EDI Billing Guide for L.A. County. Clinitrak. for Behavioral Health Providers

Transcription

1 EDI Billing Guide for L.A. County Clinitrak for Behavioral Health Providers

2 Clinitrak EDI Billing Guide Document Number CLEG First edition printed April Clinivate, LLC All Rights Reserved All brand names and product names used in this document are trademarks, registered trademarks, or trade names of their respective holders. Clinivate is not associated with any other vendors or products mentioned in this document. This document contains information that is protected by copyright. No part of this document can be photocopied, reproduced, or translated to another language without the prior written consent of Clinivate. Clinivate, LLC 99 S. Lake Ave., #17 Pasadena, CA

3 Table of Contents Clinitrak User s Guide Table of Contents Table of Contents... i Introduction... 1 Preface... 1 Audience... 1 Customer Support... 1 Conventions Used in this Manual... 2 Collateral Information... 2 Getting Started... 3 Workstation Requirements... 3 Hardware Requirements... 3 Software Requirements... 3 Clintrak Access Privileges... 5 Setting EDI Access Privileges... 6 Preparing to Use EDI... 7 Applying for a Test Digital Certificate... 7 EDI Claims Processing... 8 Submitting Claims Ready for Billing... 8 Checking Notes Requiring Action for Billing... 9 Submitting Original Claims... 9 Submitting Voided Claims... 9 Submitting Replacement Claims Sending EDI Batches to DMH Receiving EDI Responses from DMH EDI Claims Status Tracking the Status of Claims Checking Claims Submitted to DMH Checking Approved Claims Checking Denied Claims Checking Voided Claims Reconciling EDI Claims Guidelines for Submitting Corrected EDI Claims i

4 Introduction Chapter 1 Introduction Preface Clinitrak is designed to work in conjunction with your existing systems, networks, security packages, databases, and user interfaces. Audience This manual is intended for administrators who are responsible for EDI billing with L.A. County Department of Mental Health (LACDMH). Readers are expected to be familiar with basic LACDMH billing procedures, and should be capable of performing routine computer data entry tasks. Customer Support Clinivate customer support can be reached by completing a support request form on the Contacts or Support page of our Web site at The most up-to-date customer service information is posted on the Clinivate Web site. 1

5 Introduction Conventions Used in this Manual The following list shows typographic and usage conventions of this manual: Bold Bold text represents menu items, interface buttons, field and dialog names, except when they appear in window examples or the contents of files. Purple underline Purple underlined text indicates a hypertext link to a topic within the manual or a Web site. M o n o s p a c e M o n o s p a c e text represents context specific values including Windows path names. Collateral Information Visit the Clinivate web site at for the latest information about Clinitrak. 2

6 Getting Started Chapter 2 Getting Started Workstation Requirements To use Clinitrak on your desktop, your workstation must meet at least the following minimum system requirements: Hardware Requirements Intel Pentium processor at 512MHz or faster Minimum 512MB physical memory; 1GB recommended 20 GB of free disk space Internet download access speed of 768Kbps or greater Monitor screen setting set for resolution of 1024x768. USB 2.0 port available Software Requirements Windows XP or greater Internet Explorer Version 7.0 or greater Pop-ups from the CLINITRAK web site enabled. JavaScript enabled Minimum 128-bit SSL encryption strength AntiVirus and anti-spyware software recommended Adobe Reader V7.0.5 or greater 3

7 Getting Started Clinitrak Main Menu 4

8 Getting Started Clintrak Access Privileges Clinitrak is designed with seven (7) levels of Access Privilege. The most restrictive level allows the user to view (but not edit) any screens, while the top level of access allows the user depending on his/her clinical qualifications to edit data in most screens. The seven levels are 1. QA Access 2. Clerical 3. Provider 4. Supervisor 5. Clinical Administrator 6. HR Administrator 7. Database Administrator In addition to the 7 levels, individual users can be assigned specific access with regard to their ability to execute specified billing functions and their ability to countersign specific types of progress notes. Regardless of a user s Access Privilege level, Progress Notes that have been countersigned cannot be changed or removed from the system. The default for all staff is as follows: EDI Access is DISABLED. Countersignatures are REQUIRED from first day of the Clinitrak License Agreement and Countersignatures are required for ALL NOTES. 5

9 Getting Started Agencies thus receive Clinitrak with the most restrictive settings enforced. Agencies must take responsibility for changing defaults for individual staff to less restrictive levels. A user must have Database Administrator (Level 7) privileges to set any Access Privileges. Setting EDI Access Privileges 1. Click on CLINICIAN/STAFF in the MAIN MENU. 2. Select an existing Clinician/Staff person by (Last) Name. 3. Select the proper EDI Access. 4. Click on Save Changes and return to the MAIN MENU. 6

10 Preparing to Use EDI Chapter 3 Preparing to Use EDI Clinitrak allows users to submit electronic billing claims to the Los Angeles County Department of Mental Health (LACDMH) using Electronic Data Interface (EDI). Before going into Production with EDI, an agency must ensure that all information is present within Clinitrak to produce a valid electronic claim. LACDMH requires each agency to pass a testing certification process to ensure that correct electronic claims are submitted before going into Production. Because Clinitrak has been previously certified, this testing process should take about one month. Once LACDMH-required testing has been completed, an EDI Production Digital Certificate will be issued to the agency and electronic claims can be submitted for billing. Once an agency goes into Production using EDI, LACDMH will no longer allow manual claims to be entered into the IS 2.0 System. Applying for a Test Digital Certificate To obtain a Test Digital Certificate for EDI, an Agency must fill out the DMH Trading Partner Agreement forms. These forms can be found on the LACDMH web site. 7

11 EDI Claims Processing Chapter 4 EDI Claims Processing Clinitrak allows users to submit electronic billing claims to the Los Angeles County Department of Mental Health (LACDMH). Once LACDMH-required testing has been completed, designated agency personnel can upload service billing data electronically by means of an electronic data interface ( EDI ). Submitting Claims Ready for Billing 1. From the MAIN MENU click on CLAIMS PROCESSING. Note that access to the EDI Billing module is controlled by the user s Access Privileges and the link to EDI is de-activated until a digital certificate has been issued by LACDMH. 2. Select EDI Billing. 3. Select the Reporting Unit, Provider, and Client. 4. Select the service date range for the claims to be submitted. Check All Dates to search the entire set of notes ready for billing. Note that the default is to display billing ready notes that with service dates in the previous 30 days. 5. Select the Billing Status as Billing Ready. 6. Click on Update View. This will display all notes ready for billing based on the filters selected. 7. Click on the check-box at the far right of the screen to confirm that the user wishes to submit a particular claim. Clicking the x at the top of the column will automatically prepare all claims ready for billing. 8. Click on the Submit as Original Claims button. 8

12 EDI Claims Processing Checking Notes Requiring Action for Billing 1. From the MAIN MENU click on CLAIMS PROCESSING. Note that access to the EDI Billing module is controlled by the user s Access Privileges and the link to EDI is de-activated until a digital certificate has been issued by LACDMH. 2. Select EDI Billing. 3. Select the Reporting Unit, Provider, and Client. 4. Select the service date range for the claims to be submitted. Check All Dates to search the entire set of notes ready for billing. Note that the default is to display billing ready notes that with service dates in the previous 30 days. 5. Select the Billing Status as Validation Pending. 6. Click on Update View. This will display all notes that cannot be billed because they require some corrective action. Submitting Original Claims LACDMH has specific rules on submitting corrected claims. To understand the business rules for submitting corrected EDI claims, review the Guidelines for Submitting Corrected EDI Claims document in Appendix A. 1. From the MAIN MENU click on CLAIMS PROCESSING. Note that access to the EDI Billing module is controlled by the user s Access Privileges and the link to EDI is de-activated until a digital certificate has been issued by LACDMH. 2. Select EDI Billing. 3. Select the Reporting Unit, Provider, and Client. 4. Select the service date range for the claims to be submitted. Check All Dates to search the entire set of notes ready for billing. Note that the default is to display billing ready notes that with service dates in the previous 30 days. 5. Select the Billing Status as Denied or Voided. 6. Click on Update View. This will display all notes ready for billing based on the filters selected. 7. Click on the check-box at the far right of the screen to confirm that the user wishes to submit a particular claim. Clicking the x at the top of the column will automatically prepare all claims to be sent as Original claims. 8. Click on the Submit as Original Claims button. Submitting Voided Claims LACDMH has specific rules on submitting corrected claims. To understand the business rules for submitting corrected EDI claims, 9

13 EDI Claims Processing review the Guidelines for Submitting Corrected EDI Claims document in Appendix A. 1. From the MAIN MENU click on CLAIMS PROCESSING. Note that access to the EDI Billing module is controlled by the user s Access Privileges and the link to EDI is de-activated until a digital certificate has been issued by LACDMH); 2. Select EDI Billing. 3. Select the Reporting Unit, Provider, and Client. 4. Select the service date range for the claims to be submitted. Check All Dates to search the entire set of notes ready for billing. Note that the default is to display billing ready notes that with service dates in the previous 30 days. 5. Select the Billing Status as Submitted / Pending, Denied or Approved. 6. Click on Update View. This will display all notes ready for billing based on the filters selected. 7. Click on the check-box at the far right of the screen to confirm that the user wishes to submit a particular claim. Clicking the x at the top of the column will automatically prepare all claims to be sent as Voided claims. 8. Click on the Submit as Voided Claims button. Submitting Replacement Claims LACDMH has specific rules on submitting corrected claims. To understand the business rules for submitting corrected EDI claims, review the Guidelines for Submitting Corrected EDI Claims document in Appendix A. Note: Rather than submitting replacement claims, LACDMH is currently recommending that you Void the claim first, then resubmit as an Original claim. 1. From the MAIN MENU click on CLAIMS PROCESSING. Note that access to the EDI Billing module is controlled by the user s Access Privileges and the link to EDI is de-activated until a digital certificate has been issued by LACDMH); 2. Select EDI Billing. 3. Select the Reporting Unit, Provider, and Client. 4. Select the service date range for the claims to be submitted. Check All Dates to search the entire set of notes ready for billing. Note that the default is to display billing ready notes that with service dates in the previous 30 days. 5. Select the Billing Status as Denied or Voided. 6. Click on Update View. This will display all notes ready for billing based on the filters selected. 7. Click on the check-box at the far right of the screen to confirm that the user wishes to submit a particular claim. Clicking the x 10

14 EDI Claims Processing at the top of the column will automatically prepare all claims to be sent as Replacement claims. 8. Click on the Submit as Replacement Claims button. 11

15 Sending EDI Batches to DMH Chapter 5 Sending EDI Batches to DMH To send EDI claims to DMH, the 837P batch must be downloaded from Clinitrak to your local desktop, then sent from your desktop to DMH. Here s how to do that. Note: Whenever you create batches (clicking on the Submit as Original Claims, Submit as Replacement Claims or Submit as Voided Claims buttons) in the Clinitrak EDI Billing, a file is created with the following name agency_yyyymmdd_nnnnnnnnn.txt where yyyymmdd is the date when the batch was created and nnnnnnnnn is the internal batch number. You will need to send all files for the day they were created. Establishing a Secure Connection with the Clinitrak Servers Clinitrak uses the Sonicwall Global VPN Client to establish a secure connection with the Clinitrak servers. Before transferring any files between your desktop computer and the Clinitrak servers, you must make sure this connection is active. The following procedure will active the Sonicwall secure connection: 1. Start the SonicWALL Global VPN Client from your Programs list. 12

16 Sending EDI Batches to DMH 2. Double click on the entry labeled Clinitrak. 3. Enter the Username and Password given to you by Clinivate. 4. Wait for the status to change to Connected. 13

17 Sending EDI Batches to DMH Sending the EDI Batch to DMH 1. Using Secure Transport (icon located in your startup tray in the bottom right-hand corner of your screen), connect using the entry Clinitrak to your desktop for Sending Claims to DMH. 2. Select the batch or batches you want to send to DMH. 3. Click on the Download arrow. 4. Click on the Now button when the Schedule dialog box pops up. The files should be transferred to your C:\Clinitrak_EDI\DMH\Agency\to folder. 5. Close the Secure Transport application. 6. Using Secure Transport (icon located in your startup tray in the bottom right-hand corner of your screen), connect from Your desktop to DMH for Sending Claims to DMH. 7. Select all of the files you just placed in your C:\Clinitrak_EDI\DMH\Agency\to folder. 8. Click on the Upload arrow. 9. Click on the Now button when the Schedule dialog box pops up. The files should be transferred to from your C:\Clinitrak_EDI\DMH\Agency\to folder to the DMH site. 10. Go to the DMH site ( and check to make sure all files have been transferred. 11. If all files have been transferred, go to your C:\Clinitrak_EDI\DMH\Agency\to folder and move all of the files you just sent to the C:\Clinitrak_EDI\DMH\Agency\to\sent folder. This is a general housekeeping step so that you don t resend batches. 12. Send an to is_edi_prod@sierrasystems.com and CC: support@clinivate.com with the following information about all batches that were uploaded: Organization : Allen s Mental Health Center Submitter Info : LPCP Date : File name : (batch file name TXN Type : 837P # Trans : Total $: 14

18 Receiving EDI Responses from DMH Chapter 6 Receiving EDI Responses from DMH To receive EDI responses from DMH, the 277, 835 and 997 files must be downloaded from DMH to your local desktop, then sent from your desktop to Clinitrak. Notes: 1. There should be one 997 file for every batch that is submitted to DMH. A 997 file is an acknowledgement that a previously submitted 837P batch file was received. The 997 file also contains information about whether the 837P transaction file was successfully processed by DMH (See Troubleshooting 997 files below.) Typically, a 997 file is generated about hours after the 837P is submitted to DMH. 2. There should be one 277 file for every EDI batch that is successfully received by DMH. Typically, a 277 file is generated about hours after the 837P is submitted to DMH. 3. There should be an 835 file for batches of EDI claims that are successfully processed by DMH or the State. An 835 file will describe whether the 837P EDI claim was Approved (including payment amount) or Denied. Typically, an 835 file takes about weeks to arrive in your DMH Response folder. 4. The state of the EDI claim will dictate what process should be used to resubmit the claim, void the claim or replace the claim. Contact Clinivate Support for details. 15

19 Receiving EDI Responses from DMH When the 277, 835 and 997 responses get created by DMH, they will arrive in your Response folder on the site. You will need to check this site daily to identify and process the EDI responses. The folders on this site will be labeled by date (yyyy-mmdd). After identifying new responses in these folders, you will need to upload them to Clinitrak. Here s how. 1. Ensure that you have established a secure connection between your desktop and the Clinitrak servers. See Establishing a Secure Connection with the Clinitrak Servers, on page Using Secure Transport (icon located in your startup tray in the bottom right-hand corner of your screen), connect from DMH to your desktop for Receiving Responses from DMH. 3. Double click on the Response folder, then go to the subfolder labeled yyyy-mm-dd that you want to check for new batches. 4. Select the 277, 835 and/or 997 files you want to send to Clinitrak. 5. Click on the Download arrow. 6. Click on the Now button when the Schedule dialog box pops up. The files should be transferred to your C:\Clinitrak_EDI\DMH\Agency\from folder. 7. Close the Secure Transport application. 8. Using Secure Transport (icon located in your startup tray in the bottom right-hand corner of your screen), connect from Your desktop to Clinitrak for Receiving Responses from DMH. 9. Select all of the files you just placed in your C:\Clinitrak_EDI\DMH\Agency\from folder. 10. Click on the Upload arrow. 11. Click on the Now button when the Schedule dialog box pops up. The files should be transferred to from your C:\Clinitrak_EDI\DMH\Agency\from folder to the Clinitrak from folder. 12. If all files have been transferred successfully, go to your C:\Clinitrak_EDI\DMH\Agency\from folder and move all of the files you just sent to the C:\Clinitrak_EDI\DMH\Agency\from\processed folder. This is a general housekeeping step so that you don t re-process responses. 16

20 EDI Claims Status Chapter 7 EDI Claims Status Tracking the Status of Claims Clinitrak distinguishes among a series of claim states. The Clinitrak claim states and their descriptions are as follows: Claim Status Billing Ready Validation Pending Clinitrak Pending Submitted / Pending Denied Approved Voided All Claims Description Approved notes that are ready for billing. Notes that cannot be billed because billing information for the claims is either missing or incorrect. Claims that have been submitted to DMH, but DMH has not acknowledged receipt of the claim. DMH has not created a 997 Functional Acknowlegement or Clinitrak has not received a 997 transaction. Claims that DMH has received. A claim will be in this state until either DMH or Medi-Cal approves or denies the claim. Claims that DMH or Medi-Cal denied. Clinitrak has received an 835 transaction from DMH. Claims that DMH or Medi-Cal approved. Clinitrak has received an 835 transaction from DMH. Claims that DMH has acknowledged as voided by Clinitrak. All claims in Clinitrak. Checking Claims Submitted to DMH There are two possible claim states where a claim has been submitted to DMH, but the claim has not been approved nor denied. These claim 17

21 EDI Claims Status states are either Clinitrak Pending or Submitted / Pending. To check if a claim is in either one of these states, do the following: 1. From the MAIN MENU click on CLAIMS PROCESSING. Note that access to the EDI Billing module is controlled by the user s Access Privileges and the link to EDI is de-activated until a digital certificate has been issued by LACDMH. 2. Select EDI Billing. 3. Select the Reporting Unit, Provider, and Client. 4. Select the service date range for the claims to be submitted. Check All Dates to search the entire set of notes ready for billing. Note that the default is to display billing ready notes that with service dates in the previous 30 days. 5. Select the Billing Status as either Clinitrak Pending or Submitted / Pending. 6. Click on Update View. This will display all notes that have been submitted to DMH. Checking Approved Claims 1. From the MAIN MENU click on CLAIMS PROCESSING. Note that access to the EDI Billing module is controlled by the user s Access Privileges and the link to EDI is de-activated until a digital certificate has been issued by LACDMH. 2. Select EDI Billing. 3. Select the Reporting Unit, Provider, and Client. 4. Select the service date range for the claims to be submitted. Check All Dates to search the entire set of notes ready for billing. Note that the default is to display billing ready notes that with service dates in the previous 30 days. 5. Select the Billing Status as Approved. 6. Click on Update View. This will display all notes that have been approved by either DMH or Medi-Cal. Checking Denied Claims 1. From the MAIN MENU click on CLAIMS PROCESSING. Note that access to the EDI Billing module is controlled by the user s Access Privileges and the link to EDI is de-activated until a digital certificate has been issued by LACDMH. 2. Select EDI Billing. 3. Select the Reporting Unit, Provider, and Client. 4. Select the service date range for the claims to be submitted. Check All Dates to search the entire set of notes ready for billing. Note that the default is to display billing ready notes that with service dates in the previous 30 days. 18

22 EDI Claims Status 5. Select the Billing Status as Denied. 6. Click on Update View. This will display all notes that have been denied by either DMH or Medi-Cal. 7. Hover the cursor over the denial code listed in the Status column will give further insight into the reason why the claim was denied. Detailed information about the claim denial can be found in the LACDMH IS010, IS801 and SIFT data extracts. Checking Voided Claims 1. From the MAIN MENU click on CLAIMS PROCESSING. Note that access to the EDI Billing module is controlled by the user s Access Privileges and the link to EDI is de-activated until a digital certificate has been issued by LACDMH. 2. Select EDI Billing. 3. Select the Reporting Unit, Provider, and Client. 4. Select the service date range for the claims to be submitted. Check All Dates to search the entire set of notes ready for billing. Note that the default is to display billing ready notes that with service dates in the previous 30 days. 5. Select the Billing Status as Voided. 6. Click on Update View. This will display all notes that have been voided by either DMH or Medi-Cal. Reconciling EDI Claims Clinitrak claims that have been submitted using EDI can be reconciled using several methods. First, using the Clinitrak user interface, claims can be queried based on claims status. Second, the Clinitrak Claim ID can be used to query the LACDMH IS010, IS801 or the SIFT data. Using the LACDMH SIFT data, query the rpt_dmhclaims table for information about denials, voids and approvals. If a claim that has been submitted to DMH, but does not show up in any of the DMH reports, query the rpt_rulefailclaims table to see if the claim shows up there. If it does, there is a problem with the claim. Contact Clinivate Support to assess the problem. 19

23 Guidelines for Submitting Corrected EDI Claims Appendix A Guidelines for Submitting Corrected EDI Claims (draft: 11/1/2006) To be approved by the EDI User Group 1. If the original claim status is DENIED due to DMH RULES or CICS violations, what is the proper way to send in the corrected claim? Send in as an Original (new) claim with a unique submitter ClaimID. 2. If the original claim status is DENIED due to FIN ADJ at the state level, what is the proper way to send in a corrected claim? There are several possible scenarios depending upon how you wish to correct the claim. A. If you are not changing the local plan but wish to send a corrected claim back to the state, then simply send in a Replacement claim. B. If you are changing the local plan and sending the corrected claim back to the state, you must send in a Void AND a Replacement claim.* (Voiding a denied claim will only be possible when the I.S. 2.0 is implemented.) C. If you are not changing the local plan and are not planning to send a corrected claim to the state (e.g., the client is no longer Medi-Cal eligible), you may choose to do nothing. The County may pay the provider from the local plan indicated on the original claim. (However, when I.S. 2.0 is implemented, it might be best practice to send a Void for the original claim and send in a Replacement claim. 20

24 Guidelines for Submitting Corrected EDI Claims This may be less confusing in reconciling your claims since you will not have to deal with getting paid on a denied claim.) Please also see Note 1 below for further details. 3. If the original claim status is PENDING and we need to fix it for some reason, what type of claim(s) do we send? First send in a Void, then send in the corrected claim as Original (new). 4. If the original claim status is PENDING ADJUDICATION and we need to fix it for some reason, what type of claim(s) do we send? First send in a Void, then send in the corrected claim as Original (new). In IS 2.0, we will not see this status anymore. Auto adjudication will take place. 5. If the original claim status is FORWARDED and we need to fix it for some reason, what type of claim(s) do we send? What if the status in the EOB is S for suspended? First send in a Void, then send in the corrected claim as Original (new). If the status in the EOB is S (Suspended), then wait until it is denied by the State or work with the ECR. Please see Note 2 below for ECR details. 6. If the original claim status is APPROVED and we need to fix it for some reason, what type of claim(s) do we send? First send in a Void, then send in the corrected claim as Original (new). *EDI submitters must void the first claim if they want to send in a replacement claim with another local plan. If they do not void the first claim and send in a replacement claim with a different local plan, it would be considered as a duplicate and DMH would not be able to catch it. The same claim would be billed twice, hence would be paid twice from two different local plans and/or MC (if MC approves the replacement claim). If a claim is approved by the State, then it would be paid out of the MC allocation; DMH would apply the FMAP (Federal Medical Assistance Percentage) as applicable depending on the type of MC (EPSDT or not). Note 1: When the IS automatically denies a claim due to a Medi-Cal denial, this sets of a status of Denied in the IS and at this time the provider can 21

25 Guidelines for Submitting Corrected EDI Claims send in a replacement (claim frequency 7) claim. If the provider does not include Medi-Cal on the subsequent replacement claim the claim will not go to Medi-Cal. Here is the step by step detail of the process: Note 2: 1. Provider sends Claim to IS with Medi-Cal as a payer 2. Claim passes IS Rules and MHMIS edits 3. IS sends claim to Medi-Cal 4. Medi-Cal returns denied 835 to IS 5. IS automatically denies claim since Medi-Cal denies 6. IS sends denied 835 to provider 7. Provider can respond as in scenarios 2A, 2B, or 2C noted above. Note that the IS will only send the claim to Medi-Cal, if Medi-Cal is included in the replacement claim. The following is a repetition of a memo sent by: LOS ANGELES COUNTY DEPARTMENT OF MENTAL HEALTH / REVENUE MANAGEMENT DIVISION The Revenue Management Division (RMD) has been working with the State Department of Mental Health (SDMH) and the Chief Information Office Bureau in order to re-implement the Medi-Cal Error Correction Report (ECR). The ECR will allow for Medi-Cal claims to be corrected while they are still at the State. RMD was notified by SDMH that the Suspense file is ready to be re-implemented during the week of March 13, This means that RMD needs an ECR Liaison for every provider. Attached is an ECR Provider Information Sheet which should be completed by the Program Manager for each Directly Operated Program. If RMD does not receive an ECR Provider Information Sheet, the ECRs will be mailed out to the address listed in the Provider Directory. This may result in the ECR package being misdirected or even lost. Should this occur, there may be a possibility of lost revenue. If you have any questions or require further information, please do not hesitate to contact RMD at (213) or via at RevenueManagement@lacdmh.org. 22