The Basics of Claims Processing

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Nov 6, 2013 (3 years and 7 months ago)

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WellPoint Performance Solutions



1



Professional Claims Processing Module
2

Created: 1/30/03 Revised
03/09/10




02

The Basics of Claims Processing


Objective


After reading this chapter the learner will be able to:




Identify the path a claim can follow



Identify the components of a queue and how they relate to claims processing



Access the WGS 2.0 sy
stem



Access a claim in the queue



Access ITS and HPA


Where we Are

In the previous module you learned about the Inter
-
Plan Teleprocessing Services
basics. Now you are ready to learn about the WGS 2.0 system and where claims are
stored.


What you will Learn



Upon completion of this module, you will learn the following:




The paths a claim can follow after being through the ITS system



Define the function of claims queues



Define and identify the components of a queue code



Access a live claim from a proce
ssing queue





WellPoint Performance Solutions



2



Professional Claims Processing Module
2

Created: 1/30/03 Revised
03/09/10




Introduction to the WGS Claims Processing System


Once a claim is received by
ANTHEM BLUE CROSS

through the ITS system, it is
mapped on to the WGS

2.0

system

through
DDC
(
Direct Data Capture
).

The system
then routes claims to
queues

f
or processing based on claim data and group/contract
information. A claim can follow one of the following paths after it is keyed:


1.

A claim may move to a DDC

error or pend queue

for further error correction.
Claims move to these queues if critical inform
ation is missing or invalid. A keyer
must complete the missing information before the claim can be processed.


2.

A claim that cannot be system adjudicated moves to an Image Processing queue
for resolution of errors and manual calculation of benefits.


Q
ueues


A queue is an electronic storage area for claims. The WGS system routes claims into
queues based on several factors. Some examples include the member’s eligibility, the
type of service being billed, or the
place of services billed
. Factors such as

coordination
of benefits or Medicare also affect the queue a claim is routed to. For example, when a
member has more than one insurance policy, his or her claims are routed to COB
queues by the system and claims for members who have Medicare are routed t
o
Medicare queues so that those claims are processed separately from other claims.


Additionally, queues are separated by claim type. Listed below are the various claim
types:


Claim Type

Meaning

PA

Professional Claim (Claims submitted
by healthcare

professionals)

MA

Member Claim (Claims submitted by
members)

PM

Professional Medicare Claims

MM

Member Submitted Medicare Claims


IA

Inpatient Hospital Claims (Institutional)

OA

Outpatient Hospital Claims

SA

Skilled Nursing Facility Claims

IC

Inpat
ient Hospital Claims (Submitted by
non contracting facilities)

OC

Outpatient Hospital Claims (Submitted
by non
-
contracting facilities)

SC

Skilled Nursing Facility Claims
(Submitted by non
-
contracting facilities)


WellPoint Performance Solutions



3



Professional Claims Processing Module
2

Created: 1/30/03 Revised
03/09/10




Queues (cont’d)


Queue codes identify
which unit processes a claim, the type of claim, and the status of
the claim.


The three components are broken down as follows.



Listed below is an example of a queue code. It indicates that the processing unit code is
CP, and that the claim is in the
normal queue and will require image processing.


CP 00 00








1.

Processing unit code
, which identifies the claims unit responsible for
processing the claims.
For example: “
TP
” .




2.

Function code
, identifies unique circumstances that require sp
ecial processing.
The function code also allows unique claims to be processed separately from
other claims. The following is a list of common function codes:



Function
Code

Meaning

00

Regular Processing Queue

DP

Possible Duplicate Claim

ES

ITS ERISA
PROCESS IN 15 DAYS QUEUE

HB

ITS HOME (COB claims)

HE

ITS HOME (Medicare claims)

HM

ITS HOME CLAIM

MS

ITS Home Managed Care Services

PC

ITS PAR Control

PR

Price Only

PY

ITS Home ASO/Prompt Pay applies

IN 20
DAYS OF JULIAN DATE


Processing Unit
Code

Function
Cod
e

Queue Status
Code

WellPoint Performance Solutions



4



Professional Claims Processing Module
2

Created: 1/30/03 Revised
03/09/10




Queues (cont’d)


3.

Queue Status codes

indicate the disposition of a claim at a given time. The
queue status indicates whether the claim has been routed, pended or finalized.
The following is a list of some common queue status codes:


Queue
Status Code

Meaning

02

Routed
claims

49

ITS claim in PAC prior to logging

50

ITS claim pended for pricing

51

ITS claim sent for processing

52

ITS Home claim pended for DF

53

ITS Home claim awaiting RF

88

Image Claim Logged

96

Pending claim

97

Deleted claim

99

Closed cl
aim processed and
completed by batch system





WellPoint Performance Solutions



5



Professional Claims Processing Module
2

Created: 1/30/03 Revised
03/09/10




Accessing a Processing Queue


Once you have selected IMSP#1, IMSP#2 and a third IMSP screen, clear each screen.
The examiner’s assigned transaction code should be entered (followed by the space bar
and EN
TER key) in one of the screens as shown in Figure 1.1


Figure 1.1

external
(space)(enter)




The followin
g screen will be displayed. Enter the case number and hit enter.


Figure 1.2



WGMMENU WELLPOINT GROUP SYSTEMS P 07/26/04 15:26:33 1


ZKFCCIU VTC03809 EXTERNAL PROFILE VERSION 001


CASE C19219









The WGS system is a menu
-
driven system, meaning that navigation through the system
occurs by using a series of menus. Once the transaction code is entered as shown in
Figure 1.
2
, the first menu will appea
r.



This menu is known as the “
MCS BlueCard Profile
.” The selections on this menu will
vary by the user’s profile, which is determined by the transaction code that is assigned

to the user.


As shown in Figure 1.
3
, select the option for “
CLAIMS PROCESSING
,” and press the
ENTER key.


Figure 1.
3


WGMMENU WELLPOINT GROUP SYSTEMS P 07/26/04 15:33:43 1


ZKFCCIU VTC03809 MCS BLUECARD PROFILE

VERSION 001






SELECT
-

OPTION :





AA
-

CLAIMS INQUIRY


BB
-

CLAIMS PROCESSING



CC
-

MEMBERSHIP INQUIRY


DD
-

PROVIDER INQUIRY


EE
-

CORP INQ
-

CALIF



FF
-

CORP INQ
-

NATNL


GG
-

DDC CORRECTION










WellPoint Performance Solutions



6



Professional Claims Processing Module
2

Created: 1/30/03 Revised
03/09/10




Accessing a Processing Queue (cont’d)_


The menu shown in Figure 1.
4

is known as the “Claims” menu. Select the opt
ion labeled

AA
,” (PAC/Image Initialize).


Figure 1.4


WGMMENU WELLPOINT GROUP SYSTEMS P 07/26/04 15:37:45 1


ZKFCCIU VTC03809 CLAIMS VERSION 001







SELECT
-

OPTION :





AA
-

PAC/IMG INITIALIZE


BB
-

PROCESS ADJUSTMENT


CC
-

RE
-
ESTABLISH







After selecting the “PAC/IMAGE INITIALIZE” option, the following screen appea
rs as
shown in Figure 1.
5
.


Figure 1.
5

GNCIMGI WELLPOINT GROUP SYSTEM P 06/05/03 11:14:15 1


SNMSCA VTC04661 PAC/IMAGE INITIALIZATION VERSION 001





CLAIM


I M A G E P R O C E S S I N G


I N I T I A L I Z A T I O N S C R E E N





PLEASE INDICATE HOW CLAIM IMAGES ARE TO BE SELECTED FOR PROCESSING


ENTER THE APPROPRIATE CONTROL INFORMATION IN THE SPACE PROVIDED BELOW





SELECTION CRITERIA




NEXT WITHIN SPECIFIED D
CN RANGE _
NEXT WITHIN SPECIFIED QUEUE _



NEXT BY SPECIFIED GROUP NUMBER _ SELECT BY SPECIFIED DCN _


NEXT BY SPECIFIED CASE NUMBER _ NEXT BY SPECIFIED PROVIDER NUMBER _





CONTROL INFORMATION



OPER ____

O _

CLM
-
TYP __

QUEUE ______

SERVICE __ PRODUCT

TYPE __ ADJUST _

GRP __________ ___ DCN1 _____ __ ____ DCN2 _____ __ ____ PROVIDER __________

CSE __________ HIPD _





PF03=RETURN




WellPoint Performance Solutions



7



Professional Claims Processing Module
2

Created: 1/30/03 Revised
03/09/10




Accessing a Processing Queue (cont’d)_




“NEXT WITHIN SPECIFIED QUEUE” lets the system know that the examiner wishes
to process claims from a specific queue



The ex
aminer will enter their operator number in the “OPER” field



The “O” field is available for an examiner to request an English language description
of the
edits
(errors)

rather than the system assigned code. If this field is left blank,
no description wil
l appear, only the edit codes



If an ex
aminer
places a “D” in the “O” field on the PAC/Image initialize screen, all
edits may not be available to view. In some cases, it is better to leave this field
blank, but is a matter of personal preference



“CLM
-
TY
P” lets the system know the type of claim the examiner would like to
access.
Professional claims

are identified by the code
“PA”



Next, the examiner inputs the queue code, which must correspond with the operator
number. For example, if the operator number
is
TP
SR
, the queue code must also
begin with
TP




Press the ENTER key



WellPoint Performance Solutions



8



Professional Claims Processing Module
2

Created: 1/30/03 Revised
03/09/10




Accessing a Processing Queue (cont’d)_


An examiner can also choose to access a specific claim using the DCN number. Figure
1.6 displays the fields that must be entered to access a
specific DCN.



Figure 1.6

GNCIMGI WELLPOINT GROUP SYSTEM P 06/05/03 11:14:15 1


SNMSCA VTC04661 PAC/IMAGE INITIALIZATION VERSION 001





CLAIM


I M A G E P R O C E S S I N G


I N I T I A L I Z A T I O N S C R E E N





PLEASE INDICATE HOW CLAIM IMAGES ARE TO BE SELECTED FOR PROCESSING


ENTER THE APPROPRIATE CONTROL INFORMATION IN THE SPACE PROVIDED BELOW





SELECTION CRITERIA




NEXT WITHIN SPECIFIED DCN RANGE _

NEXT WITHIN SPECIFIED QUEUE _


NEXT BY SPECIFIED GROUP NUMBER _
SELECT BY SPECIFIED DCN _



NEXT BY SPECIFIED CASE NUMBER _ NEXT BY SPECIFIED PROVIDER NUMBER _





CONTROL INFORMATION



OPER ____

O _ CLM
-
TYP __ QUEUE ______ SERVICE __ PRODUCT TYPE __

ADJUST _

GRP __________ ___
DCN1 _____ __ ____

DCN2 _____ __ ____ PROVIDER __________

CSE __________ HIPD _





PF03=RETURN




“SELECT BY SPECIFIED DCN” indicates that the examiner wishes to access one
specific claim



The operator number must be entered



Type the DCN of the claim to be accessed in the “D
CN1” field


DCN

=
D
ocument
C
ontrol
N
umber



02

258

14

1254










YR

Julian

Camera Sequence






Date


Reel / #








Unit #


WellPoint Performance Solutions



9



Professional Claims Processing Module
2

Created: 1/30/03 Revised
03/09/10




Accessing the ITS system_


Once you have accessed a queue, you will want to sign on to the ITS
system. Press the
page down key to navigate to one of your other IMSP sessions. Clear the screen with
the pause break key. Type “ITFI”(space) and ENTER. The following screen appears


Figure 1.7

ITCS03
-

ITFI ***INTER
-
PLAN TELEPROCESSING SERVICES***

10/17/03 07:48


FORMATS SELECTION PAGE 001


OPTION:
.

SEQ NO: SCCF NO: SUB ID:


DT SERV: / / CLM TYP: PROV NUM:



SEQ SC CL


NO SCCF NUMBER CF ST TY LOC CTL NO/SINF KEY DATE SUB ID NUMBER


01


02



03


04


05



06


07


08



09


10


11



12


13





ENTER SELECTED SEQ NO IN THE SEQ NO FIELD FOR THE SCCF RECORD YOU WISH TO VIEW


PF8/'SF' OR PF7/'SB' IN THE OPTION FIELD TO VIEW ADDITIONAL FORMATS SCREEN(S)


OPTIONS: XA
-
VIEW SUMMARY XS
-
SIRF XD
-
COMPLETE SF/DF XX/PF3
-
EXIT



ENTER SCCF NUM OR SUB ID


You will need to BACK TAB (shift TAB) and remove the (.)


I
n
structions on how to use the ITS system will be included in the module ITS
Navigation.

WellPoint Performance Solutions



10



Professional Claims Processing Module
2

Created: 1/30/03 Revised
03/09/10




Accessing
Home Plan Aid


The last screen you will want to sign on to is
Home Plan Aid (HPA). This screen assists
the HOME Plan with creating payment when the system cannot do so. Navigate to your
last IMSP session with the page
up

key.


Type “a imsp” as shown in figure below. Press ENTER.


Figure 1.8


T
PX MENU FOR ZKFCCIU Panelid
-

TEN0041


Terminal
-

T602016


Cmdkey=PF12/24 Jump=PA2 Menu=PA1 Model
-

3278
-
2A


Print=NONE Cmdchar=/

System
-

TPXC




Sessid Sesskey Session Description Status





_ IMSP#1 PF BLUE CROSS IMS PRODUCTION


_ IMSP#2 PF BLUE CROSS IMS PRODUCTION


_ IMSN#1 PF BLUE CROSS IMS BCNMS



_ IMSN#2 PF BLUE CROSS IMS BCNMS


_ TAO PF 15 EMC2/TAO Electronic Mail System N/A


_ IMSP PF IMS Production








Co
mmand ===>
a imsp



Type in your Log On ID and Password. Press ENTER


SIGN












ENTER LOGONID


ENTER PASSWORD











The following message will display.


SIGN



DFS058I 16:04:23 SIGN COMMAND COMPLETED









ENTER LOGONID


ENTER PASSWORD




WellPoint Performance Solutions



11



Professional Claims Processing Module
2

Created: 1/30/03 Revised
03/09/10



Accessing
Home Plan Aid (cont’d)


Clear the screen with the pause break key. Type “IUCA”(space) and press ENTER. The
following screen will appear


IUCA01
-

CA01 ************ HOME PLAN
-
AID ************ 10/17/03 07:53



ADJUDICATION INPUT SELECTION


OPTION: AJ OPERATOR ID: ZGSOSB9





SCCF SERIAL NUMBER:




ORIGINAL/VOID...





ADJUSTED........




PATIENT LAST NAME...





FUNCTION CODE.......





STATUS (H,R,E,A).... A


OPTIONS: FUNCTIONS:


AJ ADJUDICATION RESULTS (ADD) 1 ORIGINAL



OV PAYMENT OVERRIDE (ADD) 2 VOID


RU REVIEW/UPDATE 3 VOID/REISSUE


RS REVIEW/UPDATE (STATUS) 4 VOID/REISSUE/CLOSEOUT



XX EXIT 5 REISSUE


A AUTOMATED ADJUSTMENT


PFKEYS: PF3 (XX)



Instructions o
n how to use HPA will be in module Finalizing a Claim.