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How to Process Carrier Billing

This article provides you with steps on how to process carrier billing.

NOTE: The information shown below is a draft of this document in HTML form. To view the complete document, download the PDF version shown here.

 Third Party Billing - Carrier Billing.pdf.

 

 

Third-Party Billing

  

To access billing functions, click the “Account” ($) (dollar sign) icon in the SMART toolbox:

 

In the Account Dashboard, click the “Third-Party Billing” button:

 

 

Processing New Billing

In the Third-Party Billing window, select a carrier from the drop down menu at the top.

Within the “Process New Billing” tab, select a Thru date. (Clicking the “…” icon to the right of the date field will display a calendar. Choose the desired date within the calendar to populate the field.)

With the date entered, click the “Set” button. This will enable the “Prepare 3rd Party Billing” button. Click this button to gather all billable invoices.

Note: Depending on the number of records to be processed, this can take a minute or two to complete.

 

A message may appear indicating an invalid date. This occurs when the carrier is set to bill weekly and the week starts on a Sunday AND at least one service billed to that carrier has the “Included in Comprehensive” box checked.

 

 

The “Prepare 3rd Party Billing” window will appear to verify the information. If correct, click the “Proceed With Billing Preparation“ button.

 

Next, click the “Print Full Billing Edit List” in the Third Party Billing window to review the third party billing edit list.

 

If any “Reason Not Billed” items appear in the last column (shown below), make the necessary corrections and repeat the steps above. If no errors appear, proceed to the next step.

 

Note: On the third party billing edit list, the “Billed to Carrier” and “Expected Remittance” column amounts will be zero if the claim doesn't qualify for billing. This is based on the carrier setting.

Click the “Post 3rd Party Billing Now” button to create the invoice and then click “Proceed With Posting”.

Note: If the “# of services selected” field is blank, go back to step 1 and proceed to the next carrier.

 

You will see that the billable items have moved to the “# of invoices” and “Total Amounts” fields. Click the “Produce New Claims” button to review qualified claims.

 

 

On the “Produce New Claims” screen (shown below), you will see that all claims have been automatically selected. You have the option to “Deselect All” or “Edit Coverage” if desired.

 

If any are pending authorizations, you can uncheck the claim to prevent it from billing.

Red Lines indicate a discrepancy between the date range selected and the insurance coverage dates indicated on the patient’s profile and services dates.

Yellow Lines mean that the patient is dosing in two different programs within a week. (NY APG Only)

Note: Based on how the “Initial Submit Claims Via” field is set on the Edit Carrier Detail > Submitter Info tab will determine if you will see “Generate EDI Claims File” (EDI) or “Print Selected Claims” (Paper)

 

Select the billable claims and click “Generate EDI Claims” or “Print Selected Claims” button.

 

For carriers set up as EDI, you will be prompted to name the EDU result file. Name the file, then click “Save” to save the file in the EDI folder. 

 

 

The “Mark Selected Claims as Submitted”? screen will prompt for a confirmation. Clicking “Yes” will mark the claims with the submission date. Now you can upload the file to the carrier’s site based on their instructions.

 

 

Once complete, you’ll see a transmittal page confirming that the carrier received the file. (Sample shown below.)

 

Paper Claims Process

For carriers that are set to paper, you will see a “Print Selected Claims” option at the bottom of the Produce New Claims screen. Clicking the button will display a dialog box confirming you want to mark the claims as submitted. Select the appropriate printer and click OK. 

 

A dialog box will appear to confirm that the claims have printed correctly. Verify this is the case prior to clicking “Yes” at “Mark Selected Claims as Submitted?” Once you click Yes, this will mark the claims with the submission date and you will not be able to reprint these claims afterward.

 

Reports:

  • Sales Journal Summary
  • Receipts Journal Summary

(Both of these reports are also used for month-end reports.)

 

 

Process Existing Claims Tab

Under the “Process Existing Claims” tab, there are 8 functions which can be performed: 

  • Reproduce Existing Claims
  • Resubmit Partially Paid Claims
  • Resubmit Denied and Voided Claims
  • Apply Remittance Advice
  • Cash Adjustment Entry
  • Credit Entry
  • Deny Claim
  • Void Claim

 

The basic process and screens for resubmitting claims are similar for the first 3 functions.

Note: The carrier configuration will determine whether you see the “EDI” or “Paper” option. This is controlled in “Edit Carrier Detail > Submitter Info Tab > Resubmit Claims Via…”

 

Reproduce Existing Claims

Select a carrier from the drop-down menu and enter the date ranges for the claims to be reproduced and click the “Reproduce Existing Claims” button.

Configuration of the “Resubmit Claims Via” option in the Edit Carrier Detail > Submitter Info tab determines whether the “Generate EDI Claims” or “Paper Selected Claims” option will be displayed.

In the “Reproduce Existing Claims” screen (shown below), there are options to “Edit Coverage”, “Select All”, or click on each claim you’d like to reproduce (when applicable) and click “Generate EDI Claims File” or “Print Selected Claims” depending on how the carrier was configured.

Items in red indicate a discrepancy between the date range selected and the insurance coverage dates listed in the patient’s profile.

 

EDI Process

A prompt will appear asking for a file name for the resulting file. Name the file and click “Save” in the EDI folder.

The “Mark Selected Claims as Submitted?” screen will appear to confirm the action. Once “Yes” has been clicked, the claims will be marked with the submission date. The file may then be uploaded to the carrier’s site based on their instructions.

 

Paper Process:

The “Print” box will appear. Select the appropriate printer and click “OK”.

The “Mark Selected Claims as Submitted?” screen will appear to confirm the action. Once you click “Yes”, the claims will be marked with the submission date. Verify that the claims have printed correctly prior to clicking “Yes” to mark the claims as submitted.

 

 

Resubmit Partially-Paid Claims

Select a carrier from the drop-down menu and enter the date ranges for the claims you’d like to reproduce and click the “Resubmit Partially Paid Claims” button.

In the “Resubmit Partially Paid Claims” screen, select the claims to be resubmitted and click “Generate EDI Claims File” or “Print Selected Claims” button based on how the carrier is configured.

 

EDI Process:

A prompt will appear asking for a file name for the resulting file. Name the file and click “Save” in the EDI folder.

The “Mark Selected Claims as Submitted?” screen will appear to confirm the action. Once you click “Yes”, the claims will be marked with the submission date. The file may then be uploaded to the carrier’s site based on their instructions.

 

Paper Process:

The “Print” box will appear. Select the 1500 printer and click “OK”.

The “Mark Selected Claims as Submitted?” screen will appear to confirm the action. Once you click “Yes”, the claims will be marked with the submission date. Verify that the claims have printed correctly prior to clicking “Yes” to mark the claims as submitted.

 

 

Resubmit Denied and Voided Claims

Select a carrier from the drop-down menu and enter the date ranges for the claims you’d like to reproduce and click the “Resubmit Denied and Voided Claims” button.

 

In the “Resubmit Denied and Voided Claims” screen, select the claims to be resubmitted and click “Generate EDI Claims File” or “Print Selected Claims” button based on how the carrier is configured.

 

EDI Process

A prompt will appear asking for a file name for the resulting file. Name the file and click “Save” in the EDI folder.

The “Mark Selected Claims as Submitted?” screen will appear to confirm the action. Once you click “Yes”, the claims will be marked with the submission date. The file may then be uploaded to the carrier’s site based on their instructions.

 

Paper Process:

The “Print” box will appear. Select the 1500 printer and click “OK”.

The “Mark Selected Claims as Submitted?” screen will appear to confirm the action. Once you click “Yes”, the claims will be marked with the submission date. Verify that the claims have printed correctly prior to clicking “Yes” to mark the claims as submitted.

 

 

Apply Remittance Advice

The Apply Remittance Advice button allows you to apply paper remittances manually.

In the “Process Existing Claims” tab, select the carrier from the drop down list and click “Apply Remittance Advice”. 

 

The “Carrier Payment Entry Screen” will appear. Enter the total payment amount, reference id, etc. then click “Save, Apply Manually”.

 

Ref. ID: Commonly used for check #

Comment: This field will be seen on the Carrier Recap Report

Type: Select payment type (cash, check etc…)

 

The “Applying Payment from…” screen will appear.

 

Sort any column by clicking on the column title. To reverse the sort order, hold down the Shift key when clicking the column title.

Search by Patient ID or other criteria in the upper-right corner of the window.

Locate the service line to be applied and click “Apply…

 There is also the option to un-apply (if a mistake is made) and deny claims here as well.

 

In the “Apply Carrier Payment Detail” screen, you will notice that the “Expected Payment” amount has been automatically populated in the Amount field.

Clicking the Apply button will take you back to the “Apply Payment From…” screen.

 

If you don’t want to apply the full amount, edit it and enter the balance in either “Leave Open”, “Sales Allowance” (contractual adjustment) or “Adj. Copay” (will send to patient balance) prior to clicking “Apply”.

 

Other Fields:

Expected Payment - is the allowed payment amount issued by the carrier (a.k.a. Fee Schedule) Edit Carrier Detail > Modify Fee-for-Service Detail > Select a service, Carrier Service Edit

Leave Open - Used if a claim isn't paid but you don’t want to write it off.

Bad Debt - Writes off bad debt. This then populates the “Write Off” column in the “Applying Payment From” screen.

Adj. Copay - invoices the patient if the billing is set on the patent’s profile.

Trx Sub Category - Transaction category which will indicate the reason for adjusting a claim.

 

The “Amount Left to Apply” field, in this case, has deducted the $55.77 and moved to “Amount Used” and the amount paid is now reflected in the “Amt. Paid” column.

 

Note: This “running calculator” will continue to run as long as you don’t exit the “Apply Remittance” function.

 

Reports:

Third-Party: Payments: Carrier Payment Recap Report

Billing: Payments: Payment List

Billing Journals: Reprint Adjustment Journal in Date Range

 

Cash Adjustment Entry

This function is used when you receive a mixed remittance that needs to be applied to more than one clinic or when you want to correct a carrier entry.

At the “Process Existing Claims” tab click “Cash Adjustment Entry” and you will see the “Carrier Cash Adjustment Entry Screen” (shown below). Click on the remit that you need to adjust and click “Select”.

 

 

Enter the amount that you want to adjust in the “Amount” field and select the payment type from the drop down menu, then click “Save”.

 

 

 

Credit Entry

In the “Process Existing Claims” tab, select a carrier from the drop-down and click “Credit Entry”.

The “Carrier Credit Entry” screen will appear wherein you can enter the number of units, service start date, service end date, transaction category, transaction sub-category, credit amount, and comment. When complete, click “Save”.

 

The “Applying Credit from…” screen will appear. Locate the service line to which you want to apply the credit and click “Apply Maximum”. If there is enough in the “Amount Left To Apply” field, this will apply the full amount of the line item you selected.

If you want to apply a portion of a balance click “Apply” on the above screen and it will bring you to the screen below. Enter amount that you want to apply in the “Amount” field, then click the “Apply” button. You will then be brought back to the “Applying Credit from…” screen.

 

 

Reports:

Unapplied Credits and Payment Report

 

 

 

Deny Claim

 

In the “Process Existing Claims” tab, select a carrier and click “Deny Claim”.

 

In the “Apply Payment From…” screen, click anywhere on a patient’s line to which you would like to apply the denial, then click “Deny Claim”.

Note: If you make an error, simply select the line and click “Un-Apply”.

 

 

In the “Select TC And Denial Reason” screen, insert *TCN (optional) by clicking in the TCN column, then press the “Tab” key to capture the entry and enter the Denial Code.

Click on the action to be taken at the bottom of the screen (Write-off, Resubmit, Save, Leave Open, or Cancel.)

 

TCN - Transaction Control Number will automatically appear if it’s on the remittance.

 

Process ERA Tab (Electronic Remittance Advice, 835)

 

In the Process ERA tab within the Third-Party Billing screen, clicking the

“Preview Summary” button will open the EDI folder.

 

Double-click the EDI file to be processed.

(Tip: You can create a folder called 835 on your Desktop to make it easier to locate.)

You will now see the clinic IDs total paid for each clinic, take-backs, sub check totals, and net totals in the Preview File Summary shown below.

Now you can click “Process File”, then double-click on the EDI file, and you will receive a “Done Processing ERA File” pop-up screen. Click “Yes”.

 

Continue processing the ERA by clicking on each of the buttons on the right side in order from top to bottom.

 

Note: “Paper Claims Detail” and “View/Process Take-back” will only produce a report if there are any paper claims or take-backs.

 

Click on “View/Post” to view the “Post ERA” screen shown below.

 

Make sure that the Total Balance and Total Paid fields match, then click “Apply All” and retrieve the Journal # from the pop-up screen.

 

 

Reports:

Carrier Payment History

Carrier Payment Recap Report

Carrier Payment

Recap Report Summary

 

 

Process 999 File

The 999 includes additional information about whether the received transaction had errors, including whether the transaction is in compliance with HIPAA requirements. The 999 Acknowledgement may produce any of three results:

 

Accepted (A)

Rejected (R)

Accepted with errors (E)

 

In the Process Ack tab, select a carrier from the drop down list and click the “Process 997 File” button.

 

The ANSI 997 Viewer will appear under the GS tab. Click the “Select File…” button and select the file. Once the file is chosen, the 997 information will auto-populate.

 

 

Check the “Transaction Set” and “Functional Group” Acknowledgement Codes shown  below.

 

 

Under the TA1 tab, in Interchange Ack Code, check for any errors.

 

Process 277CA

 

Under the Process Ack tab, select “Medicare” from the drop down, then click “Preview File Summary”  to view accepted and rejected totals.   

 

Locate the file and double-click it to open it and populate the Preview File Summary window. Click on the “Process File” button and  double-click the file. You should receive a message saying “Done Processing 277 file” prompt. Click OK.

 

 

 

 

 

 

 

Next, click on the “Print Accepted Detail” button. If there are no pages to be printed, the system will indicate that the document has no pages.

 

 

 

 

Click “Print Rejected Detail” to view any rejections.

 

Eligibility

“270 Eligibility Request” and “271 Eligibility Respond” is an inquiry transaction file set that is intended to allow the release of eligibility data to providers, suppliers, or their authorized billing agents with the goal of accurate claims, determination of beneficiary liability, or determination of eligibility for specific services.

270 Eligibility Request - In the Eligibility tab, select the date range (generally Monday’s date in both from and thru) you wish to generate, then click the “Generate 270” button.

 

The file will be saved by date to the Form 270 folder under Smart2k > EDI. It may be copied to the desktop for easy retrieval and uploading to the carrier’s site.

 

Visit the website per the carriers instructions and upload the 270 file. 

 

Note: Do not use the View/Post Button. Any carrier changes should be done manually to ensure that any necessary credits and invoices can be created. Default Medicaid carrier should be set under REV’s tab in clinic settings.

If there are any errors, the Error Log Screen will appear. Review and correct any errors, then click OK.

 

 

 

271 Eligibility Respond - The 271 report is usually available the next day.

 

Go to the website per the carrier’s instructions to retrieve 271 files and save the file in a 271 folder.

 

In the “271 Eligibility Respond” section of the screen, click Process 271, then choose the 271 file. The detail will be populated per the example below: 

 

 

Click “Print Detail” to review the patient detail. You can either save the detail or print it based on your workflow.

 

Click “Print Exception Detail” to review any exceptions.

 

Transportation (State of NY only)

 

The Transportation tab was designed to provide New York customers with tools to handle transportation claims. In the state of NY, Medicaid will reimburse qualified patients enrolled in Opioid dependency programs for fares incurred traveling to the clinic for treatment.

 

Add Medicaid Transportation carrier to the patient’s profile. Coverage dates need to match the patients Medicaid coverage dates:

Intake > Profile > Coverage tab, click “Add New”

If Medicaid carrier is already on the patient’s coverage record, click Edit/Delete. You will see a “Transportation Coverages” tab in the middle of the screen. Click “Add” and enter coverage from and thru date (if applicable) and close all windows until you are back in the Third Party Billing screen.

In the “Transportation” tab, choose “Medicaid” from the drop-down menu.

Click the “New Claim” button at the bottom of the screen.

  

 

4. The “New Transportation Claim” window will appear.

Click the “Find Patient” button and select the patient.

 

Enter the “Service Start” and “Service End” dates. The number of units will auto-populate based on service dates.

 

Enter a comment if desired.

 

Then click the “Create Claim” button.

 

Select the date range for which you’d like to generate services under the From Date and Thru Date, then click “View Details”.

 


Note: If old transportation coverage records exist, you must end the coverage to the prior record to avoid overlapping coverage errors.

 

Week Start: Displays the date that the transportation services began.

 

Week End: Displays the date the transportation ended for a particular week.

 

Total Claims: Displays the total number of individual patient transportation claims in the system for that week of service.

 

Unsubmitted Claims: Display claims with a status of unsubmitted, denied, and voided in this column.

 

Submitted Claims: Displays claims pending response from the carrier.

 

Processed Claims: Displays claims that have been approved, rejected, or voided. Select a week from the list and click “View Details” to see details for that week. (Shown below).

 

 

 

 

 

 

 

 

 

Resubmit Transportation

 

 

To resubmit claims:

 

Enter the date range for the week to be submitted and click “View Details”.

In the Transportation Details window, select the “Submitted” tab.

Click on the patient to be resubmitted and click the “Change Status” button.

In the “Transportation Claim” screen, click the “Change Claim Status to:” drop down and choose “Unsubmitted”, and click OK.

Click the close button.

The patient should not appear under the “Unsubmitted” tab.

 

 

 

Reports:

  • Patient Payment Summary
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