deadline, the rejected claims report may be printed and sent to NHIC along with a new paper claim if within 180 days of the rejection. See claim reports at the end of this section. Page 41

46 Begin claims by double-clicking Claims to display the Medicaid Claim Request/Response Summary window. To start a new claim, either click the one of the five icons in the top left corner of the screen under the menu bar, or click File New on the menu bar and then the type of claim: professional, eyeglass, dental, inpatient, or outpatient. The HIPAA transactions for Professional and Eyeglass claims are now transaction 837P (professional), Dental claims are transaction 837D (dental), and Inpatient or Outpatient claims are transaction 837I (institutional). Page 42

47 Medicaid Claims Filing Professional Medicaid Claims To start a new professional claim (HIPAA transaction 837P), either click the New Professional Claim icon under File, or click File New Professional. Medicaid Claims Professional Claim - Patient Tab Either click one of the magnifying glass icons to autopopulate the fields in the client database, or enter the fields manually. Required fields are the 1 20 character account number assigned by the provider, the nine-digit Medicaid number, the last name (without the suffix because the suffix now has its own field), first name, sex, date of birth, street address, city, state, and zip code of the client. Other fields are optional. Page 43

48 Medicaid Claims Professional Claim Provider Tab w/provider Facility Sub-Tab Click the Provider tab. Either click one of the magnifying glass icons to autopopulate the fields in the provider database, or enter the fields manually. Required for all professional claims are the nine-digit billing provider ID (TPI), the last/organization name, provider address, city, state, zip code,. If services were provided in a place other than the patient s home or the provider s facility (such as a hospital, birthing center, or nursing facility), click the Provider Facility sub-tab and enter information on the Provider Facility section of the Provider tab. Required fields are the provider facility s provider ID, name, ID type (employer ID or social security number), other ID (corresponding to ID type), service location, address, city, state, and zip code. Medicaid Claims Professional Claim Provider Tab w/referring and Other Provider Sub-Tab If required by the type of claim to enter a referring or primary care physician, click the Referring and Other Provider sub-tab and enter the 6 13 character referring provider ID as a 9 digit TPI, 6-digit Medicare number, or a UPIN. Also enter the last name and first name of the referring provider, ID type (employer ID or social security number), and other ID (corresponding to ID type). Other fields are optional. Page 44

49 Medicaid Claims Professional Claim Claim Tab If ambulance, THSteps Medical, or authorization number is necessary, click the Claim tab and enter the necessary data. Note for THSteps Medical providers: After clicking the THSteps indicator field on the Claim tab, select an appropriate Condition Code: NU (Not Used) indicates the patient had a normal screening, an abnormal screen without treatment, an abnormal screen initiated treatment, was referred to another health agency, or to family planning. S2 (Under Treatment) indicates that the client s screen was abnormal, but the condition is under treatment. ST (New Services Requested) indicates new services requested, such as when the client was referred to the Primary Care Physician or to a specialist. Page 45

50 Medicaid Claims Professional Claim - Diagnosis Tab Click the Diagnosis tab. Enter the HCPCS or CPT code to the highest level of specificity. If uncertain of the code, press F2 while the cursor is in the Code column to bring up diagnosis codes in the reference files. Enter the description in that column. More than one diagnosis code may be entered. Note: A diagnosis code is required for professional claims. For THSteps CCP Pharmacies, the following note is found in section of the 2003 Texas Medicaid Provider Procedures Manual: Pharmacies using their VP TPI should obtain prior authorization for prescription medications not paid through the Vendor Drug Program. If a claim is submitted without a diagnosis, then a provider must attach documentation establishing medical necessity and a signed prescription from a physician (MD or DO). Electronic claims must have diagnosis code V7999 for the claim to be accepted. Instead, use the HIPAA compliant diagnosis code for THSteps CCP Pharmacies is V7285 (Other Specified Examination). For Independent Laboratory providers, section of the 2003 Texas Medicaid Provider Procedures Manual states the following: Independent laboratories and pathologists do not have to supply Medicaid with a diagnosis except when billing the following procedures. If the procedure being billed by independent laboratory providers is not one of the procedures listed in that section requiring a diagnosis code by policy, they may use diagnosis code V726 (Laboratory Examination) for the claim to be accepted. For Radiology providers, if no other diagnosis code is available, use V725 (Radiological Examination, Not Elsewhere Classified). Page 46

51 Medicaid Claims Professional Claim Details Tab Click the Details tab and enter the date of service in MM/DD/YYYY format. Tab to the POS column and use the drop-down box to select place of service (POS). Click the Procedure Code ID field and use the drop-down box to select the type of procedure code (HCPCS; HIEC; National Drug Code in format or format or format or format; or Mutually Defined). Enter the procedure code. If needed, press F2 to bring up procedure codes in the reference files for assistance. Type of Service (TOS) is automatically inserted by C21 based on procedure code entered. Genetic providers must use the Remarks Code field (after the procedure code field) to enter the five-character local procedure code that identifies the DNA test or laboratory enzyme test performed. See Medicaid Bulletin no Enter any needed modifier codes. If needed, enter anesthesia (Ane) minutes. Enter the diagnosis reference to refer to the most important diagnosis code entered on the Diagnosis tab. Enter the quantity and unit price (total charges are calculated). If the provider is a member of a group, enter the nine-digit performing provider number and name. Use the scroll bar to gain access to the fields on the right hand side of the window. Page 47

52 Medicaid Claims Professional Claim Other Insurance Tab w/company Sub-Tab To list the client's other insurance, click the Other Insurance tab and select the source of payment, such as Commercial Insurance. If the other insurance delays and does not reply (110 day rule as per page 4-6 of the 2003 Texas Provider Procedures Manual), click the Delay box and enter the Bill Date. If an adjustment reason code is applicable, select an adjustment reason code and enter disposition date and paid amount. Enter the other insurance company name, address, city, state, zip code and phone number. If a verbal denial was received from the other insurer, check the verbal indicator box and enter the date they were contacted, the contact name, and a comment regarding the conversation. The disposition indicator on the Other Insurance tab can be used to indicate if the other insurer denied, did not file, paid, or issued no response. Medicaid Claims Professional Claim Other Insurance Tab w/subscriber Sub-Tab To enter information about the insured, click the Subscriber tab on the lower right side of the Other Insurance sub-tab and enter the ID or social security number, last name, first name, group/policy number and group/employer name. Page 48

53 Medicaid Claims Submitting and Retrieving Requests There are two ways to submit Medicaid claims on TDHconnect, interactive or batch. An interactive claim is accepted or rejected online while you wait, but must be done one claim at a time. A batch of claims takes 24 hours (usually overnight) to be accepted or rejected, and can include one or many claims. Note that accepted claims do not guarantee payment, only that they are accepted for further processing and will later be paid or denied. Submit/Retrieve Interactive Requests To submit and retrieve an interactive claim, click the interactive button and within a few minutes your claim will be either accepted or rejected and the claim response will be displayed. Page 49

54 Medicaid Claims Submitting and Retrieving Requests (continued) Submit/Retrieve Batch Requests NOTE: Clicking the OK button does not send the claim to NHIC; it stores the claim in Completed status on YOUR database only. You must do all four steps listed below to send and retrieve batch requests. To submit and retrieve a batch of claims involves four steps: 1. Fill out the claim and click the OK button. Repeat 2. In the System Totals window, click the Send for each claim. Claims are stored in Completed Requests tab, click Send box for Medicaid claims, status on your database. Cancel out of Claims and and click the Submit button. Requests are changed go back to the System Totals window. to Submitted status and are sent to NHIC. Note: Only check appropriate boxes hours later, go to the Systems Totals window, 4. Double click Claims under the Medicaid folder click Retrieve Responses tab, click Download box (left side of window) and double click the response for Claims, and click the Download button. Requests just downloaded to view it. are now changed to Processed status. Note: Only check appropriate boxes. Page 50

55 Medicaid Claims Eyeglass Claims After double-clicking Claims under Medicaid, either click the eyeglass icon under File or click File New Eyeglass. The Patient tab, Provider tab, Diagnosis tab, and Other Insurance tab are identical on the professional (837P) claim previously covered. The Claim tab and Details tab are described below. Medicaid Claims Eyeglass Claim Claim Tab For the Claim tab on an eyeglass claim, Eyeglass claims require eyeglass-specific information. Page 51

56 Medicaid Claims Eyeglass Claim Details Tab Click the Details tab and enter the date of service in MM/DD/YYYY format. Tab to the POS column and use the drop-down box to select place of service (POS). Click the Procedure Code ID field and use the drop-down box to select the type of procedure code (HCPCS; HIEC; National Drug Code in format or format or format or format; or Mutually Defined). Enter the procedure code. If needed, press F2 to bring up procedure codes in the reference files for assistance. Type of Service (TOS) is automatically inserted by C21 based on procedure code entered. Enter any needed modifier codes. Enter the diagnosis reference to refer to the most important diagnosis code entered on the Diagnosis tab. Enter the quantity and unit price (total charges are calculated). If the provider is a member of a group, enter the nine-digit performing provider number and name. Use the scroll bar to gain access to the fields on the right hand side of the window. Page 52

57 Medicaid Claims Dental Claims To fill out a dental claim (HIPAA transaction 837D), after double-clicking Claims under Medicaid, either click the tooth icon in the upper left-hand corner of the screen or click File New Dental. The Patient tab, Provider tab, and Other Insurance tab are identical on the professional (837P) claim previously covered. The Claim tab and Details tab are described below. Medicaid Claims Dental Claims Claim Tab Dental claims require dental-specific information on the Claim tab. Medicaid Claims Dental Claims Details Tab Dental claims require dental-specific information on the Details tab. Use the scroll bar to access fields on the right hand side of the window. Page 53

58 Medicaid Claims Inpatient Claims To fill out an inpatient claim (HIPAA transaction 837I), after double-clicking Claims under Medicaid, either click the Inpatient icon under Edit or click File New Inpatient. The Other Insurance tab is identical on the professional (837P) claim previously covered. The Patient tab, Provider tab, Claim tab, Diagnosis tab, and Details tab are described below. Medicaid Claims Inpatient Claims Patient Tab Required fields include the provider-defined account no. for the client, in addition to the client s Medicaid no., provider-defined medical record no., last name, first name, sex, date of birth, street address, city, state, and zip code. Medicaid Claims Inpatient Claims Provider Tab w/billing and Attending Providers Sub-Tab The Provider tab has two sub-tabs within it. The first is for billing and attending providers. Required fields include the billing provider s provider ID, facility name, address, city, state, zip code, tax ID no; and for the attending provider include the attending provider s provider ID, last name, first name, ID type (employer ID or social security no) and other ID (corresponding to ID type). Page 54

59 Medicaid Claims Inpatient Claims Provider Tab w/billing and Attending Providers Sub-Tab The second sub-tab within the Provider tab is for Operating and Other Providers. Required fields, if applicable, include the operating provider ID, last name, and first name; and if applicable, the other provider ID, last name, and first name. Medicaid Claims Inpatient Claims Claims-Tab Click the Claim tab to enter claim data. Required fields include statement from and to dates, authorization (if needed), patient status, type of bill, admission date and hour, admission type, admission source, days covered, days non-covered and discharge hour. Include any applicable occurrence codes and dates, and any applicable condition codes and dates. Page 55

60 Medicaid Claims Inpatient Claims Diagnosis-Tab Click the Diagnosis tab to enter diagnoses. Required fields include at least one diagnosis code. Medicaid Claims Inpatient Claims Details-Tab w/ Accommodation Details Sub-Tab The Details tab has three sub-tabs: Accommodation Details, Ancillary Details, and Surgery Details. To enter data for accommodations, click the Accommodation Details sub-tab. Required fields for the Accommodation Details sub-tab include revenue codes, days, and daily rate. Non-covered charges may be used to report specific non-covered amounts. Page 56

61 Medicaid Claims Inpatient Claims Details-Tab w/ Ancillary Details Sub-Tab Click the Ancillary Details sub-tab of the Details tab to enter Ancillary charges. Required fields include revenue codes, units, and total charges. Unit prices are required for revenue codes Non-covered charges may be used to report line specific non-covered amounts. Medicaid Claims Inpatient Claims Details-Tab w/ Surgery Details Sub-Tab Click the Surgery Details sub-tab of the Details tab to enter surgery charges. Optional fields include surgical code, procedure information (HCPCS or ICD-9 code), and date of service. Page 57

62 Medicaid Claims Outpatient Claims To fill out an outpatient claim (HIPAA transaction 837I), after double-clicking Claims under Medicaid, either click the Outpatient icon under View in the upper left-hand corner, or click File New Outpatient. The Provider tab is identical on the Inpatient (837I) claim previously covered, and the Other Insurance tab is identical on the Professional (837P) claim previously covered. The Patient tab, Claim tab, Diagnosis tab, and Details tab are described below. Medicaid Claims Outpatient Claims Patient-Tab Click the Patient tab. Required fields include the client s provider-defined account number, in addition to the client s Medicaid number, last name, first name, sex, date of birth, street, city, state, and zip code. Medicaid Claims Outpatient Claims Claim-Tab Click the Claim tab to enter claim information. Required fields include the client s admission date, admission hour, type of bill, discharge date, and discharge hour. Optional fields include the authorization number, occurrence codes and dates, and condition codes and dates. Page 58

63 Medicaid Claims Outpatient Claims Diagnosis-Tab Click the Diagnosis tab to enter diagnosis information. Required fields include at least one diagnosis code. Medicaid Claims Outpatient Claims Details Tab Click the Details tab. Required fields include the date of service, diagnosis reference, quantity, and total charges. Procedure code ID is the type of procedure code such as HCPCS; HIEC; National Drug Code in format or format or format or format; or Mutually Defined. Use the scroll bar at the bottom of the screen to access fields on the right hand side of the window. Page 59

64 Medicaid Claims Printing Reports Seven types of claim reports may be printed from the Medicaid Claim Request/Response Summary. Transmission Summary - Click a batch claim response (has Transmit Type B and a Transmission ID). Click Reports and Transmission Summary to display the report. The number of accepted or rejected claim responses is listed. Click Print for a paper copy. Transmission Detail Click an accepted batch claim response (has Transmit Type B and a Transmission ID, and the No. of Requests is greater than the No. Rejected). Click Reports and Transmission Detail. A list of claim responses in that batch is displayed. Click Print for a paper copy. Interactive Summary - Click Reports and Interactive Summary. Enter a range of beginning and ending transmit dates and click OK. A report of claim responses is displayed. Click Print for a paper copy. Error Summary Click a batch claim response (has Transmit Type B and a Transmission ID) and the No. Rejected must be greater than zero. Click Reports and Error Summary. A list of rejected claims and errors in the batch is displayed. Click Print for a paper copy. Claim Detail Double-click an interactive or batch claim response. Click Reports and Claim Detail. A detailed list of the claim is displayed. Click Print for a paper copy. Completed Claims Click Reports and Completed Claims. A detailed list of ALL completed claims will IMMEDIATELY start printing. Rejected Claims Click Reports and Rejected Claims. A detailed list of ALL rejected claims will IMMEDIATELY start printing. This report can be very useful for working rejected claims. Remember that you will not see rejected claims on your Remittance and Status Report or on a claim status inquiry. Page 60

65 Medicaid Claim Status Inquiry (CSI) Important: Before using Claim Status Inquiry, you must fax in a CSI request form, even though Claim Status Inquiry is a built-in function of TDHconnect. See page 89 of this manual for the form. Note: Rejected claims are not displayed in CSI, only claims that are in process, paid, or denied. For claims assistance call NHIC Customer Service ( ). For LTC claims assistance call the LTC Help Desk ( or in Austin dial ). Medicaid CSI New Request The purpose of Claim Status Inquiries (CSI) are to retrieve information on the status of claims that were accepted into the NHIC system, regardless of whether the claims were submitted on paper or by TDHconnect or electronically. To begin a claim status inquiry, double-click CSI to display the Medicaid Claim Status Inquiry Request/Response Summary window. To see the two types of CSI requests, in the Medicaid CSI Request/Response Summary window, click File New Request. Another method is to click either the Provider Patient Request icon or the Claim Request icon in the upper left, which are described as follows: Provider Patient Request This batch request retrieves claim information for a specific client and provider over a range of up to three months of service dates, and this three month window can go back three years. Although the range of service dates can span only up to three months, several requests could be submitted in a batch to cover a longer range of service dates. Claims Request This request is either interactive or batch and is very useful for finding the status of one claim quickly. Page 61

66 Medicaid CSI Provider Patient Request In the Medicaid CSI Request/Response Summary window, click File New Request Provider Patient Request or click its icon. Use this CSI to find the status of claims for one client over a span of service dates that can be three months. Required fields are the service Begin and End dates, the 9 digit Provider ID (TPI), the last name of the provider or the organization name, the client s Medicaid number, last name, and first name. The service Begin and End dates may either be keyed or use the down arrow to select a range of dates. A span of up to three months can be used, going back three years. The service end date may be as recent as the current date. Click OK to save as a completed batch CSI request to be sent to NHIC later. NOTE: Clicking the OK button does not send the request to NHIC; it stores the request in Completed status on YOUR database only. You must do all four steps listed on page 66 under Submit/Retrieve Batch Requests to send and retrieve batch requests. Page 62

67 Medicaid CSI Claim Request In the Medicaid Claim Status Inquiry Request/Response Summary window, click File New Request Claim Request or click its icon. Use this CSI to find specific claims. Required fields are the 24 digit claim number, nine digit provider ID (TPI), the provider s last name or organization name, and the client s Medicaid number, last name, and first name. This request may be sent either interactively by clicking Interactive and getting an immediate response, or by clicking OK to save as a batch request to be sent later. Since this request deals with just one claim, interactive mode is recommended. Page 63

68 Medicaid CSI Submitting and Retrieving Requests Submit/Retrieve Interactive Requests To submit and retrieve an interactive request (Claim Request), fill out the request and click the interactive button. Your response will be returned online while you wait. Submit/Retrieve Batch Requests Submitting and retrieving a CSI batch request (Provider Patient CSI or Claim Request CSI) involves four steps: 1. Fill out the CSI request and click the 2. Go to System Totals window, click the Send OK button. Repeat as needed for each Requests tab, click the Send box for CSI request. Medicaid CSI, and click the Submit button. 3. Go to System Totals window 24 hours later, 4. Double click CSI under the Medicaid folder click Retrieve Responses tab, click Download (left side of window), and double click the response box for CSI, then click the Download button. just downloaded to view it. Page 64

69 Medicaid CSI Printing Reports Two types of CSI reports may be printed from the Medicaid Claim Status Inquiry Request/Response Summary. Response Report Click an accepted CSI response (No. of Requests is greater than the No. Rejected). Click Reports, Response Report, and then Claim Report. Click Print for a paper copy. Batch Report Click either an interactive or a batch response, click Reports and Batch Report. The report will IMMEDIATELY start printing a detailed list of ALL CSI responses from the row you selected. Page 65

70 Medicaid Electronic Remittance and Status (ER&S) Note: Refer to the 2003 Texas Medicaid Provider Procedures Manual, Section 4 (pages 4-53 through 4-71), Appendix C (page C-3) and Appendix D (pages D-31 and D-32) for related information and ER&S Agreement forms. See page 86 of this manual for an ER&S Agreement form. EDI (Electronic Data Interchange) can also be called at for these forms. Double-click ER&S to display the Medicaid ER&S Summary List window. To display a specific ER&S report, double-click the row of the report. Download an ER&S Report Before generating a report, go to the TDHconnect System Totals window, click the Retrieve Other tab, click the Download box on the ER&S row, and then click the Download button. ER&S reports are available to download at 6:00 A.M. each Monday. A good practice is to download them weekly. Page 66

71 Generate an ER&S Report In the Medicaid ER&S Summary List window, click File, then Generate R&S to generate a report. The provider ID, start date, end date, and claim status are required. The Start Date is usually a Friday and the end date is usually the following Monday. Select Display Report to see the report. Medicaid ER&S Print Report Click Print to print the ER&S report. Use the forward or backward arrows to see other pages. The down arrow on the size (100%) box reduces or enlarges the image. Page 67

72 Medicaid Appeals Note: Refer to the 2003 Texas Medicaid Provider Procedures Manual, Section 5, for related policy information. Important: If a claim denies with zero allowed, zero paid amounts (see R&S below), follow up with a new claim instead of an appeal, within 180 days of the R&S date. See the claims section in this document for details. Also, an appeal cannot be filed on a pending claim. The Electronic R & S Report has section for pending claims, identified as THE FOLLOWING CLAIMS ARE BEING PROCESSED. The claim must finalize and once paid, an appeal may be filed. Changes to Appeals from HIPAA: ALL required data on the appeal must now be completed, not just the data being changed from the original claim. Appeals look similar to claims now, with the exception of three fields on the patient tab of the appeal. See next page. Changes to surgical procedure codes on inpatient claims must be appealed on paper with supporting documentation for review. Appeals must include all detail lines on the original claim, in the same order as the original claim. An appeal will reject if it contains fewer detail lines than the original claim being appealed. An added detail line must be submitted as a separate new day claim. Reminders: If the appeal requires additional paperwork, as on ambulance claims, the appeal must be sent on paper. Crossover claims must be submitted on paper, along with a Remittance Advice from Medicare. Appeals with dates of service prior to 10/16/2003 should contain Medicaid local procedure codes, if applicable. TDHconnect appeals are only by batch; there are no interactive TDHconnect appeals. Note to providers who file eyeglass appeals: If you convert data from TDHconnect 2.0 to TDHconnect 3.0, any rejected eyeglass appeals that were stored in TDHconnect 2.0 will have to be manually re-entered in TDHconnect 3.0 before resubmitting the eyeglass appeal. Page 68

73 Three ways to fill out TDHconnect appeals: 1. Populate an appeal from an accepted TDHconnect claim by clicking the Save as Appeal tab at the bottom of an opened claim in the Claims section of TDHconnect. Remember that the claim being appealed must be finalized (paid or denied) before it can be appealed. 2. Populate an appeal from an electronic Remittance and Status Report by clicking the Create Appeal from ER&S icon in Appeals. If you have not signed up to receive electronic Remittance and Status Reports, you may do so by filling out page 88 of this manual and faxing it in to the Electronic Data Interchange department of NHIC. 3. Start from scratch in Appeals and filling out all required fields from a blank TDHconnect appeal by selecting the appropriate appeal icon from the upper left of the screen. Appeal Fields The fields for appeals are the same as for claims of the same type with one exception: the patient tab has three additional fields not found on claims. Frequency Code: Select the value of 7 to indicate an appeal, or 8 to void (recoup) the ENTIRE CLAIM. To recoup only a DETAIL LINE on a claim, fill out the entire appeal and enter the value 0 (zero) for the Unit Price field on the Details tab. Original ICN: Enter the 15 or 24 digit claim number of the claim being appealed. Original Medicaid Number: Enter the 9-digit client Medicaid number used on the claim being appealed. Page 69

74 Medicaid Appeals Create an Appeal from an Accepted TDHconnect Claim In the Claims section of TDHconnect, open an accepted claim and click the Save as Appeal bottom of the claim. tab at the A message will pop up stating that an incomplete appeal has been generated and saved, to go to Appeals in TDHconnect to complete the appeal, and to verify that the claim is in appealable status before submitting it. Go to Appeals and double-click the Incomplete Appeals row. Page 70

75 Then double-click the appropriate appeal from the List of Incomplete Appeals. Finally, begin filling out any missing information required on the appeal. The fields for appeals are the same as for claims of the same type with one exception: the patient tab has three additional fields not found on claims. For frequency code, select 7 for an appeal or 8 for a void (recoupment), enter the original ICN as a 15 or 24-digit claim number, and the original Medicaid number is filled in for you. Remember that bolded fields are required, and other fields may be necessary depending on the type of appeal. Click OK on the appeal to save it in completed status to be submitted later to NHIC. Appeals are only submitted by batch, not interactively. A batch can contain one or more appeals. NOTE: Clicking the OK button does not send the appeal to NHIC; it stores the appeal in Completed status on YOUR database only. You must do all four steps listed on page 76 to send and retrieve batch requests. Page 71

76 Medicaid Appeals Create an Appeal from an ER&S Report Get into Appeals by double-clicking Appeals on the left side of the System Totals window. From the Medicaid Appeal Request/Response Summary window, click File, then From ER&S, or click the From ER&S icon. Page 72

77 Medicaid Appeals Create Appeal from ER&S (continued) In the ER&S Search window, enter search criteria to find the claim to be appealed and click Search. Click the claim being appealed and click Create. Page 73

78 Medicaid Appeals Create Appeal from ER&S (continued) Finally, begin filling out any missing information required on the appeal. The fields for appeals are the same as for claims of the same type with one exception: the patient tab has three additional fields not found on claims. For frequency code, select 7 for an appeal or 8 for a void (recoupment). The original ICN and the original Medicaid number are filled in for you. Remember that bolded fields are required, and other fields may be necessary depending on the type of appeal. Click OK on the appeal to save it in completed status to be submitted later to NHIC. Appeals are only submitted by batch, not interactively. A batch can contain one or more appeals. NOTE: Clicking the OK button does not send the appeal to NHIC; it stores the appeal in Completed status on YOUR database only. You must do all four steps listed on page 76 to send and retrieve batch requests. Page 74

79 Medicaid Appeals Create an Appeal from a Blank Form To create a Medicaid professional (837P) appeal from a blank form, double-click Appeals and the Medicaid Appeal Request/Response Summary window will populate. Click File, then New, then one of the following: Professional, Eyeglass, Dental, Inpatient, or Outpatient. Page 75

80 Medicaid Appeals Submitting and Retrieving Requests Submit/Retrieve Batch Requests NOTE: Clicking the OK button does not send the appeal to NHIC; it stores the appeal in Completed status on YOUR database only. You must do all four steps listed below to send and retrieve batch requests. When through entering data, click OK to save the completed appeal that will be submitted to NHIC later. Appeals are only submitted by batch, not interactively. A batch can contain one or more appeals. To submit and retrieve a batch of appeals involves four steps: 1. Fill out the appeal and click the OK button. 2. Go to System Totals, click the Send Requests tab, Repeat for each appeal in the batch. click the Send box for Medicaid Appeals, and click the Submit button. 3. Go to System Totals window 24 hours later, 4. Double-click Appeals under the Medicaid folder click the Retrieve Responses tab, click Download (left side of window), and double-click the response box for Appeals, click Download button. just downloaded to view it. Page 76

81 Medicaid Appeals Printing Reports Six types of appeals reports may be printed from the Medicaid Appeal Request/Response Summary. Transmission Summary Click an appeal response, then click Reports and Transmission Summary to display the report. The number of accepted or rejected appeals is listed, along with the amount billed. Click Print for a paper copy. Transmission Detail Click an accepted appeal response. Click Reports and Transmission Detail. A list of appeal responses in that batch is displayed. Click Print for a paper copy. Error Summary Click an appeal response with a processed status and No. Rejected greater than zero. Click Reports and Error Summary. A list of rejected appeals and errors in the batch is displayed. Click Print for a paper copy. Appeal Detail Double-click an appeal response. Click Reports and Appeal Detail. A detailed list of the appeal is displayed. Click Print for a paper copy. Completed Appeals Click Reports and Completed Appeals. A box will display, stating There are appeals to print. Do you want to continue? Click Yes to print a detailed list of ALL completed but not yet submitted appeals. Rejected Appeals Click Reports and Print Rejected Appeals. A box will display, stating There are appeals to print. Do you want to continue? Click Yes to print a detailed list of ALL rejected appeals. Page 77

82 TDHconnect Log On Error Messages TDHconnect Log On Error Messages Admin currently logged on During login, a message may appear, Admin is currently logged on to TDHconnect or whatever user ID is used. Click OK. To resolve the message of a user currently logged on, click on Start Programs TDHconnect TDHconnect Utilities. Page 78

83 TDHconnect Log On Error Messages Admin currently logged on (continued) Click the Logoff User tab, in the drop down box select the user ID (in this case, admin ) by clicking the user name, then click the Log Off button and OK. TDHconnect Log On Error Messages TDHconnect already running A message that may appear if the TDHconnect icon is clicked more than once to load is, TDHconnect is already running. To resolve this situation, press CTRL + ALT + Delete simultaneously to bring up the Task Manager. Note: Different computers will open up with a different Task Manager option, such as Task List or an Application tab. Within Task Manager, click TDHconnect and then End Task. Page 79