Thursday, 10 October 2013

Medical Billing Workflow

     Note : In Medical Billing, people use different words for the same thing; Here are those most commonly used;

  • Doctor is also referred as Physician or Provider
  • Doctor Clinic is also referred as Doctor Office, or Physician Office or Provider Practice or Provider Facility; So facility or practice or clinic or office refers to the place where the patient meet the doctor;
  • Insurance is also referred as Payer or carrier
    Use case 1 : In House Billing 
  1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.
  2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc) and insurance information;
  3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);
  4. Each Disease represents by a Code. That code is called ICD. It is also called Dx Codes or Problems or ICD Codes or Diagnosis Codes; So for each patient visit, doctor choose the correct ICD Code; ( ICD means International Statistical Classifications of Diseases. ICD codes are alphanumeric designations given to every diagnosis, description of symptoms and cause of death attributed to human beings.Some example for ICD Codes)
  5. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; (CPT means Current Procedural Terminology codes, are procedural codes published by the American Medical Association, describing what services the provider actually performed on the patient. Some example for CPT Codes)
  6. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient;
  7. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company;
  8. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
  9. Once the Claim is prepared and send to the Insurance company for payment; 
  10. Insurance company pays the doctor office;

     Use case 2 : In House Billing with Two Insurance

    Many patients only have one insurance plan but it is  possible for a patient to have two or three medical insurance policies. The first insurance billed would be
    the primary insurance. The next one billed would be the secondary, and the last would be the tertiary.

    First the primary carrier must be billed first and then balance is billed to the second insurance carrier with the primary insurance payment  information.
    If there is a third or tertiary insurance, it is billed last with payment information from the first two.

  1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment. 
  2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc) and insurance information; 
  3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease); 
  4. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; 
  5. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient; 
  6. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company; 
  7. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting; 
  8. Once the Claim is prepared and send to the Primary Insurance company for payment;  
  9. Primary Insurance company pays the doctor office; 
  10. Billing Department notified that claim has still some balance after Primary Insurance is paid. Since the Patient has another insurance (secondary), so now the billing department send the claim to the patient secondary insurance to collect the remaining balance.
  11. Secondary Insurance Process the claim and pay the remaining amount to doctor office

     Use case 3 : Self Pay

Patients who are not covered by health insurance(does not have any insurance) are considered “self pay” patients. They or the responsible party they designate are totally responsible for their own bill. Not everyone is covered by health insurance. The ones that aren’t covered are considered self pay and just like in the old days, these people must pay for their visits themselves.

  1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment. 
  2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc). 
  3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease); 
  4. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; 
  5. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient; 
  6. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company; 
  7. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting; 
  8. Once the Claim is prepared and since there is no insurance for the patient, so patient statement is generated and send to the patient for payment;  
  9. Patient Receives the Statement and Payment is made to the doctor office.
Use case 4 : Patient Responsibility

Some insurance policies pay a percentage rather than a set amount. Anywhere from 50% to 80% is very common for some insurance policies. Once they pay their  portion, there may be a patient responsibility remaining. This amount is generally billed to the patient after the insurance payment is made.
  1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment. 
  2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc). 
  3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease); 
  4. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; 
  5. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient; 
  6. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company; 
  7. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting; 
  8. Once the Claim is prepared and send to the Primary Insurance company for payment;  
  9. Primary Insurance company pays only 80 % of the Bill to the doctor office; 
  10. Since there is no other insurance for the patient and claim balance is still 20 %, so now the billing department change the responsibility of the balance to patient and patient statement is generated.
  11. Billing Department send the Statement to the Patient.
  12. Patient Receives the Statement and Payment is made to the doctor office.

     Use case 5 : Clearing House Work flow

  1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.
  2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc.) and insurance information;
  3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);
  4. Each Disease represents by a Code. That code is called ICD. It is also called Dx Codes or Problems or ICD Codes or Diagnosis Codes; So for each patient visit, doctor choose the correct ICD Code;

  5. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code;

  6. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient;

  7. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company;
  8. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
  9. Once the Claim is prepared and send to the Insurance company for payment; 

  10. Billing Department using the Practice Management System (PMS), send the claim via EDI File. The EDI Transaction used to create the claim in the Electronic format is EDI 837
    Refer the Following Link to understand more on EDI 837
    What is an EDI ?
    EDI 837 Health Care Claim
  11. Once the 837 EDI File is created, then it will be send to the Clearing House.
  12. Clearing House will validate the EDI File and send to the particular insurance company.
  13. Insurance Company Process the Claim and prepare the Check (Cheque) and Statement(This statement is called Explanation of Benefits OR Remittance Advisory (EOB)          
    Refer the following Link for EOB
    EOB - An explanation of benefits 
  14. Insurance company also generates the EDI 835 File using their System. EDI 835 is electronic version of EOB.
    The Electronic Remittance Advice (ERA), or 835, is the electronic transaction which provides claim payment information in the HIPAA mandated ACSX12 005010X221A1   Format. These files are used by practices, facilities, and billing companies to Auto Posting payments into their systems.
    Refer the following link for Sample

    EDI 835 Health Care Claim Payment/Advice:
  15. Once the Check, Statement (EOB) and ERA File are ready, then insurance company first send the ERA File and EOB to the clearing house.Second , insurance company  will send the Check and copy of the EOB to the billing provider address . Third for each patient in the statement, the copy of the EOB will be emailed.
  16. Now the Billing Team download the EOB and ERA from the clearing house. If the PMS system has Auto Posting Using ERA File, then they will download the EDI File and do auto posting. If there is no auto posting Module, then they will download the EOB PDF and apply posting manually.Remember, some time, ERA/EOB file will be reach the clearing house, even before the insurance company send the payment check to the doctor.

 

     Use case 6 : Lab Billing

  1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.
  2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc.)    and insurance information;
  3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);
    Doctor Wants to check Blood test of the patient, so he request the patient leave the blood sample in the reception.
     
    The above steps are usually handled in EMR Software running inside the doctor office.
    Search Google : EMR lab request

  4. Patient leave the blood sample in the container provided at the reception desk. If the EMR running inside the doctor office are integrated  with Lab LIS, then via HL7, the doctor office place the order using the EMR software. if not integrated, the doctor office staff fill up  lab requisition order form manually and send to the Lab via fax or email. Some LIS System having Doctor Portal where the doctor office staff can login and place the order in the portal.

    Search Google : sample lab requisition form

  5. Every day Lab Transportation department visits the doctor office and pick the patient samples and shifted to Lab on same day.

    Search Google : Lab sample transportation

  6. Once the Lab receives the Order form, it will be assigned to the lab technician to do the blood test. Test technician checks the blood sample  and he prepares the Test result which contains various components with low/high value indication.

    Step (3) 4 are usually handled  in Lab LIS Software running inside the Lab .

  7. Now the Lab has get to paid for their work. Since the patient has insurance, so the Lab team forwards all those information with final result  to billing department to generate the claim and send to insurance company. If the LIS is integrated with Billing software, then information  are send via HL7 to the Billing software. If not, lab team manually pass the information by creating as PDF and forward that to the Billing  department.

  8. Now billing billing department receives the final result with all patient demographics information and insurance information.
    Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge  entry or Charge Posting; 

  9. Once the Claim is prepared and send to the Primary Insurance company for payment;
  10. Primary Insurance company process the claim and send the payment to the Lab;

    Step 6,7,8,9 are usually handled in Practice Management Software or Medical Billing running inside the Lab or Billing company where they outsourced their work.

So three systems are involved (EMR, LIS and PMS) to do Lab Billing.  If the software supports HL7 Protocol, then the information can be easily passed between the system without manual data entry work.

HL7 is the standard to which healthcare application vendors adhere when developing application interfaces to exchange patient data. The HL7 standard defines a method of moving clinical data between independent medical applications in near real time



Example  Conversation during Patient check In process.


Jake : Calls the MyfirstHealth Landline Number.

Linda : Hello, This is Linda from MyfirstHealth Clinic . How can i help you ?

Jake : Hi Linda, My Name is Jake,I would like to meet Dr John today evening after 5 PM.

Can you please confirm doctor appointment is available ?

Linda : Sure, Let me check my records. Yes doctor is available after 5 PM. Do you like book the appointment ?

Jake : Yes Can you please make it at 5.30 PM ?

Linda : Sure. May i know you are coming first time to this clinic or you have already came ?

Jake : This is the first Time;

Linda : Good. May Know your last name, first Name and DOB to make a note in my records.

Jake : My Last Name is Jake; My First Name is : mike; and my DOB is xx/xx/xxxx.

Linda : Ok Got It. Please come 15 min before the appointment, so that we can get all your insurance information,etc.

Jake : Ok Sure.

That's all


At 5.15, Jake arrives the clinic and meet the reception the Linda.
Jake : I am jake, I've appointment with the Doctor John at 5.30 PM

Linda : Welcome Jake; Let me pull your records from the desk.

Jake : Sure

Linda : Jake. Do you have insurance to cover your illness ?

Jake : Yes. I've Insurance.

Linda : Please give your insurance information, so that after the visit, we need to send the bill to the insurance company

Jake : I am working in a company called xxx , My employer covers my health insurance. Do you want to give that insurance
information ?

Linda : Yes Please.

Jake : Here you go. Insurance Name :xxxx. Policy No :xxxx, etc.

Jake : Wait a minute. Apart from my employer insurance, i also have taken family coverage from another insurance.
Do you want to give that information also ?

Linda : Yes Please

Jake : Here you go. Insurance Name :xxxx. Policy No :xxxx, etc.

Jake : Hey apart from employer and my family, I've also have another insurance under my own name ?
Do you want to give that information also ?

Linda : Yes Please
Here what Linda does in the records She marked Employer Insurance as Primary, and Family Insurance as Secondary and Its own Insurance as third.

Jake : Hey i've question. Why you are collecting all my three insurance ?
Linda : Well, Once your visit is over, we will send the bill to your employer information company first and once we receive the payment, we will check whether still the bill has some more balance. If there is balance, then we will send the bill again to your family insurance company and so on.

Jake : Oh it is great process. I got it.

Jake : But I've stupid question if you don't mind.

Linda : Please go ahead

Jake : If you send the bill to my family insurance again, then you will get paid twice :). So you will get two payment
for one service ?

Linda : No it is not like that way it works. Once we receive the payment from your first insurance, if there is  balance, then we will send the bill to your second insurance along with the payment information of your first insurance. So your second insurance will check what is the first insurance paid and then they will pay only the remaining balance.

Jake : Wow that is great.

Jake : What happens if still there is balance in the bill, after my second insurance send the payment.

Linda : Well, since you have third insurance, we will send the bill again to your third insurance with the paid information from your first and second, so now your third insurance will know what has been paid by first and second insurance, then they will pay the remaining balance.

Jake : Wow that is really great process. You lot of work to do :)

Linda : Yes we always at your service sir.

Jake : But still I've another question if you don't mind ?
Linda : No problem. Go ahead

Jake : What happens if my bill still have balance after you paid from my third insurance ?
Linda : Well, Finally we will prepare the statement on your visit which will contains information about the service given and how much we got paid from all your insurance and at the bottom you can see how much you need to pay the balance. The statement will be mailed to you. Once you receive the statement, you can send the payment via check, or any other way.
Jake : Got It. I am done with my questions. Now what i want to do ?
Linda : Well. Please wait for 5 min. Our Nurse or Provider assistant will call you to do preliminary process.
Jake : Thank You.

Friday, 16 August 2013

Maintaining Patient Insurance



How patient insurances are maintained  in the EMR/PMS software's ?
Today, software's are maintaining the patient insurance in difference ways. Each method has its own cons and pros. I will list those methods which i found in my past experience.


Before getting into detail, let us see the terms "Primary",  Secondary, Tertiary and 4th Insurance". In some software, instead of calling 4th Insurance, they will call as Quaternary Insurance.

Actually, there is no defined process or method to identify which is patient primary insurance , and which is patient secondary insurance, and so on. For more details,
please download this article and you will know how it has been identified. Since there is no defined way, most of the time, reception people will enter the secondary insurance information into primary and vice versa. That's the reason, all the software's providing swapping option for the insurance

And also, we should know how secondary insurance billed and get paid. Please download this document to know more on that.
Now let us see how software's are maintaining the patient insurance.

Method 1 : Maintain 2 or 4 insurance at the Patient Level

Here you can always maintain 2 or 4 insurance at active state. Give important to the word "Active" here. But, HIPAA EDI 837 Transaction allow up to  11 insurance.  So what happens, at one point of time, the existing insurance get expired and patient got new insurance ? Well, you cannot remove  that insurance from the system it because it is tightly linked to Billing (Claims) Module. So only the option is to de activate the existing primary insurance and add new insurance in the active state as primary Insurance.

The advantages in this method is : Insurance are maintained only at one place i.e. at the patient level. So any changes done here, it will impact all the claims linked to that.  This might be useful when there is error in the data entry and after the correction, they want to re submit all the claims linked to that insurance.

And also, at one point of time, there will be huge number in the inactive state, and no idea which claims are linked to that.
But what happen, if the patient is coming for two different visit types : For example, you may have a patient that is being treated for injuries sustained   from an auto accident that is covered under one insurance policy; yet that same patient may receive treatment during the same visit for a condition    unrelated to the auto accident where a different policy may be billed. So in this case, you need to maintain two primary insurance dependent on the visit type.In the above method, it is not possible, so that is one of the disadvantage.

Method : 2

Another way is to clone the patient demographics insurance while claim is created and therein after maintain the copy of all insurance at the claim  level. 
 
In this method, initially, the insurance are maintained at the patient level. But when the claim is created, software will take a copy of all insurance and will maintain along with part of the claim details. So here, after the claim is created, the insurance at the patient level is plugged off and will not have tightly linked with the claim. If any error in the policy details, of course, first we should correct at the claim level and then at the patient level for error free future claims.
if the patient is coming for two different visit types, then we can easily handle here because, we need to change only at the claim level.

Method : 3

And final method is patient case. This method not only to maintain the insurance, but it can also provide a template kind of stuff to create same  kind of claim data for the same patient again  and again to save the time.
In order understand, simply you can think patient case is nothing but to maintain group of insurances.  Let us see detail now.

What will be in the patient case. ?
1. Patient case is by patient
2. Software allows to create N number of patient cases for each patient.
3. The following details will be maintained at the patient case

  • Referring Physician
  • ICDs and CPTs
  • Insurance (Here you can define upto 11 Insurance)
  • Insurance Authorization information for each insurance if available
  • ICDs and CPTs
  • For hospital type of visits, maintain different dates such as admitted date, discharge date, accident date, etc..

Creating individual cases for why a patient is being seen by a provider simplifies the selection of insurance policies and the order in  which two or more insurance plans may be billed for various types of treatment and conditions. For example, you may have a patient that is being    treated for injuries sustained from an auto accident that is covered under one insurance policy; yet that same patient may receive treatment during   the same visit for a condition unrelated to the auto accident where a different policy may be billed.
 
Creating individual cases for patient treatment also simplifies how paperwork and claims are processed when a case involves an attorney lien or    Workers' Comp claim. For example, you could have an existing patient that has been previously seen for an illness; and later sustains an injury at his    place of employment that may involve a worker's comp claim. How claims are handled for each of these two cases is quite different. In a situation like    this, you would simply locate the existing patient record; and then create a new case for that patient that covers treatment for his injury.
In this method, we can maintain different set of primary, secondary, etc. depending upon the visit types. And also, collecting insurance from the patient is handled by the front desk people and creating the claim for the visit handled by the back office people. So there is no idea for the billing people which insurance has to select on the claim, because they may not aware what is the purpose of the visit.

If we maintain case, then it is job of the front desk to select the case at the appointment level or at the check in level. Then this will be helpful for the billing team to generate the claim for the insurance for the selected case and send to the insurance company.

Happy Insurance Maintaining !!!!!!


Welcome to the Most challenging part of the Medical Billing !!!!

Interested to see some sample screen shots for Patient case ?
Here you go.

        

Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com.

Saturday, 20 April 2013

EDI 270–5010 Documentation - ISA – Interchange Control Header

 

            

ISA – Interchange Control Header  

The ISA is a fixed record length segment and all positions within each of the data elements must be filled. The first element separator defines the  element separator to be used through the entire interchange. The segment terminator used after the ISA defines the segment terminator to be used throughout the entire interchange.This results in the segment terminator always being in position 106.


PMS Product Reference

image


  Seg ID Segment Name Format Length Ref# Req Value
Header ISA Interchange Control Header 3 R ISA
Element Separator AN 1 *
ISA01 Authorization information qualifier ID 2/2 101 R 00 or 03 See below for more information
Element Separator AN 1 *
  ISA02 Authorization information AN 10/10 102 R Will contain User ID if ISA01 is 03.
Will Contain 10 Empty spaces if ISA01 is 00
    Element Separator AN 1     *
  ISA03 Security information qualifier ID 2/2 103 R Will Contain 01 if ISA01 is 03.
Will Contain 00 if ISA01 Is 00.
    Element Separator AN 1     *
  ISA04 Security information AN 10/10 104 R Will contain Password if ISA01 is 03.
Will Contain 10 Empty spaces if ISA01 is 00
    Element Separator AN 1     *
  ISA05 Interchange ID Qualifier ID 2/2 105 R ZZ
    Element Separator AN 1     *
  ISA06 Interchange Sender ID AN 2/15 106 R See below for more information
    Element Separator AN 1     *
  ISA07 Interchange ID Qualifier ID 2/2 105 R 01
    Element Separator AN 1     *
  ISA08 Interchange Receiver ID AN 15/15 107 R See below for more information
    Element Separator AN 1     *
  ISA10 Interchange Time TM 4/4 109 R Current Time in HHMM Format
    Element Separator AN 1     *
  ISA11 Repetition Separator ID 1/1 110 R ^
    Element Separator AN 1     *
  ISA12 Interchange Control Version Number ID 5/5 111 R 00501
    Element Separator AN 1     *
  ISA13 Interchange Control Number NO 9/9 112 R 000000001 (See below for more info)
    Element Separator AN 1     *
  ISA14 Acknowledgement required          
    Element Separator AN 1     *
  ISA15 Usage indicator ID 1/1 114 R P or T (See below for more details)
    Element Separator AN 1     *
  ISA16 Component Element Separator   1/1 115 R : (semi colon). this value must be different than the data element separator and the segment terminator
    Element Separator AN 1     *
               

Sample:  

ISA*00*          *00*          *ZZ*8431           *ZZ*ZIRMED         *130215*1234*^*00501*000000001*1*P*:~


Important Note on the above sample:
ISA02
Since ISA is fixed length segment, even though if no values are present, we need to fill up empty spaces. Here ISA02 is filled with 10 empty spaces.

ISA04
Since ISA is fixed length segment, even though if no values are present, we need to fill up empty spaces. Here ISA04 is filled with 10 empty spaces.

ISA06
Since ISA is fixed length segment, if the value is not 15 characters length, then we need to append empty space to make 15 characters string.

ISA08
Since ISA is fixed length segment, if the value is not 15 characters length, then we need to append empty space to make 15 characters string.


Segment Structure  

image



Sample 2
ISA*03*id27032743*01*XYXY2233  *ZZ*XX09211223     *01*030240928      *130829*1102*^*00501*290811021*0*T*:~

User Name and Password
In some clearing house, they might ask to send the user name and password along with each EDI file. That's what Authorization information Information refer ISA01, ISA02,ISA03 and ISA04.  After you sign up with the clearing house, ask your user name and password to send along the EDI File if they need.  In such case, ISA01 will have the value"03" , ISA02 will have the user id, ISA03 will have the value "01" and ISA04 will have the actual password. Very important, since ISA is fixed length segment, and ISA02 is 10 character, so if your user id is less than 10 characters, then you need to append empty spaces to make it as 10 character word.
 
Sample with the User id and Password.

 

Segment Structure  
image



ISA01 - Authorization Information Qualifier
Code to identify the type of information in the Authorization Information
Code Definition
00 No Authorization information Present(No Meaningful information in 102). Advised unless security requirements Mandate use of Additional identification information.
03 Additional Data Identification.

 


ISA03 - Security Information Qualifier
Code to identify the type of information in the Security information qualifier

Code Definition
00 No Security information Present(No Meaningful information in 104). Advised unless security requirements Mandate use of password data.
01 Password

 

ISA05, ISA07- Interchange ID Qualifier
Code to identify the type of information in the Security information qualifier

Code Definition
01 Duns(Dun & BradStreet)
14 Duns Plus Suffix
20 Health Industry Number (HIN)
27 Carrier Identification Number
28 Fiscal Intermediary Identification Number.
29 Medicare Provider and Supplier Identification Number
30 U.S Federal Tax Identification Number
33 National Association Of Insurance Commissioners Company Code (NAIC)
ZZ Mutually Defined



ISA06 – Interchange Sender ID
During the sign up process with clearing house, they will assign a unique ID to the software vendor. So in the practice information setup, software should have a option to enter this value. This is mandatory for all the EDI Files, without this ID, clearing house will not be able to process the file.

ISA08 – Interchange Receiver ID
During the sign up process with clearing house, they will provide this value. Usually, this will be clearing house name. So in the practice information setup, software should have a option to enter this value. This is mandatory for all the EDI Files, without this ID, clearing house will not be able to process the file.

ISA13 – Interchange Control Number
Control Number assigned by the Sender for tracking purpose. This number must be identical to the Interchange Trailer IEA02. Ever time
when creating the EDI File, software can generate a unique number to identify the batch for later case to track. 

ISA14 - Acknowledgment Requested.


Code Definition
0 No Acknowledgment Requested
1 Interchange Acknowledgement Requested

Default to 0. In some cases, if the software vendor integrated to clearing house via web services. then we can ask the clearing house to send the acknowledgment for each EDI File batches.

ISA15 – Usage Indicator.

Code Definition
P Production Data
T Test Data

After the  sign up process with clearing house, they will ask the software vendor to send sample files with different use cases. In such cases, all the files should be send as Test Data. So in the practice information setup, software should have this option to select. Once test files are approved, then software admin can change this value to Production.

 

            



Questions or feedback are always welcome.


Thursday, 21 March 2013

Medical Billing Process

        

Medical Billing is a Process of Submission of Bills/Claims to the Insurance Company in a specified format for the service rendered (for the treatment given) by the doctor for the patient. Why the doctors approach the insurance company for the payment? Since the Majority of patients has insurance coverage and details of such coverage are provided to the doctor before the treatment. So it is the responsibility of the doctor to send the claims to the insurance company and get paid for the treatment given.

Here is the overall medical billing process. In the later section, we will see more detail on each section.

image

Insurance Verification:
Process started from here and usually front desk people are doing this process. Its a process of verifying the patients insurance is active or inactive by calling insurance or  through online verification. If the insurance is inactive, it does not make any sense to send the claim/bill to the insurance company to get paid. So the front office people have to make sure that patient insurance is active even before the patient appointment. If the insurance is not active, then they have to collect the fee from the patient itself(In medical billing, this normally called as Self Pay claim or Patient Responsibility claim).

Charge Entry:
Charge entry is nothing preparing the claim to be sent to the insurance company. After getting the treatment details and patient disease details from the doctor, the billing department will start preparing the claim.The claim details, that are needed to get your insurance claims processed are entered here, and includes, the face sheet of the patient, doctor details, information about the insurance coverage of the patient and billing information.

Payment Posting:
Payment posting is simply posting payments from the insurance company into the system. The insurance company sends a check along with an Statement(This is statement is called as Explanation of benefit , shortly as EOB). On the EOB the insurance company will tell you the allowed amount and the amount they paid.

Denial Management:
The insurance companies reject(deny) paying claims for a number of reasons. Incomplete claim form, inconsistent patient information, etc.The insurance company indicates the reason for the denial in the Statement. Billing department will resolve those errors and again submit the claim to the insurance company.

Here is the overall medical billing process. In the later section, we will see more detail on each section.


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Questions or feedback are always welcome. You can email me at vbsenthilinnet@gmail.com.

Friday, 8 February 2013

ZK Passing Parameter between two files using MVVM–Part 2

Overview

This is the first series of articles about Passing parameter between two zul files using MVVM Design pattern.This article will focus on the how to pass values from the parent window to child window opened in modal mode.

ZK Passing Parameter between two files using MVVM–Part 1

Overview

This is the first series of articles about Passing parameter between two zul files using MVVM Design pattern.This article will focus on the how to pass values from the parent window to child window opened in modal mode.

Tuesday, 5 February 2013

ZK Passing Parameter between two files using MVC - Part 5.

Overview

This is the fifth series of articles about Passing parameter between two zul files using MVC Design pattern.This article will focus on the How to return values from the child window (Modal) to the Calling Parent Window using sendevent.

ZK Passing Parameter between two files using MVC - Part 4.

Overview

This is the fourth series of articles about Passing parameter between two zul files using MVC Design pattern.This article will focus on the How to return values from the child window (Modal) to the Calling Parent Window.

MVVM CRUD with Spring 3.1 and Hibernate 4 and ZK - Part 5

This article focus on Delete function.

Monday, 4 February 2013

ZK Passing Parameter between two files using MVC - Part 6

Overview

This is the sixth series of articles about Passing parameter between two zul files using MVC Design pattern.This article contains real world example for passing and returning values from the window.

Move List box item up and Down using MVC Design Pattern

Let us see how we can implement Moving the list box item up and down. In almost all the application, we need to change the order of the record that are displayed in the list. Say for an example, if you are defining questions for the subject/exam, then question order is very important. So this example shows how you can change the order of the question using up and down button.

MVVM CRUD with Spring 3.1 and Hibernate 4 and ZK - Part 4

This article focus on Viewing (Read only Mode) existing address in the modal window.

Sunday, 3 February 2013

Move List box item up and Down using MVVM Design Pattern

Let us see how we can implement Moving the list box item up and down. In almost all the application, we need to change the order of the record that are displayed in the list. Say for an example, if you are defining questions for the subject/exam, then question order is very important. So this example shows how you can change the order of the question using up and down button.

Saturday, 2 February 2013

MVVM CRUD with Spring 3.1 and Hibernate 4 and ZK - Part 3

This article focus on Editing existing address in the modal window.

ZK Passing Parameter between two files using MVC - Part 3.

Overview

This is the third of a series of articles about Passing parameter between two zul files using MVC Design pattern.This article will focus on the How to pass some arguments from one window to modal window.

Monday, 28 January 2013

Sunday, 13 January 2013

ZK Passing Parameter between two files using MVC - Part 1.

Overview

This is the first of a series of articles about Passing parameter between two zul files using MVC Design pattern.This article will focus on the How to pass some arguments from one window to modal window.