eBill 101 Electronic Medical Bill Processing The

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eBill 101 Electronic Medical Bill Processing The Powered By Docstoc
					Texas Department of Insurance, Division of Workers’ Compensation
             2009 Educational Conference
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                      eBill 101
  Electronic Medical Bill Processing: The
                  Basics


                               Allen McDonald
                               Director, Information Management Services
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
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Labor Code §408.0251
  – Requires the Commissioner, by rule, to adopt rules
    regarding the electronic submission and processing of
    medical bills
  – Requires insurance carriers to accept medical bills
    submitted electronically by health care providers in
    accordance with the adopted rules
  – Requires rules to include criteria for granting
    exceptions to insurance carries and health care
    providers
  – Added by HB7 (2005)
 Texas Department of Insurance, Division of Workers’ Compensation
              2009 Educational Conference
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eBill Project – Rule and Guide
Development (2006)

  – Stakeholder Work Group Meetings
  – Rule Development
  – Companion Guide Development
  – IAIABC eBill Initiatives
Texas Department of Insurance, Division of Workers’ Compensation
             2009 Educational Conference
          
28 Texas Administrative Code §133.500:
• Adopts standard electronic formats for billing,
  acknowledgements, remittance advice,
  reporting and documentation
• Medical billing transactions must contain all
  fields required in the format implementation
  guide and associated Division
  implementation guides
• Permits non-prescribed formats by mutual
  agreement. All required data elements must
  be present
Texas Department of Insurance, Division of Workers’ Compensation
             2009 Educational Conference
          
28 Texas Administrative Code §133.501:
• Requires insurance carriers and health care
  providers to be able to exchange electronic data,
  unless they meet the waiver criteria
• Establishes the waiver criteria
• Defines complete electronic bill and complete
  electronic documentation
• Establishes certain processing actions:
     – Electronic bills must be acknowledged within one business
       day
     – Limits duplicate electronic bill submission when
       acknowledged by insurance carrier
     – Prescribes five-day timeframe for remittance/payment
       advice
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
eBill Project Goals
• Align with national standards & industry
  practices
• Leverage existing technology &
  relationships
• Minimize workers’ compensation specific
  requirements
• Provide flexibility to trading partners
• Reduce administrative costs
Texas Department of Insurance, Division of Workers’ Compensation
             2009 Educational Conference
          


Key Differences Between Workers’
    Compensation and Health
            Insurance

                             v.
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
• Eligibility ID Card              • No eligibility ID Card
• Policy limits,                   • No policy limits, no
  deductibles, and                   deductibles, no
  balanced billing                   balanced billing
• Generally,                       • Documentation key
  documentation not                  component of
  required with claim                indemnity
• HIPAA                              determinations

         Health                                  W/C
    Texas Department of Insurance, Division of Workers’ Compensation
                 2009 Educational Conference
              
Workers’ Compensation
Key Data Differences

•   Employer Name/Address
•   Patient SSN
•   Date of Injury
•   State License Numbers
•   Documentation
Texas Department of Insurance, Division of Workers’ Compensation
             2009 Educational Conference
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 Texas Workers’ Compensation
eBill Transactions and Processes
            Texas Department of Insurance, Division of Workers’ Compensation
                                   2009 Educational Conference
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Electronic Billing and Reimbursement Workflow




                                                                                                                 EOB
               Patient                                                   Ack
                                eBill
              Encounter                                               (997/824)
 Provider




                                                                                                              Paper Check


                 To Carrier
                                                                                                To Provider
                                  Acknowledgement
                              (File Level – 997 Format,
                               Bill Level – 824 Format)
                                                                      To Provider




                                                             Ack
                                                          (997/824)                                            To Provider
                                Validation
                   eBill
                                  Edits
 Carrier




                                                                                     Denial       EOB

                                                          Accepted    Bill Review/
                                                            eBill     Adjudication


                                                                                               Paper Check
                                                                                     Payment
    Texas Department of Insurance, Division of Workers’ Compensation
                 2009 Educational Conference
              
Billing Formats
                                              Patient
                                                             eBill
                                             Encounter


•   Professional ASC X12 837
•
                                                To Carrier

    Institutional ASC X12 837
•   Dental ASC X12 837
•   NCPDP 5.1
•   Mutually Agreed Formats                       eBill
   Texas Department of Insurance, Division of Workers’ Compensation
                   2009 Educational Conference
               
ASC X12 837P Data String Example:
 ST*837*3456~BHT*0019*00*244579*19981015*1023*CH~REF*87*004010X098A1~NM1*41*2*
 PREMIER BILLING SERVICE*****46*TGJ23~PER*IC*JERRY*TE*3055552222*EX*231~
 NM1*40*2*XYZ CLEARINGHOUSE*****46*66783JJT~HL*1**20*1~NM1*85*2*PREMIER
 BILLING SERVICE*****24*587654321~N3*234 SEAWAY ST~N4*MIAMI*FL*33111~
 REF*G2*PBS3334~HL*2*1*22*1~SBR*P**2222-SJ******CI~NM1*IL*2*ABC*PLUMBING****
 34*11223333~N3*1234 TEXAS BLVD~N4*TEXAS CITY*TX*77590~NM1*PR*2*KEY
 INSURANCE COMPANY*****PI*999996666~N3*3333 OCEAN ST~N4*SOUTH
 MIAMI*FL*33000~HL*3*2*23*0~PAT*20~NM1*QC*1*SMITH*TED****MI*123456789~N3*236 N
 MAIN_ST~N4*MIAMI*FL*33413~DMG*D8*19730501*M~REF*11*WC1234~CLM*26463774*100*
 **11::1*Y*A*N*1*EM*S~DTP*439*D8*19981001~PWK*OZ*FX*AC*J8123456~HI*BK:7242*BF:72
 45~NM1*82*1*KILDARE*BEN****24*999996666~PRV*PE*ZZ*203BF0100Y~REF*0B*MDA1234
 TX~NM1*77*2*KILDARE ASSOCIATES*****24*581234567~N3*2345 OCEAN
 BLVD~N4*MIAMI*FL*33111~LX*1~SV1*HC:99213*40*UN*1***1**N~DTP*472*D8*19981003~LX
 *2~SV1*HC:87072*15*UN*1***1**N~DTP*472*D8*19981003~LX*3~SV1*HC:99214*35*UN*1***2
 **N~DTP*472*D8*19981010~LX*4~SV1*HC:90703*10*UN*1***2**N~DTP*472*D8*19981010~S
 E*51*3456~
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
Acknowledgment Formats
                                                             Ack
                                                          (997/824)

• File Level
   – Functional ASC X12 997
• Bill Level                                              To Provider




   – Detail (or Application Advice)
                                                 Ack
                                              (997/824)


     ASC X12 824
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
                                                                  EOB




Remittance Format                                   To Provider




• Electronic EOB
  ASC X12 835
                                      Denial          EOB




                                     Payment
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
eBill Documentation

Electronic Format or Methods of Submission
• ASC X12 275 Documentation/Attachment
• Facsimile
• Electronic Mail

Documentation related to eBill
• Submit electronically
• Within 7 days of eBill
 Texas Department of Insurance, Division of Workers’ Compensation
              2009 Educational Conference
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28 Texas Administrative Code §133.210:
Medical Documentation
  – Two highest level E&M encounters
    (new/established patient)
  – Surgical services with MAR greater than $500
  – Return to Work rehab programs
  – Description of Procedure (DOP)/No MAR codes
  – Hospital itemized statement
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
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How are the electronic bill and the
documentation matched?

  – Through the data contained in the PWK
    Segment in the ANSI X12 837 transaction

  – Insurance carriers need to clearly identify
    which fax numbers or email addresses to use
    for documentation submission
 Texas Department of Insurance, Division of Workers’ Compensation
              2009 Educational Conference
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• PWK Paperwork Segment
  – Links documentation and eBill transaction
• PWK Segment Values
  – Report Type Code (what sent)
  – Report Transmission Code (how sent)
  – Attachment Control Qualifier (AC)
  – Attachment Control Number (document id)
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
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Electronic Documentation Must Include:
• Document identification number
• Injured employee
• Insurance carrier
• Health care provider
• Related medical bill(s)
• Date(s) of service
    Texas Department of Insurance, Division of Workers’ Compensation
                 2009 Educational Conference
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eBill Implementation

•   HIPAA Implementation Guides
•   Workers’ Compensation when specified
•   HIPAA/WC Gap Analysis
•   Jurisdiction Requirements
 Texas Department of Insurance, Division of Workers’ Compensation
              2009 Educational Conference
           


• Accredited Standards Committee X12
  – www.X12.org
• Texas Clean Claim and eBill Companion
  Guide (eBill Companion Guide)
  – http://www.tdi.state.tx.us/wc/ebill/index.html
    Texas Department of Insurance, Division of Workers’ Compensation
                 2009 Educational Conference
              
eBill Agents/Clearinghouses

•   eBill Rule allows for the use of agents
•   Rules do not require use of clearinghouse
•   Rules do not regulate cost
•   Agent-to-agent cooperation
Texas Department of Insurance, Division of Workers’ Compensation
             2009 Educational Conference
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                      Direct Data Entry




                        Clearinghouse

                     eBill Perception
Texas Department of Insurance, Division of Workers’ Compensation
             2009 Educational Conference
          




                      eBill Reality
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
eBill Waivers
• Small Provider Waiver
  – Ten or fewer employees, and
  – Less than 10% of practice is workers’ comp


• Unreasonable Financial Burden Waiver
  – Exception based on cost
  – Temporary waiver for delayed implementation
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
eBill Financial Burden Waivers
• Provide documentation of estimates and
  discussions with current eBill agents
  and/or clearinghouses
• Timeframe
  – Generally approved for 1 year
  – Another request with new documentation will
    be needed upon expiration
Texas Department of Insurance, Division of Workers’ Compensation
             2009 Educational Conference
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    Frequently Asked Questions


                                Health Care
                                 Providers
 Texas Department of Insurance, Division of Workers’ Compensation
              2009 Educational Conference
           
            How do I find
   clearinghouses that support
      workers’ compensation
           transactions?
• Call your current software vendor and
  clearinghouse
• Contact the insurance carrier eBill agents
  listed on our website at:
  – http://www.tdi.state.tx.us/wc/ebill/documents/
    ebcarriercontact.xls
          Texas Department of Insurance, Division of Workers’ Compensation
                                    2009 Educational Conference
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INSURANCE CARRIERS ELECTRONIC BILLING CONTACT INFORMATION

ORGANIZATION NAME            FEIN        TYPE                  CONTACT URL      eBill Agent Name        eBill Agent   eBill Agent Contact information
                                                                                                           FEIN

AAA Cooper Transportation    630364620   Cert Self-insured                      Ingenix Health          352170347     Andy.Tolsma@ingenix.com
                                                                                Intelligence Inc.
                                                                                                                      Tele: 801-982-3313

                                                                                                                      Fax: 801-982-4026

Abbott I.S.D.                746000001   Self-ins Gov Entity                    StrataCare Inc.         330894977     sosterberg@stratacare.com

                                                                                                                      949-743-1275

                                                                                                                      949-743-1299

Abilene I.S.D.               756000004   Self-ins Gov Entity                    CompIQ Corp.            330803325     eBilling@CompIQ.com

                                                                                                                      Tele: 949-923-4048

                                                                                                                      Fax: 505-856-1568

ACIG Insurance Co            751940467   Comm Carrier                           CorVel Corp.            953382819     Clearinghouse_TX@corvel.com

                                                                                                                      Tele: 1-866-353-9768

                                                                                                                      Fax: 866-915-0663

Adrian I.S.D.                751095345   Self-ins Gov Entity   http://www.tas   Jopari Solutions Inc.   200787505     provider_customersupport@jopari.com
                                                               brmf.org/wc/c
                                                               ontacts.aspx                                           Tele: 925-459-5200

                                                                                                                      Fax: 925-459-5222

America First Insurance Co   580953149   Comm Carrier                           P2P Link                270008097     acctmgmt@p2plink.com

                                                                                                                      Tele: 866-450-3898

                                                                                                                      Fax: 972-417-7711
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
    What is the Payer ID for
       XYZ Insurance
          Company?
• Payer IDs are assigned by clearinghouses, not
  by TDI-DWC
• Contact your clearinghouse for their list of
  payer IDs
• Contact the insurance carrier eBill agents listed
  on our website at:
  – http://www.tdi.state.tx.us/wc/ebill/documents/ebcarri
    ercontact.xls
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
     Do I have to include the
   state license number on the
                 bill?
• For certain fields, the state license
  number is required for paper and
  electronic w/c medical bills
• See the Clean Claim and eBill
  Companion Guide at:
  – http://www.tdi.state.tx.us/wc/ebill/index.html
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
   Do I have to include the w/c
   carrier claim number on the
                bill?
• The workers’ compensation claim number
  assigned by the carrier is required only if the
  health care provider knows the number
• See the Clean Claim and eBill Companion
  Guide at:
   – http://www.tdi.state.tx.us/wc/ebill/index.html
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
   Do I have to electronically
   submit my medical bills?
• Unless you are exempt from the
  requirement, TDI-DWC expects medical
  bills to be filed electronically
• Complaints regarding compliance will be
  reviewed on a case-by-case basis
Texas Department of Insurance, Division of Workers’ Compensation
             2009 Educational Conference
          


    Frequently Asked Questions


                                Insurance
                                 Carriers
  Texas Department of Insurance, Division of Workers’ Compensation
                2009 Educational Conference
             
      Why hasn’t my eBill agent
      received ANY electronic
           medical bills?
• The business model used by your selected vendor is
  likely creating barriers
• Ask them:
   – Do you have any data sharing agreements with other eBill
     agents, clearinghouses, or practice management system
     vendors?
   – Do you require a proprietary or closed system (requiring
     specialized software)?
   – Do you offer a variety of solutions to health care providers?
   – Do you support electronic attachments/documentation?
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
     Why do I have to support both
     paper and electronic medical
                 bills?
• It is required by the current regulatory
  environment:
  – Labor Code §408.0251
  – Labor Code §408.027
  – 28 TAC §133.200
  – 28 TAC §133.230
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
     I need more documentation to
    process a medical bill. How do I
                get it?
• Submit a written request to the health
  care provider as required in 28 TAC
  §133.210
• The health care provider must provide
  the documentation within 15 days
  Texas Department of Insurance, Division of Workers’ Compensation
               2009 Educational Conference
            
    Am I in compliance if my
     eBill agent is “able” to
          receive ebills?
• Probably not
• The best evidence of “compliance” is the
  actual receipt and processing of
  electronic medical bills
• See Labor Code §408.0251
Texas Department of Insurance, Division of Workers’ Compensation
             2009 Educational Conference
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                    Questions?


                           This presentation was produced by the Information
                           Management Services Section of the Division of
                           Workers’ Compensation, Texas Department of
                           Insurance, 7551 Metro Center Drive, Suite 100, Austin,
                           Texas, 78744; (888) 489-2667. This information is for
                           educational purposes and is not a substitute for the
                           statute and rules.