MSU HEALTH TEAM MPV ELIGIBILITY TRAINING MANUAL

Transcription

1 MSU HEALTH TEAM MPV ELIGIBILITY TRAINING MANUAL MSU HealthTeam Training and Education (M-F 8a 5p) Melody Frye

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3 MPV ELIGIBILITY What Is It? MPV Eligibility captures a patient s upcoming appointments in Centricity Business and electronically verifies eligibility and benefits of the patient s insurance information. The system electronically receives the insurance verification and benefits information from specific payers, and populates the returned information into the appropriate fields in the FSC Follow-Up questions. MPV Eligibility does not eliminate the need for all manual insurance verification. There are certain scenarios when manual verification will still be required. In those cases, the data drops into a work file where the data can be reviewed and worked. Verification Process MSU HealthTeam Scheduler enters/updates the patient s insurance at the time the appointment is scheduled. MPV ACTIONS MPV Eligibility extracts patient eligibility transactions from Centricity Business and posts them into MPV Eligibility. On a daily basis, extraction files are created based on FSC, appointment, department, and other parameters. The extraction runs during off-hours. MPV Eligibility sends patient eligibility transactions to each insurance carrier (payer). Once the initial extraction process from your Centricity Business to MPV Eligibility is completed, the transactions are transmitted to each insurance carrier (payer) for verification. The insurance carrier (payer) verifies the eligibility information and returns eligibility responses. Most insurance carriers (payers) return all files within 6-24 hours of the time they receive the eligibility requests. Transactions returned by the insurance are identified by one of the following states: Rejected Eligible Ineligible Insurance carrier could not find the patient in its database. The patient has active coverage on the date requested. The patient is in the insurance carrier s database, but the patient does not have active coverage on the date requested. Example - Coverage may have expired 3

4 All patient eligibility transactions are batched by date and verified against MSU HealthTeam s business rules. After the insurance has verified the file and returned the eligibility and benefits information, the transactions are batched and checked. Then they are entered in a PBatch (processed batch) and classified as one of the following: Clean Rejected Accepted [also called Accepted (No Edits)] These transactions passed the verification against MSU HealthTeam s business rules (see addendum B and C) and are not sent to work files. The trading partner (payer) could not find the patient in its database. These transactions are sent to work files. The eligibility transactions contained mismatched information. Transactions may be either eligible or ineligible for payor benefits. These transactions are sent to work files indicating they did not pass the verfication. RESULTS Clean transactions are automatically posted to Centricity Business. If the patient eligibility transactions pass the verification process, the transactions are marked as clean and the information returned is automatically posted into Centricity Business. Transactions requiring review are dropped into work files. If the patient eligibility transactions do not pass the verification process, the transactions are placed into a work file. These transactions are flagged as having edits and are classified as: 1. Rejected 2. Accepted patient in insurance data base but edits exist Accepted transactions may be either eligible or ineligible for benefits from the payer. FOLLOW-UP Work the transactions in the work files. Working patient eligibility transactions means that you: 1. Review any edits (see Appendix B and C) 2. Make any necessary corrections 3. Mark the transactions to be posted or not posted (omitted because you manually made changes in Centricity Business) from Posting (Y/N). 4

5 The transactions in the work files are reprocessed or rerun against the business rules. MPV will reprocess the transactions at regularly scheduled times (11:00 AM and 6:00 PM). When it reprocesses transactions, it verifies against the requirements (business rules). After reprocessing, the system updates the work files, and posts the appropriate transactions to Centricity Business. Then the work file is reviewed and worked until there are no outstanding transactions. 5

6 Accessing MPV Eligibility Access to MPV Eligibility can be accomplished in three ways. Through the MPV Internet Website (MPV Portal) Through Centricity Business Web Vertical Tool Bar (MPV Portal as above, moves outside of Centricity Business) Note: Must first save any data entered in Demographics or insurance table. Through the Centricity Business Insurance Table Action Code (Stays inside Centricity Business) Website (AKA Portal ) Centricity Business Vertical Tool Bar Link (takes user to MPV Website) Can verify insurance for all insurance carriers but does not update Centricity Business FSC Follow-up Questions. Action Code Can check eligibility for top six carriers only but will update Centricity Business follow-up questions. Use for Aetna, BCBS (includes BCN and Out of Area), Cigna, Medicaid(includes HMOs), Medicare (includes Advantage), and PHP. 6

7 LOGGING IN The first page you seen when you initially access MPV Eligibility is the login page. To log in to MPV Eligibility: Type your User Name in the User Name field - Name will be the standard msu + first 6 digits of last name + first two digits of first name. Type your Password in the Password field. (Passwords are case sensitive) The First Time you sign in to MPV the password you will use is msu The system will then prompt you to change your password. The system can remember your user name so you do not have to type it each time you log in. It will not remember your password. You must type your password each time you log into the system. To make the system remember your user name: Click in the Remember Me check box. To complete your login: Click Login If you have forgotten your password click on the hyperlink Forgot your Password. The system will reset your password and you a temporary password you can use to log in to the system. 7

8 Changing Your Password. The system will prompt you to change your password at your initial sign-on. Your password should also be changed periodically as required by MSU. 8

9 MPV Portal: Real-Time Eligibility Search Accessing the Real-Time Search Through Website or Vertical Tool Bar (Portal): Note: Real Time verification through the MPV portal does not update Centricity Business automatically. CB must be updated manually. MPV Eligibility Login Page 1. Type your User Name and Password. 2. Click Log In 9

10 3. Always use the default values as they are in the Module and Line of Business fields. Clicking on the drop down list and selecting (highlighting) a different Module will not allow access to a different module due to security set up. NOTE: If you select a Module to which MSU HealthTeam does not subscribe, a message such as the following displays. The Line of Business is your Clinic Name. It will always default in for you. If you work in Multiple Clinics you will be able to select the correct clinic from the drop down list.. 10

11 4. Click Go. The first time you log in to a MPV session, the default tab and Outbound Batch page will display. After you have worked in the system, it remembers the last tab and page you used and returns there when you log in. Transactions Tab, Trading Partner (Payer) Summary Page 5. Click Real-time Search on the navigation panel on the left side of the screen. 11

12 Real Time Eligibility Window Opens (separate window from Work Files). Real Time Eligibility Search Page To specify the search criteria: 1. Click to select (highlight) a Trading Partner (payer) from the drop-down list. 12

13 Note: Real Time verification through the MPV portal does not update Centricity Business automatically. CB must be updated manually. The Real Time Eligibility Search page displays the options and required patient information fields for searching eligibility information with the selected trading partner (payer). 2. Click to select (highlight) a Search Type from the scrolling list. 13

14 3. Click to select (highlight) a Service Type from the drop-down list for this carrier. Select "Health Benefits Plan Coverage" (the default value) to receive generic benefits information from the search. Select a specific type of service, such as Hospital to receive that particular type of benefit information from the search. 14

15 4. Complete all required Patient Information fields. 15

16 To submit the Real-Time Search: 1. Click Submit. If the Real-Time Search finds no matching eligibility information: The Eligibility Response page displays Rejected Eligibility Status. 1. Click the Edits heading bar to view the Rejection Reason and Follow-up Action messages. 16

17 The Rejection Reason and Follow-up Action messages display. See Appendix A for complete lists of possible Rejection Reason and Follow-up Action Messages and Codes. 2. Return to To specify the search criteria: by clicking on the Search Tab to correct any necessary information and resubmit the corrected search criteria (see page 17). 17

18 OR 3. Click on Clear to clear the page and start a different Real-Time Search: (see page 29). If the search finds matching eligibility information: The Eligibility Response page displays the patient eligibility information: To expand (show) a particular section of the eligibility information: 1. Click the heading bar of the selected section. 18

19 Expanded Benefits Information; All Other Sections Collapsed You can expand multiple sections at once. Scroll up and down to view all of the information displayed. To expand (show) the details of a particular type of benefits: 1. Click the Service Type name of the details you want to expand. Hovering over Service Type Name will Display more information regarding the item. The expanded benefit details display. 19

20 Expanded Benefit Details You can expand the benefit details for multiple Service Types at once. Scroll up and down to view all of the benefit details. To collapse (hide) the benefit details: 20

21 1. Click the Service Type name of the details you want to collapse (hide). The selected details are collapsed (hidden).. To collapse (hide) a particular section of the eligibility response: 21

22 1. Click the heading bar of the expanded section. The selected section details are collapsed (hidden). Eligibility Information Collapsed To expand (show) all sections of the eligibility information: 1. Click Expand All in the top right portion of the page. 22

23 To collapse (hide) all sections of the eligibility information: 1. Click Collapse All in the top right portion of the page. All section details are collapsed (hidden). Eligibility Information Collapsed To print the eligibility information: 1. Click Print in the top right portion of the page. 23

24 The print dialog box displays. 2. Select the appropriate print options. 3. Click Print. To cancel the Real-Time Search after you have submitted it, but before it is completed: 24

25 NOTE: The Real-Time Search usually completes within a few seconds, so you must act very quickly to cancel a search. 1. Click Cancel. A message indicates that you successfully cancelled the search. To clear the page and start a different Real-Time Search: 1. Click Clear. The Real-Time Search page displays: The trading partner (payer) information you typed or selected remains. The Patient Information you typed or selected is cleared. 2. Repeat To specify search criteria: (page 17) and submit different search criteria.. To review or reprint recent search results: 1. Click the Recent Searches tab. 25

26 The Recent Searches List page displays. Recent Searches List Page The following information displays: Date & Time The date and time the search was performed. Trading Partner The trading partner (payer) to which the search was submitted. User The MPV Eligibility user ID of the person who submitted the search. Status Shows whether the patient whose information was submitted was eligible, ineligible, or rejected. If the status is rejected, the rejection and follow-up codes also display in parentheses Criteria Displays the information (such as the certificate number) submitted for the search. 2. Click a search row to view the full search results. 26

27 For complete lists of Rejection and Follow-Up Codes, see Appendix A The Eligibility Response page displays the patient eligibility information (Results). From the Eligibility Response page you can view or print the search response. 27

28 Real Time Search Through Centricity Business Insurance Table Action Code MPV Real Time searches can be accessed through Centricity Business utilizing Action Code 1 in the FSC Table. Highlight the insurance from the insurance table list that you wish to search. NOTE: Only the top six HealthTeam Insurances can be verified through the MPV Verify Action Code 1 in CB. Real time search through MPV Action code will however, automatically update the insurance table for those six main insurance carriers. Aetna (Currently not up and running) Cigna BS of MI (includes BCN, Federal and BS out of area) Medicaid, (checks HMO s using Medicaid 10 digit number). Medicare (includes Medicare Advantage products using Medicare Part B number) PHP of Mid-Michigan (Currently not up and running) Click on action code 1 (MPV Verify) Enter Y at your line of business (Must be in caps) Enter? at the Enter Command or enter the command such as C to check Eligibility 28

29 Enter Command List Check Eligibility Enter END date: will default as today, can override Transaction will display indicating date, time, verification status, Edit (y/n), and carrier name. View Benefits When checking eligibility and viewing benefits through Centricity Business MPV Action Code, CB will be updated automatically for the six main insurance carriers. Aetna BCBS of MI (all products including BCN and Out of Area) Cigna Medicaid Medicare PHP of MI 29

30 Processing Work Files You will probably spend the majority of your time in the MPV Eligibility system processing work files. Work files contain edits and rejections from the top six MSU HealthTeam Payer List for patient appointments up to five dates out. All work files are worked on a daily basis. After seven calendar days any actions taken in a work file will not process. These work files are monitored by HealthTeam Operations who will then notify MPV to delete the work files. To Access The Work Files: 1. Select the OBEV Module from Drop Down List and Click on GO. 2. Select Line of Business This will default based on user s security access 30

31 If you select the wrong module, a message in red will display alerting you that you chose a module that is not available. 3. Click on the Transaction Tab (if it is not already highlighted in yellow). 4. Click on Work File on the navigation panel on the left side. The Work Files Screen Will Display 31

32 5. Click on the Trading Partner from the Drop Down List for the work file to be worked (multiple users can be in the same work file at the same time). Note there are multiple categories for each insurance carrier depending on where MPV searches in Centricity Business. You may see TES Charges, BAR Charges and Appointments, or any combination of same. The page re-displays showing your work files for the selected Insurance Carrier and Category. 6. Click on the Work file to be worked 32

33 The screen below shows that the Cigna Insurance Appointment Category work file was selected. It may include multiple batches and will list the number of transactions within that batch, how many transactions were accepted, how many rejected, and the number of outstanding transactions. NOTE: Accepted indicates the number of transactions accepted into the insurance carriers s system. Rejected indicates the number that the carrier could not locate in their system, and outstanding indicates the total items in the batch that have not been worked. Click the Batches/Page drop-down list to select the number of batches that display on each page 7. Click on the line for the batch to be accessed and the transaction detail of the batch will display. To view multiple pages click on Next or Previous. 33

34 Batch Details/Transaction Details Processing Work Files continued Sections Batch Information Header Legend and Page Navigation Content Section Header Header Batch # Load Date Age Total Pts. Posts Do Not Posts Open Total Pts In Batch Content Legend and Page Navigation Legend Gray- IDX White- Posted Navigation Post Y/N Prev/Next Page Edits/Page Status Filter Content Name Post Y/N MRN Links - Benefits DOB Edit FSC Notes Eff Date Translate Cert # Invoices Verification Date Visits Edit EDI (Not Available-Address Verification) 34

35 Content Field/Column and Descriptions of Batch Details Page Information shown on a gray background Original information from Centricity Business Information shown on a white background Information created from the insurance carrier s response. Field Name MRN DOB FSC Eff. Date Cert # Verification Date Edit Post (Y/N) Column Description Patient s name Medical Record Number Date of birth Financial Status Class Eligibility date returned from the insurance Certificate number The patient s visit date or appointment date Edit error message indicating the reason for the patient s ineligibility Hover the Mouse Over an Edit Message to See More Information This indicator tells the system whether or not this batch of patient eligibility transactions is ready to be reprocessed. These options are rarely, if ever, utilized as most batches contact a mix of Y/N. Y Click to change the Post indicator to Yes for all transactions in this batch. N Click to change the Post indicator to No for all transactions in this batch (used only when you have completed a manual update (fix) in Centricity Business. The system automatically performs reprocessing and posting: MPV automatically performs reprocessing of edits in the work files twice a day at 11 A.M. EST and again at 6 P.M. EST, Monday through Friday. Post automatically updates Centricity Business with clean data (including any clean new patient eligibility transaction and any clean reprocessed patient eligibility transaction) every hour from 8 A.M. EST to 8 P.M. EST, Monday through Friday. 35

36 Links to Other Information and Tools Shown in Blue Post (Y/N) Box Changes Color When You Select (Check) Y or N Link Benefits Edit Notes Translate Invoices Visits EDI Address Verification Link Description Click the Benefits link to see the benefits information returned by the trading partner (payer) for the selected patient displayed in a separate window. Click the Edit link to view the edits (error message) information returned from the payer. Click the Notes link to add comments to the patient information. This would be used only when you wanted to enter a reminder to yourself regarding where you in processing this item (or to someone else who may be working the batch). Click the Translate link to display (in view-only mode) the same information that displays (in edit mode) when you click the Edit link. Click the Invoices link to view outstanding invoices, if any, for the selected patient s account. The number of invoices for this patient displays in parentheses after the link. (See attached process for edits with attached invoices) Click the Visits link to view details of the selected patient s visit, if any. The number of visits for this patient displays in parentheses after the link. Click the EDI link to view the electronic data Inter-change (EDI) files sent to and from the payer, and see how the data is translated and posted into Centricity Business by MPV s DOME (Dynamic On-line Mapping Environment) posting mechanism. Feature Not purchased 36

37 Rejection and Follow-Up Codes Rejection and Follow-Up Codes are returned for patient eligibility rejected transactions from the insurance. MPV Eligibility displays the relevant Rejection and Follow-Up Codes after the associated edit message in the work file batch. For example, you might see one the following edit messages followed by the Rejection and Follow-Up Codes shown in parentheses: Edit: F INVALID: Rejected Transaction from Payor (64^C~Invalid/Missing Patient ID) Edit: F INVALID: Rejected Transaction from Payor (67^C~Patient Not Found) Edit: F INVALID: Rejected Transaction from Payor (75^C~Subscriber/Insured Not Found) Edit: F INVALID: Rejected Transaction from Payor (78^N~Subscriber/Insured Not in Group/Plan Identified) You can look up the Rejection and Follow-Up Codes to find out what action is required to correct the problem. For example, if the Rejection and Follow-Up Codes shown are 64 and C, you will find the following descriptions for them: Rejection Code Rejection Message 64 Invalid/Missing Patient ID Follow-Up Code Follow-Up Message C Please Correct and Resubmit Or if the Rejection and Follow-Up Codes shown are 78 and N, you will find the following descriptions for them: Rejection Code Rejection Message 78 Subscriber/Insured Not in Group/Plan Identified Follow-Up Code Follow-Up Message N Resubmission Not Allowed For complete lists of Rejection and Follow-Up Codes, see Appendix A. 37

38 WORKING EDITS Below is a work file consisting of BCBS of MI SCHEDULED APPTS For Sports Medicine. Notice it has multiple batches with outstanding edits between 1 and 14. Batches 1. To access the edits within a batch click on the batch number. The items in the batch will display with an explanation of the edit. 2. Click on the Edit Link in Blue to view the detail of the MPV edit. Y/N Edit 38

39 The Edit Detail Screen will display. The Edit Detail screen will display the FSC-Followup questions. The far left column is the field description. The middle column displays the information from the insurance carrier. The far right column displays the information stored in Centricity Business. 3. Use the Arrow on the bottom right corner to move up and down the fields or use the up and down arrows on your keyboard. 1. To change or add information in the middle column (information returned from carrier, click in the field and delete and modify or add information as needed. 2. Click on Save. NOTE: If you wish to revert back to the information stored in the field prior to your change click on Roll Back. If you did not change or add any information to the middle column click on Close to close the Edit Detail screen. 39

40 MPV Yes Versus No When Working Work File Edits Completing Edits with ELIGIBLITY STATUS OF REJECTED OR INACTIVE Post (Y) vs. Post (N) When to Post (N) Edits that include eligibility status of REJECTED or INACTIVE on the Edit Screen must be worked in Centricity Business. Toggle and correct manually. When to Post (Y) NEVER Post (Y) to an edit that includes the eligibility status of REJECTED or INACTIVE REJECTED STATUS or INACTIVE STATUS + Manual updates in IDX = Post (NO) When the system reprocesses (11am and 6pm) the Post (N) edits fall off your Work Files. 40

41 Completing Edits with ELIGIBILITY STATUS OF ELIGIBLE Post (Y) vs. Post (N) When to Post (No) Edits in a GRAY/WHITE field on the Edit Screen FSC follow-up questions with a YELLOW Discrepancy must be worked in Centricity Business. Complete the changes if appropriate in the FSC follow-up questions and/or demographics (may include deleting/adding FSCs). Return to MPV and Post (N). Edits will not leave work file until you answer no. GRAY/WHITE edit + YELLOW discrepancy + Manual updates in IDX = Post (NO) When the system reprocesses (11am and 6pm) the Post (N) edits fall off your Work Files. 41

42 Completing Edits with ELIGIBILITY STATUS OF ELIGIBLE (Continued) When to Post (Y) Edits that can be worked in MPV Portal without TOGGELING back to CB Fields on MPV Edit Screen that appear in RED with a YELLOW discrepancy Verify Trading Partner Column FSC follow-up information on MPV Edit Screen o if it is correct you can click close and Post (Y) to complete edit. o if it is incorrect you can change the field information, click save and Post (Y) to complete edit. RED fields + YELLOW discrepancy + No TOGGELING to CB for updates = Post (Y) Screen with correct FSC follow-up information in Trading Partner Column (Close) Screen with incorrect information in Trading Partner Column (Change and Save) Can override effective date with because this is a renewal effective date carrying forward from (January 1, 2009). Click Save after change is made When the system reprocesses (6am and 6pm) the Post (N) edits fall off your Work Files. 42

43 Posting (Y) vs. Posting (N) Examples When To Post (No) Edits that do not pertain to a Red Labeled insurance follow-up field must be worked manually in Centricity Business. POST NO Edit Examples requiring manual updates in Centricity Business Insurance in Wrong FSC Medicaid identifies patient as having a Medicaid HMO Remember it is important to research discrepancies to verify the correct information such as a mismatch on a patient name. The insurance carrier may have the patient listed with a nickname. In Centricity Business registration the patient s name fields should always be the patient s legal name. After you have made manual updates in Centricity Business to fix an edit you must return to MPV and post (No). The edits will not be completed in MPV until this is done (it will remain in the batch/work file). Edit example that requires manual updates. Patient should be in FSC 24 Steps Verify Accuracy of MPV Edit (check Blue Shield Alpha Prefix Grid). Delete the incorrect FSC saving the FSC follow-up information (click no in popup) Add correct FSC Verify accuracy and completeness of added insurance FSC by checking insurance fields in insurance table. Complete Eligibility Status field for new FSC Toggle back to MPV and Check Invoices by clicking on Invoices hyperlink if it indicates other than zero Copy the invoice screen and insert in . Send to CBO Claims Manager. Say (N) to Post 43

44 When To Post (Y) Edits that pertain to specific Centricity Business insurance follow-up questions as displayed in the Edit Detail Screen are posted with a (Y). POST YES - Edits Corrected by clicking on the (Y) Subscriber name mismatch Incorrect Certificate number Edit example that is fixed by saying (Y) to Post. Certificate number is different Steps To view the FSC follow-up information click on Edit If there are no changes to be made on descriptions in red click Close The system returns to the Edit list. Click on (Y) to Post. 44

45 Review Examples Post (Y) or (N)? - Remember manual updates No FSC Field label in red with discrepancy post Y 45

46 Review Examples (Answers) Post (Y) or (N)? Patient is not eligible Post (N) Multiple Edits requires manual update in CB to change to correct FSC. Post (N) (Overrides sub dob, name and cert number which would be yes.) Must update subscriber name and cert number manually in new FSC Note: This insurance probably needs verification. Rejected for missing/invalid subscriber ID. Research for subscriber ID and enter in CB FSC follow-up screen. Do real time check through FSC Table action code. Post (N) Different Cert Number and patient has replacement HMO. Research. Once the correct HMO cert number and address is verified, can be loaded into MPV FSC follow-up fields if replacement HMO is also a non Medicare Advantage. Post (Y) If diff fsc Post (N) Missing Subscriber and Insured ID. Research and add info to CB. Post (N) Patient Not Found. Research and identify correct insurance information. Do manual correction in CB and Post (N). Subscriber/insured not found. Research and change insurance in CB (do real-time verification with CB action code MPV. If insurance is correct FSC, make changes in CB FSC follow-up questions and verify insurance using MPV action code. Post (N). 46

47 MPV Edits That Result in a Deletion of a FSC Any time an Insurance (FSC) that has outstanding invoices is deleted from the Insurance Table, the Billing Office must be notified so they can evaluate the outstanding invoices with the deleted carrier and make appropriate corrections. STEPS Click on the MPV Invoices hyperlink to display the invoice detail. Copy the invoice detail Copy into an and send to the Billing Office Claims Manager. Click N to Post in MPV 47

48 MPV IMPORTANT TIPS Hovering the Mouse Cursor over a Link, Button, or Data Entry Field will display additional information about the message. Clicking on Real Time Search on the Vertical Tool Bar opens another session. Click on the real time session on the bottom of your screen to move between Centricity Business, MPV Real Time and your Work File. Performing real-time within in Centricity Business Insurance Action Code MPV will update the system for the insurances listed in your MPV work files. Copy and Pasting between MPV and Centricity Business will reduce typing errors and save time. MPV MSU EXTRACTION SCHEDULE 1. Appointments extract at 2:00 am EST. 2. Bar Charges extract at 3:00 am EST. 3. TES Charges extract at 9:00 pm EST. 4. These extractions begin to run on Sunday Friday evenings Posting Times MPV automatically reprocesses edits that have been worked in the work file twice daily at 11:00 am and 6:00 pm EST Monday-Friday. Dome posting updates IDX with clean data, including any clean new patient eligibility transactions and any reprocessed patient eligibility transactions, every hour from 8:00 am 8:00 pm EST Monday- Friday. ********Please remember that these transactions are set up in a queue on a server. MPV has several servers. The number of transactions that are in the queue, and the number of clients ahead of MSU, determines the time that the actual transaction is posted back to CB. One other extremely important factor to remember is how quickly the Trading Partner responds to MPV s batches, also determines how long before MPV can post back the information. 48

49 WORK FILE REJECTIONS APPENDIX A ALWAYS RESEARCH ALWAYS POST (N) Rejection Code Description C Please Correct and Resubmit I Not Covered N Resubmission Not Allowed P Please Resubmit Original Transaction R Resubmission Allowed S Do Not Resubmit; Inquiry Initiated to a Third Party U Contact for Benefit Information V Cannot Process W Please Wait 30 Days and Resubmit X Please Wait 10 Days and Resubmit 5 Active Pending Investigation 6 Inactive 7 Inactive Pending Eligibility Update 8 Inactive Pending Investigation 15 Required application data missing 41 Authorization / Access Restrictions 42 Unable to Respond at Current Time 43 Invalid/Missing Provider Identification 45 Invalid/Missing Provider Specialty 47 Invalid/Missing Provider State 48 Invalid/Missing Referring Provider Identification Number 49 Provider is Not Primary Care Physician 51 Provider Not on File 52 Service Dates Not Within Provider Plan Enrollment 56 Inappropriate Date 57 Invalid/Missing Date(s) of Service 58 Invalid/Missing Date-of-Birth 60 Date of Birth Follows Date(s) of Service 61 Date of Death Precedes Date(s) of Service 49

50 62 Date of Service Not Within Allowable Inquiry Period 63 Date of Service in Future 64 Invalid/Missing Patient ID 65 Invalid/Missing Patient Name 66 Invalid/Missing Patient Gender Code 67 Patient Not Found 68 Duplicate Patient ID Number 71 Patient Birth Date Does Not Match That for the Patient on the Database 72 Invalid/Missing Subscriber/Insured ID 73 Invalid/Missing Subscriber/Insured Name 74 Invalid/Missing Subscriber/Insured Gender Code 75 Subscriber/Insured Not Found 76 Duplicate Subscriber/Insured ID Number 77 Subscriber Found, Patient Not Found 78 Subscriber/Insured Not in Group/Plan Identified 80 No response received, Transaction Terminated 1184 Use this code in a batch environment where an information source returns all requests from the 270 in the 271 and identifies Unable to Respond at Current Time for each individual request (subscriber or dependent) within the transaction that they were unable to process for reasons other than data content (such as their system is down or timed out when generating a response). 50

51 APPEDIX B MPV Business Rules All Trading Partners CB =Centricity Business Rule Action MPV WORK FILE Post Y/N Patient Name from Payor is different than CB Certificate/Policy # from Insurance is different than IDX Patient's DOB from Trading Partner is different than IDX Patient is Ineligible Contact the payor for Eligibility Information The payor cannot process the transaction at this time Effective date is greater than 365 days in the future Termination date is greater than 3000 days in the past Effective Date mismatch and the patient has outstanding invoices. Current Plan in CB has a Termination date Research and verify patient's legal name. If CB holds patient's legal name do not change. If CB does not hold legal name, change in CB to correct legal name. Say yes to post to CB Research and verify the patient's correct date of birth. If CB does not hold correct birth date, change to correct dob. Research to verify. Edit FSC follow-up question field with expiration date and status of ineligible. Delete the insurance from the FSC Table, retaining the FSC follow-up questions. Contact patient to obtain correct insurance. If other insurance replaces this deleted insurance, add to patient's account. Notify Billing if there are outstanding invoices in the deleted fsc. See work file Invoices Link Call the insurance carrier to determine the status of eligibility. If Patient is eligible and all information is correct in CB indicate status of eligible. If patient has is ineligible make FSC follow-up question changes in system and delete insurance as appropriate Run through Real Time to verify eligibility and update FSC follow-up questions manually. Change status to ineligible, delete insurance from FSC table and retain insurance followup questions. Update FSC follow-up questions, delete insurance from FSC table and retain followup questions.. Notify billing office by that invoices may be impacted by the change in effective date housed in CB. Add termination date in CB if in the past, delete insurance and retain FSC follow-up questions. Y Y Y N N N N N Y N 51

52 Termination date mismatch and patient has outstanding invoices. Patient is Ineligible with no outstanding invoices Patient is Ineligible with outstanding invoices Patient's First Name from payor is different than CB first name Patient's Last Name from payor is different than CB last name Newborn Rejection Transaction is rejected from Payor. Please correct and resubmit Sex from Payor is different than CB Update FSC follow-up questions, delete insurance and retain FSC follow-up questions. Notify Billing by that patient has invoices in a fsc that was deleted and invoices may be impacted by dates of eligibility Update FSC follow-up questions, Delete insurance from the insurance table, retaining the FSC follow-up questions. Update FSC follow-up questions, Delete insurance from the insurance table, retaining the FSC follow-up questions. Notify Billing that patient has invoices in the fsc that was deleted and invoices may be impacted by dates of eligibility Research and verify patient's legal first name. If correct in CB do not change in CB. If incorrect in CB make change. Research and verify patient's legal last name. If correct in CB do not change. If incorrect in CB make change. Contact the policy holder and ask if patient is being added to insurance. Enter eligibility status and place eligibility comment in insurance follow-up questions. Delete insurance from insurance table Review edit from carrier as listed in work file. Research missing information and correct FSC follow-up question(s) as referenced by insurance carrier. Do real time search and add insurance verification information to FSC follow-up. Retain in Ins Table if active insurance or place in deleted table if ineligible. Research and Verify Patient's Sex as entered in CB. If correct do not change. If incorrect in CB correct sex. Subscriber's SSN from the payor is different than CB The Subscriber's DOB from the payor is different than CB Subscriber's Name from the payor is different than CB Verify eligibility dates for insurance. Edit FSC follow-up questions if Terminated. Delete insurance and retain FSC follow-up Termination Date is Present questions. If there are invoices in this FSC notify Billing that patient has invoices in a fsc that was deleted and invoices may be impacted by dates of eligibility Wrong patient returned from Trading Partner Verify patient information (name, date of birth), Verify patients insurance, correct as appropriate either by changing patient demographics information or by changing insurance FSC. N N N Y Y N N Y Y Y Y N N 52

53 Appendix C MPV Business Rules CB =Centricity Business Rule Specific Carrier Standard Rules Action Post Y/N Self Pay Appointments Patient is Eligible Add Medicaid information to FSC Table. Notify Billing of coverage if N outstanding invoices. Self Pay Invoices Patient is eligible Add Medicaid information to FSC Table. Notify Billing of coverage if N outstanding invoices. Medicare - Date of death is present Verify insurance. If incorrect Medicare number change in CB and do realtime eligibility check. If number is correct, complete expiration date in FSC follow-up questions and delete insurance keeping fsc follow-up N questions. Notify Billing if invoices are impacted. Research and verify Patient's Date of Death. Complete deceased information in CB. Delete any pending patient appointments. Medicare - Patient does not have Part B Delete Medicare from the insurance table and place comment in General Comments that patient does not have N Medicare Part B benefits. Medicare - Patient has Railroad Medicare Research through real time and verify Patient insurance coverage. Change Medicare number to correct Railroad Medicare number. If unable to obtain N correct number delete Medicare and notify billing if invoices are impacted. Medicare- Patient has HMO Replacement Plan Research through real time and Verify Patient insurance coverage change FSC to correct Medicare Plan and complete follow-up questions. If unable to obtain correct insurance N plan, delete Medicare and notify billing that there may be invoices impacted by deleted insurance. Aetna - Patient has Medicare Primary Research and verify patient's Medicare insurance. Add Medicare as primary or move to priority one if in system. Notify Billing if there are Y invoices impacted by the added insurance FSC or change in priority. Aetna- Medicare should be secondary in CB Change FSC priorities and notify Billing if there are invoices impacted Y by the change in insurance priority. Aetna Patient should be in /FSC 41 - HMO Move to correct FSC N Aetna Patient should be in /FSC 64 - PPO Move to correct FSC N 53

54 Aetna Patient should be in /FSC 64 POS Move to correct FSC N Aetna Patient should be in /FSC 64 Indemnity Move to correct FSC N BCBS Patient has hospital coverage only Delete insurance and do not retain follow-up questions. Research and verify patient's correct insurance information and add to insurance N table. If no insurance just delete BCBS ins. Notify billing if there are invoices impacted by the change. BCBS Patient should be in FSC 21 Indemnity Move to correct FSC N BCBS Patient should be in FSC 170 POS Move to correct FSC N BCBS Patient should be in FSC24, 96 or 301 PPO Move to correct FSC N BCBS Patient should be in FSC 42 HMO Move to correct FSC N CIGNA Patient should be in FSC 41 HMO Move to correct FSC N CIGNA Patient should be in FSC PPO Move to correct FSC N CIGNA Patient should be in SPHN - POS Move to correct FSC N CIGNA Patient should be in SPHN - Indemnity Move to correct FSC N 54

55 SUMMARY STEPS TO ACCESS WORK FILES AND WORK EDITS To Access Work Files: 1. Select the OBEV Module from Drop Down List and Click on GO. 2. Select Line of Business This will default based on user s security access 3. Click on the Transaction Tab (if it is not already highlighted in yellow). 4. Click on Work File on the navigation panel on the left side. 5. Click on the Insurance Carrier/Category from the Drop Down List for the work file to be worked (multiple users can be in the same work file at the same time). 6. Click on the Work file to be worked 7. Click on the line for the batch to be accessed and the transaction detail of the batch will display. To view multiple pages click on Next or Previous. Do not use windows back arrow as the system may disconnect from MPV. Working Edits: 1. To access the edits within a batch click on the batch number. The items in the batch will display with an explanation of the edit. 2. Click on the Edit Link in Blue to view the detail of the MPV edit. 3. Use the Arrow on the bottom right corner to move up and down the fields or use the up and down arrows on your keyboard. 4. To change or add information in the middle column (information returned from carrier, click in the field and delete and modify or add information as needed. 5. Click on Save. NOTE: If you wish to revert back to the information stored in the field prior to your change click on Roll Back. If you want to Close the Edit Detail screen (no changes made) click on Close POST NO - Edits that require manual updates in Centricity Business and MPV does not update CB. ALL Edits showing REJECTED OR INACTIVE ELIGIBILITY STATUS are posted with (N). Never post (Y). After you have made manual updates in Centricity Business to fix an edit you must return to MPV and post (No). The edits will not be completed in MPV until this is done (it will remain in the batch/work file). POST NO Edits leave the work file batch and MPV does not update Centricity Business POST YES - Edits that are in an Eligible status and pertain to specific Centricity Business insurance follow-up questions as displayed in Red in the Edit Detail Screen and you want MPV to update CB insurance follow-up questions. POST YES Edit leaves the work file batch and MPV updates the FSC follow-up fields. 55