Background:
The Validator was designed specifically to address the issue of
sending PRIMARY insurance claims to any carrier who accepts
a HIPAA compliant
form file. That being said, there is often a need to also send
secondary claims electronically through the Validator, especially
to Medicare.
There are, however, some limitations
to the Validator’s
ability to send these secondary claims. Specifically, the practice
management
systems which we support simply DO NOT contain the fields necessary
to get claims paid when sent as a secondary. This coordination of
benefits information simply is not available in any of the Lytec
programs, and to be fair, most practice management systems are not
designed to carry this information like they should be.
While this is likely a future enhancement you will see in all practice
management systems, we have a need NOW to send claims in this manner,
as many Medicare intermediaries are either strongly compelling or
outright forcing providers to submit their secondary claims electronically.
Thus we have made sure with our Validator
5.12 that our clients have the ability to send these claims electronically,
with the use
of Lytec’s ability to use custom fields to provide the missing
information.
What you will need:
The changes neccesary to make Validator
able to send the extra fields Medicare has been asking for make
it neccesary for you to have the following in order to be able
to send it:
Setting
Up Lytec
The following fields are required
now in order to get your secondary claims paid.
Claim Level COB Information
•
Coordination of Benefits (COB) Payer Paid Amount
•
Coordination of Benefits (COB) Allowed Amount
•
Claim Adjudication Date
Service Line COB Information
•
Coordination of Benefits (COB) Primary Payer Line Item Approved (aka
Allowed) Amount (AMT02)
•
Coordination of Benefits (COB) Primary Payer Line Item Paid Amount
(SVD02)
•
Coordination of Benefits (COB) Primary Payer Line Item Adjustment
Amount (CAS03)
•
Coordination of Benefits (COB) Line Item Expected Amount (usually this
is the Patient Responsibility Portion)
Note that we should re-iterate that
there are many pieces of information that are required at the detail
level.
This
means
that we have to utilize the billing
detail custom fields which are available only on Lytec XE or newer
versions. If you have the need to send Medicare Secondary Claims
electronically, and are still on Lytec 2001 or prior, we highly
encourage you to upgrade your Lytec system.
Preparing for Medicare Secondary Claims
You will need to set up custom fields to hold the information Medicare
is now requiring. To do this, go to Settings\Custom fields from
within your Lytec program. Click on the Billing tab and fill in
the fields as shown below.
Then click on the Billing Detail tab and fill in the information
as follows.
Now before sending your Secondary Medicare claims off, you will
need to fill in Coordination of benefits information on the charges
and payments screen. Click on Billing\Custom fields to fill in
(in this order):
1. The EOB Date
2. The total claim allowed amount
3. The total claim adjusted amount
Then go to each detail line, click on Detail\Custom Fields to fill
in (in this order):
1. How Much You expect Medicare to Pay for this procedure (usually
the patient responsibility portion)
2. The Primary Insurance Paid Amount for this procedure
3. The Primary Insurance adjusted amount for this procedure
4. The Primary Insurance Allowed amount for this procedure
When filling in the custom fields, you should consider the following:
1. The Line Item Date of Adjudication is Taken from the Claim Adjudication
Date
2. If Claim Detail - Custom Field 3 is not filled in, we will not
pull any information from custom fields 4 and 5 (no adjustment information)
3. All Date custom Fields must be set as a Date field in Lytec
6. All Amount fields must be entered with the smallest number of
characters necessary. For Example, $50.00 would be just 50, $50.50
would be 50.5 and $50.23 would be 50.23.
Finally, when printing the claims, you will need to remember to
make sure to choose types of Claims as “Secondary”
