CREATIVE PLAN BUILDING

PRESENTED BY: FRED PORTER , YONETTE BOWEN AND CHARLEEN MULLANEY

AG E N DA

• Episode Records

• Pre-Certification Requirements

Benefit Plan Setup

Adjudication Logic Setup

• ICD9 and ICD10 Category Definitions

• Dental Logic

• Copay by DOS

• Out of Network payment options (Creatively!)

EPISODE RECORDS

E L I G I B I L I T Y / E N R O L L M E N T

O P T I O N S / U T I L I T I E S

I N D I V I D U A L / PAT I E N T E P I S O D E S

I N D I V I D U A L / PAT I E N T E P I S O D E S

• If any exist a list will appear

C R E AT I N G R E C O R D S• Select (A)dd to create new record. Patient

information will populate

E P I S O D E R E C O R D H I G H L I G H T S

• Pricing methods

P R I C I N G O P T I O N S

• NORMAL PRICING

Allows you to attach multiple Providers to a single

episode

• EVENT PRICING

Allows you to attach a single Provider to a single

episode

• CASE PRICING

No Providers are attached to the episode

A D D I N G P R OV I D E R S

• Search for Provider to add.

A D D I N G P R OV I D E R S• Can add single or multiple Providers. Depending

on Case Price Method

AC T I O N S / R E A S O N• Exceed Except is most common. Will create EXC

when conditions of Pre-Cert are not met.

P R OV I D E R VA L I DAT I O N• Can select all Providers with same TIN or a Single

Provider assigned by System ID

N E T W O R K M ATC H I N G

• NOT for forcing In-Network

P E N A LT Y O P T I O N S

• Network, Penalty or Force the Network?

AC C E P TA N C E O F T H E R E C O R D• Exact matching or “some” matching

R E V A N D D I AG N O S I S C O D E S

• Enter your codes required for this Episode

I C D , H C P C S A N D C P T C O D E S• Add other necessary Service Codes here

C O D E RA N G E S

• Always put “from” and “through”.

O T H E R I N F O R M AT I O N• Authorized/Accumulated and Comments

P R I C I N G O P T I O N S

• Command line options of pri(C)ing

P R I C I N G O P T I O N S• Can price claim differently for each Episode

AC C E S S I N C L A I M S• Can access Episode to view during Claims

Processing

E X I S T I N G E P I S O D E R E C O R D S

• Can Identify Case Record vs. Manual Episodes

PRE-CERT SETUP PLAN BUILDING

P R E - C E RT V I A B E N E F I T P L A N• Per Benefit Plan setup. Plan details.

D E F I N E D S E RV I C E S

• Can add multiple Categories requiring Pre-Cert

C AT E G O RY D E F I N I T I O N S

• F4 will allow for searching Categories

D E N Y N O N - P R E C E RT E D C L A I M S

• Can auto-deny if needed

S E PA RAT E P R I C I N G O P T I O N S

• Can apply separate pricing if needed.

P R I C I N G O P T I O N S

C A N U S E S E PA RAT E S C H E D U L E

S E PA RAT E B E N E F I T S C H E D U L E• If enter “Y”, will see different schedule option

B E N E F I T E XC E P T I O N P E N A LT I E S

• Can apply Non-Precert Penalties

B E N E F I T E XC E P T I O N P E N A LT I E S

• Can Penalize by percentage or flat dollar

C A N P E N D AT E XC E P T I O N L E V E L• Can choose to Pend even if no Penalty set

PRE-CERT SETUP ADJ. LOGIC

A D J U D I C AT I O N LO G I C• Same Benefit Code can be set two ways

A D J U D I C AT I O N LO G I C• Same code Pend if no Pre-Cert

A D J U D I C AT I O N LO G I C

ICD9/10 CATEGORIES

C AT E G O RY D E F I N I T I O N S• ICD9 and ICD10 options on same Category

I C D 9 D I AG N O S I S C O D E S• Same options for both codes

I C D 9 C O D E E N T RY• Separate ranges for ICD9 codes

I C D 1 0 D I AG N O S I S C O D E S

I C D 1 0 D I AG N O S I S C O D E S• Separate ranges for ICD10 codes

H C FA F O R M• Same options for HCFA form

H C FA F O R M

• ICD9 Code ranges

H C FA F O R M

• ICD10 code ranges

DENTAL LOGIC

W H AT C A N D E N TA L LO G I C D O ?

• Dental logic is by Group. If it is set up, it is used.

• Ability to do multiple things on one ADA code

• Ability to change ADA codes or use a particular Benefit

Code as in regular Adjudication Logic.

• Multiple variations on Tooth, Arch, Quadrant and Provider.

• Patient Age Limitations

• Limitations base on services Reported With, History of or

Without History.

D E N TA L LO G I C

• All U/W, Groups within single U/W or single Group

D E N TA L LO G I C

• Rules are set per ADA Code

D E N TA L LO G I C• Multiple options for what to do with the Code

D E N TA L LO G I C

D E N TA L LO G I C

• Age based limitations without using Benefit Exceptions

D E N TA L LO G I C• Multiple rules for same Code

D E N TA L LO G I C

• Dental Claims Processing. Entered D1120

D E N TA L LO G I C• Switches ADA Code to D1110

D E N TA L LO G I C• Also ensures use of Benefit Code 902

D E N TA L LO G I C

• Conditional exception without using Benefit Exceptions

D E N TA L LO G I C

• One issue: Can’t use “Pay as MM” option in Group Master set up.

COPAY BY DOS

C O PAY D E F I N I T I O N S• Add Office Visit and Lab Categories and designate

Inpatient Codes

TA B L E O F C O N T E N T S -B I L L T Y P E• Bill Type defines In-Patient Confinement

B I L L T Y P E

• Control Flag equal to “I” for Inpatient

C O PAY P L A N S E T U P

• Set at each Basic Policy Information screen

C O PAY BY D O S• Warning will appear on initial set up

C O PAY BY D O S

• Inpatient can be Day or Stay

C O R E R E Q U I R E M E N T S

• Type of Service Code input for Inpatient and Office Visits

C O R E R E Q U I R E M E N T S• F4 for list of 270/271 Service Types

D E D U C T I B L E O P T I O N S

• New in 4.11.0!!

L A B C L A I M O P T I O N S

• What to do when Lab claim comes in before Office Visit?

C O PAY E XC E P T I O N S

D E D U C T I B L E O P T I O N S• Exception options for Deductible

OON PENALTY OPTIONS

E X E M P T C AT E G O RY O P T I O N• Penalize…”except when…”

E X E M P T C AT E G O RY O P T I O N• Can add categories such as Emergency or

Ambulance.

E X E M P T P R I C I N G O P T I O N• Separate pricing if needed

Any Questions?