claims user guide tools - medical mutual user guide.pdf · claims tools user guide 5 | claims tools...

Claims ToolsUser Guide

ClaimsTools User Guide

PCAT-1275 8/13/13

http://provider.medmutual.com

claims tools

i | CLAIMS TOOLS USER GUIDE Table of Contents

Claims Tools User Guide Table of Contents

Introduction and Overview ............................................................................................................................ 1

Getting Familiar ............................................................................................................................................... 2Home Screen .......................................................................................................................................................3Navigation Menu ................................................................................................................................................4

Claims ................................................................................................................................................................ 5Submit Professional Claims ..............................................................................................................................5

Tab 1: Patient and Insured Information ................................................................................................................5Tab 2: Physician & Occurrence .............................................................................................................................6Results .......................................................................................................................................................................10

Estimates ......................................................................................................................................................... 11Submit Professional Estimates ...................................................................................................................... 11

Tab 1: Patient and Insured Information ..............................................................................................................12Tab 2: Physician and Occurrence .......................................................................................................................13Results .......................................................................................................................................................................16Member Estimator Results ...................................................................................................................................17

Administration ............................................................................................................................................... 18Contact Information ........................................................................................................................................ 18Office Notice .................................................................................................................................................... 18

claims toolsClaims Tools User Guide

1 | CLAIMS TOOLS USER GUIDE Introduction and Overview

Medical Mutual® strives to provide our customers with innovative solutions to their business needs. We have developed two web-based tools that allow providers to submit claims for immediate adjudication and to estimate patient liability prior to an office visit.

First, the Real-Time Claims Adjudication tool allows our providers to submit CMS-1500 claims online. Barring any benefit questions or need for a medical review, the claim is adjudicated immediately, in real-time. After successfully submitting the claim you can see and print a preliminary Explanation of Benefits (EOB) that specifies the patient’s liability for that visit. Your office may choose to collect any monies owed by the patient, including the deductible and coinsurance, at the time of the visit, permitting the patient to dispose of any financial obligation, while eliminating the need to bill for services later.

Second, the Treatment Cost Estimator allows our providers to estimate a patient’s out-of-pocket costs prior to submitting a claim. Estimates of patient responsibility are based on the patient’s actual benefit structure, real-time benefit accumulations, and the provider’s contracted rate with Medical Mutual. A similar, but somewhat scaled-back Treatment Cost Estimator, is also available to our members so they may estimate the cost of service for selected codes.

In addition to the Real-Time Claims Adjudication and Treatment Cost Estimator tools, the Tools and Resources section of the Provider ePortal has links to various patient informational documents and also gives providers the ability to obtain support from Medical Mutual.

Introduction and Overview


2 | CLAIMS TOOLS USER GUIDE Getting Familiar

Getting FamiliarACCESSING THE SITE1. To access these tools, you must log in or register for the Provider

ePortal at Provider.MedMutual.com.

2. Once you are signed in, select Dashboard.

3. At the next screen, select Claims & Eligibility.

4. Then select the Claim Tools tab.

5. Next, follow the Claims Tools Site link.

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claims toolsClaims Tools User GuideHOME SCREEN

After selecting the Claims Tools Site link, the Claims Tools Main Menu will appear. The menu includes choices for Claims, Estimates and Administration.


claims toolsClaims Tools User GuideNAVIGATION MENU

The Navigation Menu in upper right corner is available for all screens under Claims Tools to help you navigate the site.

�� HOME — returns you to the Claims Tools Home screen.

�� CLAIMS > Submit Claim — transfers you to the Real-Time Claims Adjudication tool

�� ESTIMATES > Submit Estimate — transfers you to the Treatment Cost Estimator tool.

�� ADMINISTRATION > Contact Info — explains how to get help. > Office Notice — provides a sample deductible and coinsurance collection notice to post in your office.

�� LOGOUT — exits you from the system, and returns you to the login screen.


5 | CLAIMS TOOLS USER GUIDE Claims

ClaimsSUBMIT PROFESSIONAL CLAIMSThe claim processing forms used in the Real-Time Claims Adjudication tool are modeled on the CMS-1500 form used by professional providers. All claims should be completed and submitted in accordance with CMS guidelines and your contract with Medical Mutual.

The Real-Time Claims Adjudication tool has two screens that require completion before a claim can be submitted.

Tab 1: Patient and Insured Information

The Real-Time Claims Adjudication tool will search for and automatically populate the patient’s name, address and policy information.

1. Start by choosing the patient’s Insurance type from the drop-down box located in the top left corner.

2. Next, enter the patient’s Date of Birth in mmddyyyy format (e.g. 06022012 is June 2, 2012).

3. Next, select the patient’s Sex from the drop-down box.

4. Then enter either the Insured’s ID#, which can be either the policy number or Social Security number. The Insured’s ID number should be between 7-12 characters and may be a combination of letters and numbers.

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5. Once these fields are completed, select the Patient Info button to auto-populate the remaining sections of the form.

6. Please review the populated information, and then complete the process by selecting the appropriate entry from Patient Condition Related To field.

7. If applicable, enter the information for Other Insured and Additional Patient Info before moving on to the Physician and Occurrence Tab.

NOTE: You will see an alert if the patient’s information cannot be found, for example if the patient’s coverage was terminated. You may also see an alert if the patient belongs to a Network Access group for which Medical Mutual does not record eligibility. Claims for patients whose eligibility information is not tracked by Medical Mutual cannot be processed using the Real-Time Claims Adjudication tool.

Tab 2: Physician & Occurrence

SUBMIT PROFESSIONAL CLAIMS (continued)

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After verifying the information you entered under Patient and Insured Information, please complete the Physician and Occurrence section. Not all fields may apply to the patient’s visit; required fields are marked with a red asterisk. Enter the information as you would on a paper or an electronic CMS-1500 form.

Following are descriptions of the Physician and Occurrence fields.

1. Date of Current Illness, Injury, or Pregnancy: This field is required if the Patient’s Condition Related To Auto Accident or Other Accident is populated on the Patient and Insured Info tab.

2. If Patient had Similar Illness, Give First Date: If not applicable, leave blank.

3. Patient Unable to Work in Current Occupation: If not applicable, leave blank.

4. Referring Physician ID/NPI: If not applicable, leave blank.

5. Hospitalization Dates Related to Current Service: Enter the admission date in the From field and the discharge date in the To field. If not applicable, leave blank.

6. Diagnosis/Illness/Injury: A claim must have at least one diagnosis code. The code you enter is checked for accuracy; if you enter an invalid code, it will highlight in red.

7. Outside Lab: If not applicable, leave blank.

8. Outside Lab Charges: If not applicable, leave blank.

9. Claim Detail Lines: The Real-Time Claims Adjudication tool requires at least one claim detail line before a claim can be processed. You can enter a maximum of 21 claim detail lines on one claim. To add a detail claim line, select the Add button. To

delete a detail claim line, select the Delete button to the right of the line you want to delete. Following are descriptions of the fields in the Claim Detail.

a. DOS (Date of Service) From: An entry is required for each claim detail line. The only accepted format is mmddyyyy (e.g. 06022012 is June 2, 2012).

b. DOS To: An entry in this field is required only if the last date of service is different from the first date of service. The only accepted format is mmddyyyy (e.g. 06022012 is June 2, 2012).

c. POS (Place of Service): An entry in this field is required for each claim detail line. The entry must be two characters; it will highlight in red if invalid.

d. EMG (Emergency): If not applicable, leave blank.

e. CPT/HCPCS: An entry in this field is required for each claim detail line. The entry must be five characters long (a combination of numbers and letters is acceptable); it will highlight in red if invalid.

f. NDC: National Drug Code (NDC) identifiers must be submitted on professional claims when billing for select medications. For affected claims, select NDC and enter a valid Health Care Procedure Coding System (HCPCS) code and NDC identifier, which include the 11-digit drug code, quanity of medication dispensed and unit of measure. Visit the Medical Drug Management website located under Tools & Resources, Care Management, Medical Drug Management section of


https://provider.medmutual.com/TOOLS_and_RESOURCES/Care_Management/DrugMgmt.aspx



Provider.MedMutual.com for a complete list of HCPCS codes requiring NDC identifiers.

g. Modf: Modifiers are not required; however, if included, a maximum of four modifiers can be associated with each CPT/HCPCS. Each modifier is two characters; it will highlight in red if invalid.

h. Diag (Diagnosis) Pointer: An entry in this field is required only if there are two or more diagnoses associated with the claim. The entry is one digit and must be 1, 2, 3 or 4.

i. Charges: An entry in this field is required on each claim detail line. This field holds a maximum of nine digits and it must contain a decimal point.

j. Days/Units: An entry in this field is required only if the service dates cover more than one date, or if the charge is for more than one unit of service. The entry may contain a decimal, but it will be rounded to the nearest whole number.

k. EPSDT (Early Periodic Screening, Diagnosis & Treatment): If not applicable, leave blank.

l. ID Qual: If not applicable, leave blank.

m. Provider ID: An entry is required in this field; it will auto-populate based on the Provider information selected.

n. NPI: An entry is required in this field; it will auto-populate based on the Provider information selected.

10. Federal Tax ID (TIN): An entry in this field is required. It will auto-populate based on the TINs with which you are associated. Choosing the TIN

you want to associate with the claim will auto-populate the Provider and Address fields.

11. Patient’s Account Number: If not applicable, leave blank.

12. Accept Assignments: If not applicable, leave blank.

13. Total Charges: This field shows an accumulation of the charges entered in the claim line detail. These charges are converted to currency and rounded to two decimal places.

14. Amount Paid: Values entered in this field are converted to currency and rounded to two decimal places. If not applicable, leave blank.

15. Balance Due: Values entered in this field are converted to currency and rounded to two decimal places. If not applicable, leave blank.

16. Provider: The information in this field will auto-populate based on the TIN previously chosen and the information about your practice on file at Medical Mutual. Choose from the drop-down boxes to complete this section. Please check the information for accuracy. If you need to make a correction, use the Update Your Records feature in the Provider ePortal to submit a modification request.

17. Address: The information in this field will auto-populate based on the TIN previously chosen and the information about your practice on file at Medical Mutual. Choose from the drop-down boxes to complete this section. Please check the information for accuracy. If you need to make a correction, use the Update Your Records feature in the Provider Portal to submit a modification request.




18. Remit: The information in this field will auto-populate based on the TIN previously chosen and the information about your practice on file at Medical Mutual. Choose from the drop-down boxes to complete this section. Please check the information for accuracy. If you need to make a correction, use the Update Your Records feature in the Provider Portal to submit a modification request.

19. NPI: Information in this field will auto-populate based on the TIN previously chosen and the information about your practice on file at Medical Mutual. Choose from the drop-down boxes to complete this section. Please check the information for accuracy. If you need to make a correction, use the Update Your Records feature in the Provider Portal to submit a modification request.

20. Form Signed by Physician or Supplier: This box must be checked to process your claim using the Real-Time Claims Adjudication tool.


21. Date Signed: You must enter a signature date to process your claim using the Real-Time Claims Adjudication tool. The only accepted format is mmddyyyy (e.g. 06022012 is June 2, 2012).

22. Facility Information: These fields will auto-populate based on the TIN, Provider and Address fields.

23. Physician Information: These fields will auto-populate based on the TIN, Provider and Address fields.

24. After verifying the accuracy of all fields, select the Submit Claim button to send the claim to Medical Mutual for immediate processing. Before the claim is processed, a Claims Submission Confirmation screen (shown below) will prompt you to check the claim for accuracy. Select Cancel Processing if you need to make any changes. Otherwise confirm your choice by selecting OK, Continue Processing. If you receive an error message, correct errors for the fields indicated in the error message. Check that all required fields are completed in the proper format. Select Submit Claim again. (The system will not submit a duplicate claim.)



Results

Usually within seconds after you successfully submit your error-free claim—the actual time will depend on your internet connection—Medical Mutual will display one of three possible responses to explain the status of your claim. Below are descriptions of each response.

�� Claim Successfully Submitted: This message (above) displays a preliminary EOB that shows the claim was successfully adjudicated in real-time by the Real-Time Claims Adjudication tool. There are four parts to this screen:

1. Insured subscriber’s name and address, the claim number, provider name, and patient’s first name.

2. Each service line processed on the claim.

3. The patient’s responsibility.

4. Claim status.

This preliminary EOB can be printed for your files and a copy may be given to the patient. The

patient will received a final EOB from Medical Mutual that mirrors the preliminary EOB.

�� Claim Submitted and Pending: This claim status indicates the claim has been successfully submitted and received; however, the claim has pended for manual intervention. You will be notified of the final benefit determination in the normal course of business.

�� Claim Cannot Be Processed: The claim submission could not be accepted. Please submit the claim using your usual electronic or paper process.


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11 | CLAIMS TOOLS USER GUIDE Estimates

EstimatesSUBMIT PROFESSIONAL ESTIMATESThe Treatment Cost Estimator tool is based on the CMS-1500 forms used by professional providers. The Treatment Cost Estimator has two tabs that require completion before an estimate can be requested.

1. The first tab, Patient and Insured Information, has patient demographics.

2. The second tab, Physician and Occurrence¸ has the estimate detail.

You may switch between screens by selecting the appropriate tab at the top of the screen.


claims toolsClaims Tools User GuideSUBMIT PROFESSIONAL ESTIMATES (continued)

Tab 1: Patient and Insured Information

The Treatment Cost Estimator will search for and automatically populate the patient’s name, address and policy information.

1. Start by choosing the type of Insurance the patient has from the drop-down box located in the top left corner.

2. Next, enter the patient’s Date of Birth in mmddyyyy format (e.g. 06022012 is June 2, 2012).

3. Select the patient’s Sex from the drop-down box.

4. Enter the Insured’s ID#, which can be either the policy number or Social Security number, and should be between 7-12 characters.

5. Once these fields are completed, select the Patient Info button to auto-populate the remaining sections of the screen. Some fields default to predetermined values to facilitate claim estimation. These fields cannot be changed. Please review this information to ensure a best estimate.

NOTE: You will see an alert if the patient’s information cannot be found, for example if the patient’s coverage was terminated. You may also see an alert if the patient belongs to a Network Access group for which Medical Mutual does not record eligibility. Estimates for patients whose eligibility information is not tracked by Medical Mutual cannot be processed using the Treatment Cost Estimator tool.

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Tab 2: Physician and Occurrence

After verifying the information you entered under Patient and Insured Information, you may complete the Physician and Occurrence tab. Not all fields may apply to the estimate you want; required fields are marked with a red asterisk. Enter the information as you would on a paper or electronic CMS-1500 form.

Following are descriptions of the Physician and Occurrence fields.

1. Diagnosis/Illness/Injury: An estimate must have at least one diagnosis code. The code you enter

SUBMIT PROFESSIONAL ESTIMATES (continued)

is immediately checked for accuracy and, if you enter and invalid code, it will highlight in red.

2. Outside Lab: If not applicable, leave blank.

3. Outside Lab Charges: If not applicable, leave blank.

4. Claim Detail Lines: The Treatment Cost Estimator tool requires at least one claim detail line before a claim can be processed. You can enter a maximum of 21 claim detail lines on one claim. To add a detail claim line, select the Add button. To delete a detail claim line, select the Delete button to the right of the line you want to remove.

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Following are descriptions of the fields in the Claim Detail.

a. DOS (Date of Service) From: An entry is required for each claim line. The only accepted format is mmddyyyy (e.g. 06022012 is June 2, 2012).

b. DOS To: An entry in this field is required only if the last date of service is different from the first date of service. The only accepted format is mmddyyyy (e.g. 06022012 is June 2, 2012).

c. POS (Place of Service): An entry in this field is required for each claim line. The entry must be two characters; it will highlight in red if invalid.

d. EMG: If not applicable, leave blank.

e. CPT/HCPCS: An entry in this field is required for each claim line. The entry must be five characters long. (A combination of numbers and letters is acceptable.) It will highlight in red if invalid.

f. Modf: Modifiers are not required for an estimate; however, if included a maximum of four modifiers can be associated with each CPT/HCPCS. Each modifier is two characters; it will highlight in red if invalid.

g. Diag (Diagnosis) Pointer: An entry in this field is required only if there are two or more diagnoses associated with the claim. The entry is one digit and must be 1, 2, 3 or 4.

h. Charges: An entry in this field is required on each claim line. This field holds a maximum of nine digits and it must contain a decimal point.

i. Days/Units: An entry in this field is required only if either the service duration covers more than one date, or if the charge is for more than one unit of service. The entry may contain a decimal, but it will be rounded to the nearest whole number.

j. EPSDT: If not applicable, leave blank.

k. ID Qual: If not applicable, leave blank.

l. Provider ID: An entry is required in this field; it will auto-populate based on the Provider information selected.

m. NPI: An entry is required in this field; it will auto-populate based on the Provider information selected.

n. Federal Tax ID (TIN): An entry in this field is required. It will auto-populate based on the TINs with which you are associated. Choosing the TIN you want to associate with the estimate will auto-populate the Provider and Address fields.

o. Patient’s Account Number: If not applicable, leave blank.

p. Accept Assignments: If not applicable, leave blank.

q. Total Charges: This field shows an accumulation of the charges entered in the claims line detail. These charges are converted to currency and rounded to two decimal places.

r. Amount Paid: Values entered in this field are converted to currency and rounded to two decimal places. If not applicable, leave blank.

s. Balance Due: Values entered in this field are converted to currency and rounded to two decimal places. If not applicable, leave blank.




t. Provider: Information in this field will auto-populate based on the TIN previously chosen and the information about your practice on file at Medical Mutual. Choose from the drop-down boxes to complete this section. Please check the information for accuracy. If you need to make a correction, use the Update Your Records feature in the eProvider Portal to submit a modification request.

u. Address: Information in this field will auto-populate based on the TIN previously chosen and the information about your practice on file at Medical Mutual. Choose from the drop-down boxes to complete this section. Please check the information for accuracy. If you need to make a correction, use the Update Your Records feature in the Provider Portal to submit a modification request.

v. Remit: Information in this field will auto-populate based on the TIN previously chosen and the information about your practice on file at Medical Mutual. Choose from the drop-down boxes to complete this section.

Please check the information for accuracy. If you need to make a correction, use the Update Your Records feature in the Provider Portal to submit a modification request.

w. NPI: Information in this field will auto-populate based on the TIN previously chosen and the information about your practice on file at Medical Mutual. Choose from the drop-down boxes to complete this section. Please check the information for accuracy. If you need to make a correction, use the Update Your Records feature in the Provider Portal to submit a modification request.

x. Facility Information: Information in this field will auto-populate based on the TIN, Provider and Address selected.

5. After verifying your information, select the Submit Estimate button to request an estimate from Medical Mutual. If you receive an error message, please correct errors for the fields indicated in the error message. Check that all required fields are completed and that all information is in the proper format. Select Submit Estimate again.




Results

Usually within seconds after you successfully request an estimate—the actual time will depend on your internet connection—Medical Mutual will display one of two possible responses to explain the status of your request. Below are descriptions of each response.

�� Estimate Successfully Submitted: This message means that the estimate was successfully processed by the Treatment Cost Estimator. The screen accompanying this message is displayed above, and provides you with information illustrating the Patient’s Responsibility. This screen can be printed using the print button in the top right corner of the screen. A copy of this


screen should be given to the patient for his/her records if the provider intends to collect monies based on this estimate. Any monies collected in excess of the final out-of-pocket costs noted on the patient’s EOB should be immediately refunded to the patient by the provider.

�� Estimate Cannot Be Processed: This message means that the estimate was pended for one or more reasons. Estimates can pend for a number of reasons, including the patient’s benefit plan design, prior approval requirements and medical policy edits.


claims toolsClaims Tools User GuideSUBMIT PROFESSIONAL ESTIMATES (continued)

Member Estimator Results

A Treatment Cost Estimator tool has also been made available to our active members who have registered and log into My Health Plan at MedMutual.com. This estimator is based on the same information as the provider’s Treatment Cost Estimator (benefit plan

design, real-time benefit accumulations and provider’s contracted rate), but it limits the number of services that can be estimated (see codes below). These codes, modifiers and diagnoses will return the same estimate to the member as they do to the provider.

PROC_CD MOD POS_CD DIAG_CD43239 00 11 7872073221 00 11 7194177057 00 11 621277080 00 11 7339080048 00 81 4011 80053 00 11 4011 80061 00 11 2724 80076 00 11 2724 81002 00 11 791083036 00 81 2500084153 00 81 6000084443 00 81 2449 85025 00 81 4011 86140 00 81 7140 88142 00 81 7950190658 & 90472 00 30 V048190680 00 11 7999 90700 00 11 7999 90734 00 11 7999

PROC_CD MOD POS_CD DIAG_CD92567 & 99213 00 30 382.994010 & 99213 00 30 493.9095810 00 11 7805095811 00 11 7805097001 00 11 719797002 00 11 7287197012 00 11 7233 97014 00 11 739197032 00 11 7391 97035 00 11 7391 97110 00 11 7371097124 00 11 7391 97140 00 11 7391 98940 00 11 7391 98941 00 11 723299203 00 11 4619 99213 00 11 4011 G0289 & 29871 00 20 836.0

http://medmutual.com


18 | CLAIMS TOOLS USER GUIDE Administration

AdministrationCONTACT INFORMATION�� For claims inquiries, please call 800.733.3706 to be directed

to Medical Mutual’s Provider Inquiry Department.

�� For technical assistance, please call 800.218.2205 to be directed to Medical Mutual’s Web/ePortal Technical Support.

�� Company mailing address: Medical Mutual of Ohio 2060 East Ninth Street Cleveland, Ohio 44115

OFFICE NOTICEYou may find it helpful to post a sign in your office to notify patients that you use the Real-Time Claims Adjudication tool. Medical Mutual has prepared an Office Notice for your use, which can be found under the Administration link of the Claims Tools Main Menu. We encourage you to post this notice so patients are aware of their opportunity to dispense their financial obligation at the time of service.



PCAT-1275 8/13/13

http://provider.medmutual.com

claims user guide tools - medical mutual user guide.pdf · claims tools user guide 5 | claims tools...

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