User Manual CHAPTER 2. Claims Tab (for Part B Providers) Originated July 31, 2012 Revised June 3, Copyright, CGS Administrators, LLC.

Transcription

1 mycgs User Manual CHAPTER 2 Originated July 31, 2012 Revised June 3, Copyright, CGS Administrators, LLC.

2 Table of Contents 3 Accessing Detailed Claim Information 3 Viewing Detailed Claim Information 4 No Claims Data Appears 4 Submitting Part B Claims (eclaims) 5 Accessing the mycgs eclaim Form 5 Completing the mycgs eclaim Form 5 Billing Provider Information Section 5 Patient Information Section 6 Miscellaneous Claim Information Section 7 Diagnosis Information Section 7 Line Item Section 8 Attachments Section 10 Submitting Specialty Claims 11 Completing Primary eclaim with Medicap/Crossover 14 Medicare Secondary Payer (MSP) eclaims 15 eclaim Submission Summary 19 Messages Tab 19 Rejected Claims 20 DISCLAIMER This educational resource was prepared to assist Medicare providers and is not intended to grant rights or impose obligations. CGS makes no representation, warranty, or guarantee that this compilation of Medicare information is error-free, and will bear no responsibility or liability for the results or consequences of the use of these materials. CGS encourages users to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. Although this material is not copyrighted, the Centers for Medicare & Medicaid Services (CMS) prohibit reproduction for profit making purposes. Page 2

3 The Claims tab allows users to check the status of a beneficiary s claim which has been submitted to CGS. Once you have signed into mycgs, select the Claims tab by clicking on it. Reminder: Provider Administrators have access to all tabs within mycgs. Provider Users only have access to those tabs granted by their Provider Administrator. If you are a Provider User and the Claims tab is grayed out, but you believe you need access to the, you should contact your Provider Administrator. The Claim Status Inquiry screen will appear. Accessing Claims Data To access claim status information, you must enter the beneficiary s HIC (Health Insurance Claim) number, also known as Medicare number. You must also enter a date range in a MM/DD/CCYY format. The date range will default to 45 days from the beginning date. You can choose a shorter date range, but you cannot choose a date range of more than 45 days. Retrieving claims information older than 6 months may take additional time. In addition, offline claims will not be displayed. Many claims are offline after 3 years, sometimes earlier. If there are claims in the date range you entered, you will receive a list of claims found. Viewing Detailed Claim Information Each claim line will have a link to the claims details. By clicking on the Claim # link, you can view the Detailed Claims Status Information screen. Page 3

4 The Detailed Claims Status Information screen provides detailed information for each claim line, including: Revenue codes HCPCS codes Service date Total charge Allowed amount Non-covered charges Once you have reviewed the detailed claim information, you can either click Back to return to the claim list, or click New Inquiry to submit a new claim status inquiry. No Claims Data Appears If no claims are displayed for the date period you have chosen, you may want to choose a different date range or double-check your records to make sure you have entered the correct HIC number. Claims that are paid, in process, returned, or denied are displayed. Information is retrieved from CMS standard systems and is as current as the standard systems. Claims that are offline or returned without processing will not appear. Page 4

5 Submitting Part B Claims (eclaims) Part B users can access the electronic claim submission (eclaim) option within mycgs. In addition, users may submit additional supporting documentation, monitor the status of the submission and make corrections to eclaims failing our front-end edits. Before you begin, gather the same information you would need prior to submitting a claim through PC-ACE Pro32, a commercially-available billing software or a paper CMS-1500 claim form. You will enter detailed information that corresponds with CMS s claim submission requirements. Accessing the mycgs eclaim Form The eclaims form is available under the Claim Submission sub-tab located under the Claims tab. If the Claim Submission sub-tab is not displaying, the user may not have been granted access to this feature by the office Provider Administrator. Completing the mycgs eclaim Form Identify whether Medicare is the primary or secondary payer for the claim being submitted. Also identify if the patient is signed up for Medigap or crossover. NOTE: If you select an option in error and need to change it, simply click the Claim Submission sub-tab again or the Clear button located at the bottom of the form and start over. Billing Provider Information Section You must complete the following fields to submit your eclaim: Organization or Solo Practice option: Entities such as Ambulance suppliers need to select Solo Practice and enter the Organization Name Provider Organization Name Provider Last Name/First Name: This section will display only when Solo Practice is selected but only required by solo practice physicians/practitioners Provider Contact Name and Phone Number: Required should we need to speak with someone regarding the eclaim, i.e., office manager Complete Address: Street address and ZIP code + 4 are required. No PO Boxes are accepted Federal Tax ID Type and Number Page 5

6 Provider Signature Indicator Accept Assignment Patient Information Section You must complete the following fields: Patient Medicare Number Patient Account Number Patient Last Name/First Name Patient Date of Birth Patient Sex Patient s Complete Address: Including ZIP+4 Patient Signature Indicator: If you have patient authorization to submit the claim to CGS, select the P indicator in the dropdown box Release of Information Benefits Assignment Certification Page 6

7 Miscellaneous Claim Information Section This section is not required but may apply in certain situations. If you have a referring provider to report; CLIA number for clinical lab services; facility information; homebound indicators; the date care was assumed/relinquished for split post-op care; if you enter this information when submitting claims by other means, you will need to enter the information on an eclaim. Diagnosis Information Section Enter at least ONE diagnosis code. List the primary diagnosis in the Diagnosis A field. Up to 12 diagnoses may be entered on the form. Page 7

8 Line Item Section This section is where you enter the line item details. Date of Service CPT/HCPCS Code Place of Service Description (if needed) Diagnosis Pointer (at least one) Days or Units Charge Rendering Provider: Complete this area when Organization is selected at the top of the form Enter line items one at a time. After entering all applicable information, click the Add Line Information button. Page 8

9 After entering all line item information for the claim, verify the information entered is correct. Use the sliding scroll bar to view the line item details. If you find charges are needed, select the Edit link and the section will re-populate with the line item details to allow you to make the necessary changes. If you want to delete the line item altogether, simply select the Delete link. When you are finished with editing, select the Save Line Information button. Page 9

10 Attachments Section Additional required fields are located at the bottom of the form. Submitter Name: Enter the name of the person authorized to submit the eclaim on behalf of the provider. This will serve as an electronic signature. Total Charges: This field is auto-populated based on the line item charges entered above. If you are submitting a service you know requires additional documentation such as an operative or radiology report, you can attach it to the eclaim. An eclaim can include up to 5 documents. Each being up to 5MB in size and in a PDF format. If you maintain paper records, you can scan the document you want to attach to the eclaim and save it as a PDF. Click Submit to file the eclaim. Page 10

11 Submitting Specialty Claims mycgs eclaims are available for various types of services rendered by various specialties. Ambulance suppliers will find the eclaim will populate with details required with an ambulance claim, such as point of pick-up fields and an area to enter condition codes. The eclaim will display these fields when the ambulance place of service code is selected. Page 11

12 Chiropractors will have access to different fields when one of the chiropractic CPT codes are entered on the form. Fields for x-ray date and for you to identify whether the patient s condition is acute or chronic will be available to you. For providers submitting claims for Erythropoietin for the treatment of anemia for patients with chronic renal failure who are on dialysis, entering the HCPCS code will display a field to note the patient s hematocrit or hemoglobin levels. Page 12

13 Submitting Mammography services will display a field for the certification number. Submitting a Not Otherwise Classified (NOC) drug code will display a field to enter the NDC number. Other NOC codes will require the Description field to be completed. Podiatry services submitted will allow users to enter the date the patient was last seen by their MD, DO or qualified non-physician practitioner who diagnosed the condition. Page 13

14 A Date Last Seen field will display when physical therapy services are submitted. The mycgs eclaim will accept the non-payable quality measures associated with the Physician Quality Reporting System, or PQRS, as well. Completing Primary eclaim with Medigap/Crossover eclaims may be submitted if the patient has a medigap or crossover insurer. Selecting the Medigap/Crossover option will display additional fields to be completed. A Patient Relationship to Insured field and Insured Information section located further down must be completed. Page 14

15 Medicare Secondary Payer (MSP) eclaims eclaims may also be submitted when Medicare is the secondary payer. When Secondary is selected, the form will display a Patient Relationship to Insured field and Insured Information section located further down. Under Miscellaneous Claim Information, additional fields will display. Page 15

16 Under Line Items, additional fields will display. Identify line items individually. MSP claims will display a field to enter the Primary Insurance Paid Amount and the Adjudication Date or Payment Date. Reason/remark codes from the primary insurance explanation of benefits (EOB) are required in the Line Adjustments section. (Coincides with the CAS Segment of an electronic claim.) The Group Codes available are: CO (Contractual Obligation) OA (Other Adjustment) PR (Patient Responsibility) Page 16

17 Click Add Line Adjustments after entering each line item. Select Edit to make changes or Delete to remove line items. The Secondary Line Items section is to be completed identifying the services being submitted to CGS as secondary payer. Once all line item details are entered, click the Add Line Information button. Do this for each line item. Page 17

18 Enter the Primary Paid Amount in the appropriate field. The primary insurance EOB is NOT required. Include any attachments needed to support allowing the service(s) submitted. Click Submit to file the MSP eclaim. Page 18

19 eclaim Submission Summary After submitting the eclaim, the Claim Submission Summary page will display. It is confirmation the eclaim was received. The summary page includes a CGS Transaction ID and other details from the claim. Messages Tab After submitting the eclaim, you will receive a secure message confirming it was sent. Within 24-48hrs (excluding weekends and holidays), a second secure message will be sent confirming eclaim was accepted or rejected. If accepted, a Submission ID (ICN or DCN) will be assigned to the eclaim. Page 19

20 The Submission ID can be used to check the status of the eclaim. Check the remittance advice for approval or denial information. Rejected Claims Electronic claims must pass Front End Edits prior to entering our processing system. These edits verify all required information is on the claim. Claims submitted through mycgs are subject to the same editing process. Claims failing these edits are rejected and an ICN/ DCN is not assigned. Check the Rejected Claims sub-tab. Click on Edit to make corrections to the claim. The details of the rejected claim will display identifying Error Data at the top of the form. Fields that failed an edit will be displayed. Page 20

21 Scroll down and make the necessary corrections to identified fields of the eclaim. After making ALL corrections, click Submit to resend the eclaim to CGS. NOTE: Documentation attached to the original claim MUST be re-attached after making corrections to rejected claims. Also, making corrections to rejected claims is limited to those submitted through mycgs. Page 21