837 moop reporting hands on - etouches · moop reporting 1. member out of pocket (moop) reporting...
TRANSCRIPT
837 MOOP Reporting – Hands On
Presented by:
Rini Jose and Tracie Diaz
Assisted by:
John Ritchie
Session Agenda
1. MOOP Reporting Requirement
2. Summary of mapping updates
3. Mapping Functions
• Assign constant value to a required field
• Drag and Drop custom mapping
4. Hands on • Create custom map
• Create 837 file
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MOOP Reporting
1. Member Out Of Pocket (MOOP) reporting requirement is mandated by the Affordable Care Act.
2. Copay + Coinsurance + Deductible = MOOP
3. 5010 Balancing requirements apply when reporting adjudicated claims
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MOOP Reporting – Required Segments
• 2320 & 2330A - Other Subscriber Information
• 2330B - Other Payer Information
• 2430 - Line Adjudication Information – SVD (Net pay is reported here)
– CAS Segments (Assumption – Contract minus OOP = Net Pay)
• Adjustment Amount (CAS segment 1)
• Billed minus Contract (CAS Segment 2)
• Member Out Of Pocket (CAS Segment 3)
– DTP (Check Remittance Date)
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5010 Balancing requirements (Line Level)
• Billed Amount - Reported in SV1/SV2 segment• Net Pay - Reported in SVD Segment• Adjustments – Reported in CAS segments• The calculation for Service line level balancing is as follows:
– {sum of CAS Service Line Adjustments} plus {SVD02 Service Line Paid Amount} = {SV102 Line Item Charge Amount}
EZ-CAP Example:• Line 1 Billed Amount - 80.00• Line 1 Contract Amount - 50.00• Line 1 Copay - 10.00• Line 1 Payment – 40.00
837 File• SV102 – 80• SVD02 – 40• CAS segment 1 – 30 (Billed minus Contract)• CAS segment 2 – 10 (Patient Responsibility)
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How to do Mapping?
• Hands on steps Include
– Drag & Drop Mapping
– Assign constant value
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Assigning a Constant
1. Open Mapping Definition Screen
2. Select the field
3. Expand Elements to selected field
4. Right Click
5. Assign Constant
6. Designate Constant
7. Confirm Change
8. Constant Assigned Dialog box
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1 Opening Mapping Definition
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2 & 3. Select and Expand to Field
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4 & 5 Right Click and Assign
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Assigning a Constant
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6. Designate the Constant
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8. Constant Assigned Successfully
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User Confirmation
• After
• Before
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Mapping Left to Right
1. Select Field on EZ-CAP Database Side (Left Side)
2. Expand to the select Field
3. Select Field on EZ-CAP Repository Side (Right Side)
4. Expand to the selected field
5. Drag Field from Left to the selected Right Field
6. Confirmation is displayed
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1. Select Field on EZ-CAP Database
Side (Left Side)
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2. Expand to the select Field
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3. Select Field on EZ-CAP Repository
Side (Right Side)
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4. Expand to the selected field
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5. Drag Field from Left to the selected
Right Field
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6. Confirmation is displayed
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Visual display of Mapping
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MOOP Mapping
• EZ-CAP Database side– 2000B – Subscriber Hierarchical
– 400 Subscriber Information
– 200 Company Information
– 600 Claim Information
– 800 Claim Detail Information
– 1200 Claim Adjust Information
• EZ-CAP Repository side– 700-2320 Other Subscriber
– 2330A Other Subscriber Name # Secondary
– 700 - 2330B Other Payer Name # Secondary
– 1200-2430 Line Adjudication Information
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Hands On
• Follow the steps from the mapping document
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