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PB RPB102 PB Billing
Resolute Professional Billing Fundamentals for SBO
| Term | Definition |
|---|---|
| EPT | Patient (e.g., demographics, contact information, PCP, Medical information, employment, etc.) |
| EAR | Guarantor. Person that is financially responsible for the self-pay portion. |
| HAR | Hospital Account Record. Hub for a visit that allows a user to see information stored elsewhere. HAR allows the user to see the guarantor and guarantor info w/outt having to look up the guarantor separately. Guarantor's info is not stored in the HAR. |
| CVG | Coverage (Payor, Subscriber). Contains information about a patient's insurance benefits. |
| PB HAR | Holds PB charges from a visit. Lives on the Guarantor Account. Created automatically when an encounter gets a professional billing filing order. User never creates a PB HAR |
| HB HAR | Holds HB charges from a visit.Technical charges for hospital visit. HB HARs are created manually. |
| HB HAR Statuses | Open (available to collect charges) DNB (Discharged Not Billed--Holding Status) Billed (Trying to get $ from someone--patient or insurance) Closed (No longer actively trying to collect) |
| PB HAR Statuses | Closed (Not trying to get money) Billed (Trying to collect money--insurance or self-pay)--Liability is assigned Closed |
| What status does the appointment change to once it has been checked in? | Arrived |
| What is the purpose of counting the number of bills and recording the checks and their amounts? | To reconcile the physical $ collected with the money posted in the system. |
| Clicking which button automatically matches the money you recorded from your cash drawer with the money posted in the system? | Select All |
| What is the purpose of the cash drawer in the system? | To reconcile the physical $ you collected with the $ that you posted in the system |
| What must you do when the cash drawer is out of balance? | First, try to balance the cash drawer by re-counting and re-entering the contents of your physical $. If it still does not balance, contact a supervisor and enter a reason why the drawer is not balanced. |
| Reasons why customers need to manually enter charges. | - Clinicians are not placing orders - Services at outside place of service - Interim clinical staff continue to hand in charge tickets. - Coding from provider documentation |
| Why are there multiple charge entry modules? | - Different features for different work flows - Different organizational needs when entering charges. |
| List 3 Charge Entry Modules | - Charge Router Charge Entry - Professional Billing Charge Entry - Anesthesia Charge Entry |
| Name 2 different options for Preparing Charge Tickets | - Procedure counter (# of procedures to be entered) - Procedure Hash (Numerical sum of all of the procedure codes to be entered)--more detailed. When there are alphanumeric codes, end users and the system will replace the letters with numbers. |
| Charge Entry Batch | Creates a holding tank in the system into which all charge tickets are entered. Holding tank is called a batch (contains charge sessions). |
| Each charge entry batch contains only one charge entry session. True or False. | False. Each charge entry batch can contain an unlimited number of charge entry sessions. |
| Each charge entry batch only contains information for one patient's charges. True or False | False. The batch can contain charges for an unlimited number of different patients. |
| One charge ticket is the equivalent of one charge entry session. True or False | True |
| What is the purpose of processing your batch in manual charge entry? | Processing the batch posts the charges and make them available for billing. |
| Charge Router Review workqueues catch (major/minor) charge errors? | Major |
| Charges go through Charge Router Review workqueues after they enter the billing system. True or False. | False. They go through Charge Router Review before they enter the billing systems. |
| Charges can only be entered through manual Charge Entry. True or False. | False. |
| The Charge Router (identify ALL that apply) A. Checks charge sessions for errors. B. Routes charges from clinical applications to billing applications. C. Contains work queues to hold problem charge sessions. D. Allows for manual entry of charges | A, B, C, and D (all) |
| What do Charge Review Workqueues Do? | Review PB charges for errors. |
| When do Charge Review Workqueues take place? | While charges are still considered temporary. |
| If a charge session qualifies for multiple workqueues, how do you know what to fix in order to remove the charge session from your workqueue? | Look at the system comments section. Fix issues associated with your own workqueue. |
| If a charge session is from a clinical source, do changes in the charge session update the clinical chart? | No |
| If you want the chart and account to match, who needs to update the charge? | The clinician (in the clinical encounter). |
| What does defer do when you are working on reviewing and correcting charge errors? | Moves session to the deferred tab. It comes back to the active tab when the time expires. |
| You can add new procedures when you access a charge session from charge review. True or False. | True |
| List the 3 steps to resolving duplicate charges | 1) Confirm (double-check) session is a duplicate 2) Transfer session to a supervisor 3) Supervisor deletes session. |
| Why can't this user perform the function of Delete on a charge session? | Security controlled (access)--configurable. |
| What does the Transfer function do to the charge session? | Removes session from this workqueue and sends it to a designated workqueue. |
| Which buttons in the reviewing and correcting charge errors workflow are security controlled? | Delete and Force Resubmit |
| When deleting a session in a charge review workqueue, the charge session is removed from our workqueue, but can still be worked on by others. True or False. | False (it is gone) |
| What is the difference between a warning and error for reviewing and correcting charge errors? | Warning: Soft stop that you can ignore Error: Hard stop that you have to fix. |
| What does the Transfer button in a charge review workqueue do? | It moves the charges session from the current workqueue to a designated workqueue. |
| When should you resubmit a charge session? | You should resubmit a charge session when you believe it has been corrected. |
| Where are the charges located that are ready and waiting to process for claims? | The claims queue |
| What tool in the system automates processes? | Batch scheduler. |
| Creating claims is mostly (manual/automatic) processes. | Automatic. |
| What is the purpose of a claim edit workqueue? | To view and correct claims with errors before sending to payors (payor specific checks). |
| Claim Edit workqueues: What are user errors and what are Master file errors and who fixes them? | Users Errors can be fixed by an end user in Hyperspace. Master File errors must be corrected in the build by an application coordinator or IT person. |
| What does the Claim Edit Workqueue Companion do? | Gives you instructions about how to correct claim errors. |
| What do you do to get more detailed information about a claim edit error? | From the Claim Edit Workqueue Double-Click the claim (or click Edit) |
| Which button in the Companion lets you run the CDF edit checks on the claim in real-time? | Refresh |
| What Epic tool identifies claims with errors? | CDF (Claim Definition File) |
| What does the refresh button in the Companion do? | Tests claim errors against the CDF in real time. |
| Once the system creates a run of clean claims, what does an end user do to complete the process? | Accept the run (after verifying everything has printed successfully) |
| How do you reprint the paper claims if there was a problem? | Select the run and click "Print Forms". |
| What is the purpose of the Claim Run Report? | To verify claims printed successfully. |
| How do you record in the system that the claim run is no longer needed? | Accept the run. This will allow you do perform future follow-up. |
| It is possible to accept a port of a claim run. True or False. | True (e.g., accept paper or electronic). |
| What additional step is needed for electronic claims? | Confirm that the electronic claims have been received by the clearinghouse. |
| If there is a problem when the paper claims are printed automatically, there is no way to manually reprint them? True or False. | False, highlight the run and click Print Forms. |
| What is the purpose of the Claim Run Report? | To validate that all the paper claims are printed and all of the electronic claims are received by the clearinghouse before the claim run is accepted. |
| After accepting a claim run, it is easy to reprint the claims if needed. True or False. | False, once the run is accepted, it cannot be reprinted. |
| Where can you find the payor contact information for a claim in your workqueue? | Insurance Coverage section of the Assistant |
| Which activity do you perform when the payor did not receive the claim and you need to send them a new claim? | Resubmit claim. |
| Which activity do you perform when you want to summarize all of the actions taken while working on a claim? | Note |
| Which activity do you perform when you can't work the claim right now so it shouldn't be on your Active tab? | Defer |
| How do you prioritize your workqueue to work the claims with oldest service dates first? | Click the Svc Date column heading |
| Where can you view the past activities performed on claims? | Activity History in the Assistant; Follow-up Activities section in the workqueue information display. |
| What does Resubmit Claim do? | Resubmit Claim sends the entire claim back to the claims queue; the system will determine which charges need to go on the resubmitted claim based on the payors' needs. |
| What does Resubmit Selected do? | Resubmit Selected allows you t choose which charges from the claim will go back to the claims queue and be resubmitted to the payor. |
| What is the consequence of deferring a claim, and why might you defer a claim? | Defer moves the claim off your Active tab (work list) and sends it to the User Deferred tab. You would do this if you were prevented from working on a claim for a certain period of time. |
| Creating Records of Deposited Payments--happens automatically Cash Control Records and Group | Cash Control Records: One created per check that is deposited in bank and needs to be posted into Epic. Group: A list of Cash Control records. Cash Control Groups should be created using information from the bank, not information from the payor. |
| Payment posting batches can only be created from Cash Management if your organization is using Enterprise Payment Posting. | The batch will only be available for use through Enterprise Payment Posting. Enterprise Payment Posting can be used to post both PB and HB payments in the same batch. |
| Cash Posting. What button can be used to pull forward information such as the payor from one cash row to the next? | Set Defaults Button |
| Cash Management lets you track the amount of a deposit posted in the system. True or False. | True. |
| Multiple checks can be combined into one cash control group. True or False. | True (multiple checks and multiple payors). |
| Confirming a cash control group posts the payments into Epic. True or False. | False. Pymt posting batches are required to post the $ into Epic. Cash control grps are representations of a bank deposit. Matching a cash control grp to a pymt posting batch allows for the posting of the $ in Epic to reconcile to the bank.. |
| Account # on the CMS 1500 claim form = Invoice # in the system. True or False. | True |
| What type of Action does NRP stand for? | Next Responsible Party (moves the remaining balance t other next party in the visit's filing order. |
| What type of Action does NAA stand for? | Not Allowed Adjustment. Writes off the amount over the allowed amount. |
| New Detail Versus New Check. What is the difference? | New Detail: Same check, new invoice New Check: Post from another check |
| From where does the system pull in the allowed amount during Insurance Payment Posting? | Reimbursement Contracts |
| If the allowed amount in the EOB differs from what shows up on the Insurance Payment Posting form, should you change it? | Yes (go with what the EOB says not the system). |
| Which button allows you to tell the system which responses remain in fields when you move to another check? | Set Defaults Button |
| Correcting Posting Errors: If you forgot to post to one invoice. What do you do? | Click the check-level pencil and select ADD PB Detail |
| Correcting Posting Errors: If you posted to an invoice incorrectly. What do you do? | Click the detail-level pencil and select Edit Detail |
| Correcting Posting Errors: If you posted to an invoice more than once. What do you do? | Contact supervisor who clicks detail-level pencil and selects Delete Detail (Foundation System) |
| What is the purpose of creating a payment posting batch? | It is used as a holding tank for the payment information you enter in the system. |
| To track the amount of a bank deposit posted in the system, payment posting batches can be linked to? | Cash Control Groups |
| How do you look up an invoice # in PB Insurance Payment Posting when you can't read it or it doesn't appear on the EOB? | Use ".p" to look up by patient or ".a" to look up by guarantor account. |
| If a payor sends payment for an invoice or patient that does not exist in the system, what should you do? | If you can't find the invoice or the patient, post the payment undistributed to a clearing account. (If you can't find the invoice, but can find the patient in the system, consider posting by Patient and Service Date or Account and Service Date). |
| An allowed amount always automatically appears on the Insurance Payment Posting form. | False |
| What should you do when the system allowed amount is different from the allowed amount on the EOB? | Override the system amount by entering the amount from the EOB in the Allowed field. |
| What should you enter in the Post field when posting a PB denial? | Claim Denied. |
| What step in payment posting sends payments to guarantor accounts? | Processing the batch. |
| A batch must balance before you can process it. True or False. | True. |
| Name one ay you can identify where you made a posting error. | Run the Pending Payment Posting Batch report (click the Report button). |
| Which tool can you use to review the history and details of a cash control group? | The Cash Control Group report. |
Created by:
dlarson1978