Step 1- Create claim by importing your data from a spreadsheet or manual entry
Step 2- Populate claim data in only the required fields
Step 3- “Price” claims and export results (summary and/or full claim detail report)
Medicare PPS AND EDITS
Medicare Perspective Payment Systems:
Medicare Institutional Data (CMS-1450/ UB-04 / ANSI 837i)
- Hospital acute inpatient (IPPS / MS-DRG)
- Hospital outpatient (OPPS)
- Ambulatory surgery center (ASC)
- Durable Medical Equipment (DME)
- End stage renal disease (ESRD with "composite" rates and OPPS/Fee Schedule)
- Skilled nursing facilities (SNF)
- Inpatient rehabilitation facilities (IRF)
- Inpatient psychiatric facility (IPF)
- Long term care hospital (LTCH)
- Outpatient rehabilitation facility (ORF)
- Critical access hospitals (CAH)
- Sole community hospitals (DRG plus an SCH "add on")
- Comprehensive outpatient rehabilitation facilities (CORF)
- Rural health clinic (RHC)
- Hospice, federally qualified health centers for IP and OP (FQHC)
- Community mental health centers (CMHC)
- Swing bed
- Home health agency (HHA)
Medicare Professional Data (CMS-1500/ HCFA-1500 / ANSI 837p)
- Professional / physician (RBRVS) including all localities
- Parenteral and Enteral nutrition (PEN)
- Clinical labs
- Prosthetics, orthotics and surgical suppliers (POS)
- Diagnosis Code Validation
- Local Coverage Determination (LCD)
- National Coverage Determination (NCD)
- Age Edits
- Gender Edits
- Outpatient Code Edits (IOCE)
- Medically Unlikely Edits (MUE)
- Correct Code Initiative (NCCI)
- CPT Edits
- RVU Edits
- Modifier Edits
- Advance Benefits Notice of Non-Coverage (ABN)
CMSP functions include:
The CMSP processing handles the HIPAA protected information as each user must register securely within the application. Each user is assigned a workspace for processing their claims. The login form requires user name and password. The configuration of the user determines the next form. The user role determines features available to the user – there are two roles: user and admin. The user has access only to the claim list and associated processing, the admin has access to all functionality available.
The system provides ability to store the configuration – providers, company information, etc. The purpose of the configuration setup is to make preparation of claims easier. The configuration is associated with the user and available for subsequent sessions until removed by the user.
This process handles inserting the claim data to the CMSP loader in preparation for re-pricing. The intake is the first step of the claim pricing. User can enter the claims directly using input forms (UB-04, CMS1500, etc.) or import the claims in bulk. The bulk import is also available from a properly formatted files. The intake claims associated with each user session is never persisted, and it will vanish once the session is terminated.
Regardless of manual entry or bulk loading, the pricing of all claims formulates the pricing request for the appropriate payment type, submits the request, and returns the re-priced results. The results are associated with each claim for easy error resolution. The CMSP processing uses external pricer services for pricing of the claim. The service charge is based on number of times the claim was priced. The CMSP software will perform basic validation of data before it is submitted for pricer so as to minimize the number of times the pricing is needed. The comments and messages will be available after the pricing run. The structure is populated during the processing and resides only in memory.
The priced claims can be viewed directly in the CMSP system or exported for further processing. The CMSP provides the standard JSON formatted output with the pricer which can easily be exported to an Excel document, if preferred. The user selects one of the available formats and generates the export in that format.
The CMSP operates through secure layers and does not store any PHI (Private Health Information) data. The claim information uploaded or entered is maintained only in memory and vanishes when the user logs off. CMSP supports the ability to persist the claim information in a text form on the client system/hardware.
The CMSP system does not persist the claim information in a database or other persistent storage. This means that the claims entered or loaded to the system are available only for the duration of the session. It is stored in the session claim database. Once the client logs off, all PHI information is relinquished. The CMSP system only keeps the data used in the accounting of the activity.
The users who desire to store their work and resume it at later time can use the Store-Resume feature of the system. The Store saves the content of claims on the user’s hardware in a specially formatted text file (JSON) and the Resume will read the specially formatted file and load the content to the session claim database. The key feature of this operation that any persistent PHI information is maintained outside of CMSP.