SpokeChoiceBillingEDI Analysis - Billing Process Steps 1, 2 & 3

EDI Analysis - Billing Process Steps 1, 2 & 3

SpokeChoice billing is a 3-step process for filing claims to billing companies. This articles describes these steps and how to use the EDI Analysis interface to start, monitor, and complete the billing process.

EDI stands for Electronic Data Interchange. It is the ability to have a standard method for businesses to communicate information. See Understanding 837/835/TA1/999 files and CPT Codes at the bottom of this article for information about the EDI files.

Step 1 - File Claims

The 837 file is generated by SpokeChoice and contains claim information you select in the Home Care>Billing page and Ready To File view.

Claims are submitted to DDD through the 3rd party billing website user interface. You may submit all claims in the Billing-Ready To File section of SpokeChoice to the 3rd party website through a special file called an 837 file.

To download the 837 file from SpokeChoice:

  1. Go to Home Care>Billing and select the Ready To File view.
  2. Select the start/end date range and click Search. 
  3. Click the Download 837 button to create and download the file to your system Downloads folder. 
  4. Last, log into 3rd party billing website and follow their instructions to upload the 837 file.

After you upload the 837 file in the billing website, it is critical that you continue to Step-2 to ensure your claims were accepted.

Step 2 - Check Filing Status

Sometime after uploading an 837 file, the 3rd party billing website will perform a 2-step analysis of the file.

First, the file will be analyzed for basic formatting errors and a TA1 file will be ready for you to download from the 3rd party website. This is a special file that contains instructions for SpokeChoice to know if there were problems. If problems were found, SpokeChoice will delete the claim batch so the claims can be submitted again. Failure to check a TA1 file could lead to the claims not being paid.

To load a TA1 file into SpokeChoice to check for errors:

  1. Download the TA1 file from the 3rd party website. The file should go to your device downloads folder.
  2. In SpokeChoice, go to ths EDI Analysis app.
  3. Upload/load the TA1 file into SpokeChoice using the Step 2 section. SpokeChoice will let you know if the file was accepted or rejected. If a TA1 file indicates the 837 file was rejected, SpokeChoice will delete the claim batch so the claims can be resubmitted. If a TA1 indicates the 837 was rejected AND you are not sure why it was rejected, please send the 837 file to SpokeChoice support so it can be analyzed. Note: It is common for a TA1 to indicate claims were rejected if your Sender ID is incorrect. Do not worry about sending the 837 to us, rather correct your Sender ID. If you are not sure how to do that click here to determine your sender ID

Note: If everything in the TA1 file indicates your file was accepted but you do not receive a 999 file you will need to contact Wellsky/DDD and let them know their system is not working.

To load a 999 file into SpokeChoice to check for errors:

  1. Download the 999 file from the 3rd party website. The file should go to your device downloads folder.
  2. In SpokeChoice, go to ths EDI Analysis app.
  3. Upload/load the 999 file into SpokeChoice using the Step 2 section. SpokeChoice will let you know if the file was accepted or rejected. If a 999 file indicates one or more claims in an 837 file were rejected, SpokeChoice will delete the claim batch so the claims can be resubmitted.

Step 3 - Reconcile

The 835 file containing information about claims that were sent for payment and were either paid or denied. Uploading this file into SpokeChoice will perform reconciliation on the claims. It is important to note that an 835 file may not contain all claims from a 837 file/batch. That is to say that claims submitted through an 837 could be returned in multiple 835 files. Don't worry about this, just be sure to upload all 835 files from the 3rd party website into SpokeChoice.

The process of reconciliation marks claims in SpokeChoice as paid or denied. Remember that an 835 file may contain some or all of the claims from one or more 837 files. You may receive multiple 835 files (i.e. one per day) for claims submitted in an 837 file.

To reconcile claims:

  1. Download the 835 file from the 3rd party website. The file should go to your device downloads folder.
  2. In SpokeChoice, go to Home Care>Reconciliation>Automatic Payments.
  3. Upload the 835 file into SpokeChoice using the Upload 835 section and follow the prompts.

Notes:

  1. If you receive a denial for reason precertification/notification/authorization/pre-treatment exceeded this is a FOCUS issue for which you need to put in a ticket and ask DDD to fix it. This is not something you have done incorrectly or lack authorizations for.
  2. When you upload the 835 file into SpokeChoice and get an error indicating the file is not an 835 file, you must verify the 835 file you obtained from Wellsky. Open the file in a text editor but do not attempt to modify the file! The file should start with something like: ST*835*1234~
    If it does not please notify Wellsky of the problem.

Understanding 837/835/TA1/999 files and CPT Codes

837 is the standard within that EDI document for exchanging information between healthcare partners, mostly for sending claim information to insurance companies. Medicaid has adopted this standard.

People claim that the 837 is HIPAA compliant but this isn't true. Because it is a text file, albeit difficult to read, the information contained is readable by a human with the assumption you understand loops and segments.

CPT codes

A CPT code (Current Procedural Terminology) is the standard billing code that is used when billing a payer. Sometimes it is referred to as a HCPCS code (Healthcare Common Procedure Coding System). You are familiar with the three letter code used by DDD to bill. In order for DDD to be reimbursed by the state for those services they have to translate the 3 letter code to the CPT code internally. They will now require you use the industry standard for biling codes. They have provided a translation document so you understand how to map the 3 letter code to the CPT/HCPCS code.

 

You can find the rate conversion chart and other documents here.

CPT Unit Multiplier.

Some CPT codes require you bill by 15 minute or 30 minute increment. We call this a multiplier. The reason we call this a multiplier is so that you can still pay someone for an hour of service and bill by the multiplier. Otherwise employees would need to be paid by 15 minute rates on some services and 60 minute on other services.  Keep in mind that authorizations are given out by the "unit". Which means that if someone gets 100 hours of service and it has a multiplier of 4 then they would have 400 unites of that service.  You will still pay the employee by the hour regardless of what the payer multiplier is. SpokeChoice will calculate the amount of auths against the time that the member is served. Keep in mind the rates for a given CPT will be by the UNIT. Which means you can calculate the hour amount by multiplying the multiplier times the rate. You will ALWAYS put in the unit price into SpokeChoice and not the hourly amount.

835

835 files are EDI files but contain remittance information for payment (or denials). These files are used to mark claims as paid and be uploaded to SpokeChoice.

TA1

TA1 files is an acceptance file that indicates if the 837 file you've uploaded was accepted or not. Using the EDI Analyzer within Spokechoice you can easily decode the information and it is not necessary to learn how to read it.

999

999 Files are syntax EDI files that indicate what was wrong with the 837 file that was uploaded. Again, you can use the SpokeChoice EDI analyzer to read these files and do not need to guess or learn how to read them, which is almost impossible.

Diagnosis Pointers

A diagnosis code pointer is called such because of how it was entered on the old 1500 form. Below you'll see that there are 12 places for diagnosis codes

Then on each claims within the 1500 form you will see a column called diagnosis pointer

If you were to enter F89 as a diagnosis code in 21A then the diagnosis pointer in 3 would be "A". This is to say that the claim you are billing for is for the diagnosis of the patient of F89 found in box A.

The good news with all this mess is that SpokeChoice handles it but it has to know based on the "billing code", ie: S5152, you are billing with a certain diagnosis code. This means that every client has to have a billing code pointer to each diagnosis code the member might have.  Understand that certain billing codes go with certain diagnosis codes. It is up to you to ensure you have assigned the proper billing code to the proper diagnosis code or run the risk of denial when the claim is submitted. This only has to be setup once per member/diag/CPT code and not each time you are billing a claim.