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This release was focused on logic updates for claim and ERA processing.
Summary
This release was focused on logic updates for claim and ERA processing.
Enhancements & Filled Gaps
Update CMS1500 preview fields to use conditional logic
The logic was updated on the CMS1500 preview to match the backend logic.
The table below summarizes the updates:
|
CMS1500 Field |
Logic |
|---|---|
|
Use Supervising NPI in HCFA Box 24 |
If bill_to_supervising_npi is true, and the supervising NPI is present, then the supervising provider’s NPI’s in 24J If bill_to_supervising_npi is true, and the supervising NPI is not present, then use the rendering provider NPI in 24J If bill_to_supervising_npi is false, then default to rendering provider NPI in 24J |
|
Include Facility Info in HCFA Box 32 |
include_service_facility_location= True, then box is checked include_service_facility_location= False then, the box is unchecked |
|
Include Taxonomy in HCFA Box 24 |
include_taxonomy_in_box_24j= True, then the box is checked include_taxonomy_in_box_24j= False, then the box is unchecked |
|
Include Taxonomy in HCFA Box 33 |
include_taxonomy_in_box_33= True, then the box is checked include_taxonomy_in_box_33j= False then, the box is unchecked |
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Create a task for invalid dob from sync
When a patient find has a future DOB, a task will be created for the provider to update the DOB in the source system.
Unable to download files with special characters in the filename
Gentem users were unable to download and open files with special characters. This issue has been resolved.
Wrap working status
The working status in the Gentem Portal was overlapping other columns within the claims table. The Status was wrapped so that the columns no longer overlap.
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OA 23 updates
Logic was updated for ERA processing when OA 23 is present ensure payments are posted appropriately.
The logic includes:
-
When OA 23 is present on the ERA and secondary insurance pays, only post the payment.
-
When OA 23 is present and partial payment and patient responsibility (PR1, PR2 or PR3 present), do not post OA 23 should not be posted as an adjustment.
-
When OA 23 is present on the ERA and there is no payment or patient responsibility, post OA 23 as a denial but adjustments can be posted for the amount reflecting the primary patient responsibility.
-
When secondary insurance process the claim with payment, but the payment amount is less than the primary patient responsibility post the payment. The remaining balance should be adjusted under OA 23.
-
When the secondary EOB has a denial code other than OA 23 (PR 27, PR 204, PR 96, PR26 etc.) Post the denial so that AR can work the claim as a denied claim.
Fixed Bugs
Unable to download files with special characters in the filename
Gentem users were unable to download and open files with special characters. This issue has been resolved.
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Wrap working status
The working status in the Gentem Portal was overlapping other columns within the claims table. The Status was wrapped so that the columns no longer overlap.
SimplePractice Specific Updates
No specific updates for SimplePractice customers at this time!