Billing work process project

Process: HB Coverage Issue- Insurance

Role(s): Hospital Billing

WORK

PROCESS

Location: Business Office

Department: Hospital Billing

Document Owner: Hospital Billing Supervisor

Date Prepared:

8/28/19

Date 1st Approved:

Date Revised:

8/28/2019

Essential Tasks:

The HB Coverage Issues are listed below:

· 12691 INS – NMR – HB COVERAGE ISSUES

· 12749 INS – MGH – HB COVERAGE ISSUES

These WQs house all accounts with an insurance balance that have coverage issues including but not limited to: multiple of same/similar coverages listed, coverages not attached to the account, or coverage attached but not active on the DOS.

Sort WQ based on work assignment direction. Open your first account and navigate to the Coverages tab. Review the insurance listed and proceed based on what you find below.

Multiple Coverages of Same/Similar

Coverage may have been added for Medicare and a Medicare replacement or MA and PMAP on Same HAR

· Verify coverage on Healthia and determine if customer has a replacement or just traditional Medicare/MA.

· Has a Replacement: Term out Medicare/MA the day before Replacement starts. Remove coverage related Stop Bill/DNB if applicable and complete from WQ

· Has Traditional Medicare/MA only: Term out Medicare/MA replacement the day before MA starts. Remove coverage related Stop Bill/DNB if applicable and complete from WQ

· Has Medicare and Supplement: Term out the Replacement plan and add appropriate supplement plan. Remove coverage related Stop Bill/DNB if applicable and complete from WQ

*To remove Stop Bills and DNBs- see end of process

Duplicate Coverage

Plan listed twice- could be two Medicare with different IDs or same plan just listed twice

· If exactly the same and payer is NOT Medicare: Term the plan that is not attached, Remove coverage related Stop Bill/DNB if applicable and complete from WQ

· If Same coverage for Medicare but has different IDs

· Do not fully term the old Medicare ID Number. The Old Medicare ID should term out some day in 2019 and the new ID would start the day after the old one termed.

· The New ID below should start 7/1/19. Once that is updated it would disappear from account

· If the old ID number has already been billed, do not change the plans.

· Remove coverage related Stop Bill/DNB if applicable and complete from WQ

*To remove Stop Bills and DNBs- see end of process

Coverage Not Effective on DOS

· Verify coverage on Healthia to determine correct insurance.

· Update Payer as needed and attach to HAR

· Remove coverage related Stop Bill/DNB if applicable and complete from WQ

Note- this could be the same plan listed twice but different payers- see below. The correct plan would be the active plan and need to be swapped

*To remove Stop Bills and DNBs- see end of process

Note: WI MA should be billed as WI MA payer, not Medicaid Out of State. If you see this duplicate coverage, ensure the WI MA is the active plan.

Coverage attached to GT but not Attached to HAR

· If active coverage is attached to the GT but not attached to the HAR, link coverage apparently

· Remove coverage related Stop Bill/DNB if applicable and complete from WQ

*To remove Stop Bills and DNBs- see end of process

Coverage not attached is correct but should NOT be added

This typically occurs with VA and Medicare/Medicare Replacements as well as Skilled Nursing Billing. Only one plan should be billed but the other can remain active. **We do not want to add both plans or term either plan.

· Add BI 184 Coverage Review Complete (this will cause account to no longer qualify for WQ)

· Remove coverage related Stop Bill/DNB if applicable and complete from WQ

*To remove Stop Bills and DNBs- see end of process

Insurance looks correct, all coverages active for DOS and no additional changes

· Remove coverage related Stop Bill/DNB and complete from WQ

*To remove Stop Bills and DNBs- see end of process

To Remove Coverage Mismatch Stop Bill:

· Under Account Activities tab, select Modifier Stop Bill [28]

· From the section on the right, all current stop bills on the account will be listed.

· Click the X next to the stop bill(s) you wish to remove. (should all be coverage related stop bills)

· This should cross out the stop bill to have it removed from the account

Note the account in the Add Note section to the left.

To Remove Coverage Related DNBs:

· Navigate to the DNB Icon in the top task bar of the account

· Review the Stop bill reason. And proceed as listed below:

· Account has Stop bill 41404: close out of DNB window and follow steps above on how to remove a stop bill

· Any other Coverage Reason: Select the Override DNB Warning button then Initiate Billing

Utilize the appropriate SmartPhrase based on the action taken:

.COVERAGEISSUE

Working HB Coverage Issues WQ ***. Verified all insurances via Healthia and updated account appropriately. Removed Stop Bill/DNB and completed from WQ.

.COVERAGEISSUENOCHANGE

Working HB Coverage Issues WQ ***. Verified all insurances via Healthia and coverage is currently set up appropriately. Removed Stop Bill/DNB and Completed from WQ.