Since September 1st 2022, FOCUS switched to an Electronic Data Interchange (EDI) process for billing. This process consists of:

1. Agencies submit an 837-file with claims being billed to WellSky.
2. WellSky should then return a TA1-file & 999-file indicating (a) claims rejected due to errors and (b) how many claims were accepted and will be sent to FOCUS for payment. When these files are read into SpokeChoice, the rejected claims are marked READY so you can fix and resubmit them.
3. Once FOCUS pays or denies claims, it notifies WellSky at which point WellSky should create an 835-file containing information about how FOCUS dealt with the claims. When you read an 835-file into SpokeChoice, PAID claims are marked PAID, DENIED claims are marked READY so you can fix and resubmit them.

Since September, the FOCUS/WellSky EDI process has been plagued with bugs making it difficult to (a) get paid, (b) know which claims were rejected, (c) know what was paid and (d) know what was denied. As a result, the SpokeChoice support staff have taken the brunt of questions/complaints/concerns about these issues. SpokeChoice support & development teams have spent hundreds of hours attempting to understand the issues and where possible provide careful checks in the SpokeChoice software to prevent many of the EDI issues from occurring. However, in December 2022 we identified several bugs in the FOCUS and WellSky systems that are out of our control. These bugs (referred to as EDI bugs) include but are not limited to the following:

1. TA1/999-Files Not Always Returned - It has been reported that many 837-files have been submitted to WellSky but a TA1-file and/or 999-file were not returned as they should have been.
2. 835-Files Are Not Returned - It has been reported that claims paid by FOCUS do not get reported in a WellSky 835-file.
3. 835-Files Are Incomplete - It has been reported that even though an 835-file is returned and some claims are noted as paid/denied, that other claims that were paid/denied were not in the file. Some 835-files were found to be empty.
4.  When an 835 should have rejected claims "before" it went to FOCUS Wellsky should have returned something but failed to do so, leaving claims in SpokeChoice as "submitted" waiting for an explanation.

TA1/999-File Not Returned - If Harmony (WellSky) rejects a claim and it never gets sent to FOCUS and a 999-file is not returned, SpokeChoice is never notified, and the claim will remain in the SUBMITTED state and will go unpaid.

835-Files Are Not Returned - When FOCUS has paid/denied a claim and an 835-file is never returned, the claim remains in the SUBMITTED state.

835-Files are Incomplete - When FOCUS has paid/denied a claim and an 835-file does not include the claim information, the claim remains in the SUBMITTED state

The result of these bugs has left hundreds of thousands of SpokeChoice claims stuck in the SUBMITTED state. Some agencies have manually changed claim state to READY and resubmitted the claim. This does not always work because of the EDI Bugs mentioned above. Here is a list of possible outcomes of doing this:

1. If WellSky rejects a claim but never returned it in a 999-file, the subsequent claim is rejected again and may or may not be indicated in a 999-file leaving you to think it might be paid.
2. If FOCUS actually received and paid the claim but it was not reported in an 835-file, the subsequent claim will be rejected by WellSky as a DUPLICATE. This action may or may not be reported in a 999-file or 835-file once again leaving you to think it is being processed for payment.
3. If FOCUS actually received and denied the claim but it was not reported in an 835-file, the subsequent claim will be resent to FOCUS and will be once again denied. This action may or may not be reported in a 999-file or 835-file once again leaving you to think it is being processed for payment.

The end results of these EDI bugs could be:

1. You are paid but the claim is stuck in an endless SUBMITTED loop or is in the ready state but constantly comes back as a duplicated denied state.
2. You are not paid and the claim is stuck in an endless SUBMITTED loop leaving you unaware of often simple issues you can fix to get paid.

We have temporarily circumvented the 835-file reconciliation process by using PBS Billing Detail Reports from the FOCUS website. This is in addition to any TA1/999/835-files you receive which should be loaded first.

The main issue the EDI bugs cause in SpokeChoice is that claims are "stuck" in the SUBMITTED state even though they may have been rejected by WellSky, or paid/denied by FOCUS.

The temporary process is:

1. Agencies submit an 837-file with claims being billed to WellSky.
2. Hopefully WellSky will return a 999-file which you must load into SpokeChoice. If a 999-file is not returned, some claims could be rejected, and you will not know. These will be fixed by the Reset Stuck Claims feature described later.
3. Once FOCUS pays or denies claims, you should first look for any 835-file(s) which you must load into SpokeChoice. As noted above, you may not get an 835-file or it may not include all paid/denied claims.
   Always load all the files you get even if you do not believe they are accurate.
4. Download PBS-file(s) from FOCUS and load them using the EDI Workaround App.
5. A week after some claims have not been paid/denied, use the Reset Stuck Claims feature in the EDI Workaround to change SUBMITTED claims to READY so they can be resubmitted. This feature only changes claims for service dates preceding the Last Paid Date from all loaded PBS files.

The EDI Workaround is not a perfect solution. Some claims may not be matched by loading PBS files. This is especially true if you have manually marked claims from SUBMITTED to READY. In these cases, you will still need to manually update these claims using information from the PBS files and/or WellSky.

PLEASE NOTE: This workaround is TEMPORARY and reading in your 999-files & 835-files (if you are lucky enough to get them) is still REQUIRED.

The first step in using EDI Workaround is to download all PBS file from FOCUS.

1. Login to FOCUS and click on Vendor PBS Reports.

2. Select Provider Billing Detail Report to view past bills.

3. Set Claim Status to All.

4. Set Report Format to EXCEL.

5. Click on the Bill ID for each bill between 9/1/2022 and TODAY. It is not necessary to retrieve bills prior to 9/1/2022. These files are referred to as PBS Files.

!! PLEASE NOTE: ONLY EXCEL FILES CAN BE LOADED INTO SpokeChoice !!

PRO TIP: When you click on a Bill Id on the FOCUS page, the page will scroll to the top forcing you to scroll down each time. If you hold the Control key down when you click (Ctrl+Click), the window will not scroll down each time.

The PBS files are downloaded to your device and saved in the Downloads folder.

From the SpokeChoice main window, click on the EDI Workaround App icon.

Please note that only users with the Super Admin role are able to view & use this app.

This screen contains 2 buttons used in the EDI Workaround process:

• Select File - This button will load a PBS file that has not already been loaded.
• Reset - This button is used after all PBS files from 9/1/2022 to the current date have been loaded. This button will fix all stuck claims as described in this article.

The grid at the bottom of the page shows the previously loaded PBS files and their status. The columns are as follows:

• Date - The date the file was loaded.
• File Name - the name of the file you loaded.
• Billing ID - the Bill ID found in the PBS File. This is also the number you clicked on in the FOCUS Billing Detail page to download the PBS File.
• Last Date Paid - This is the greatest claim payment date found in the file.
• Aggregated Claims - This is the number of payments in the file. Each payment represents 1 or more SpokeChoice claims since claims for the same client, service, date are aggregated (grouped) together and submitted as a single entry.
• Individual Claims - This is the number of claims that were matched against the aggregated claims. For example, if a file contained a single aggregated payment representing 2 SpokeChoice claims, the Individual Claims number would be 2.
• Claims Paid - This is the number of SpokeChoice claims that were marked PAID.
• Claims Denied - This is the number of SpokeChoice claims that were marked DENIED.
• Unmatched Claims - This is the number of payments in the file that the process could not identify SpokeChoice claims for. Most payments should be matched. However, if you manually modified claims as paid, denied, etc, it is possible they couldn't be matched.
  For example, if a single payment represents 2 aggregated SpokeChoice claims and you manually marked 1 of them and resubmitted the other, it is likely the payment will not be matched.
  You will need to manually lookup and update these claims in SpokeChoice.

To load the PBS Files downloaded from FOCUS as shown above, click on the Select File button and select the file name to load.

This will start a reconcile job. You must wait until this job finishes before loading the next file.

When a file is complete, an email is sent to the email address specified in the Reconcile Email field on the Back Office>Company Options page.

Repeat this process for all PBS Files you downloaded.

NOTE: You may only load a PBS File once. There is no need to load them multiple times.

After you have downloaded and loaded ALL PBS Files between 9/1/2022 and the current date, it is possible there are claims that are stuck in the SUBMITTED state because of the FOCUS/WellSky bugs. The Reset Stuck Claims button will fix these stuck claims.

!! WARNING !! Do not click this button until you are 100% sure you have downloaded all TA1/999/835-files from WellSky and loaded them into SpokeChoice and you have waited some amount of time ensured you are not getting back an 835 file.

To run the process, click on the Reset Stuck Claims button and follow the onscreen instructions.

After I have run this process and then get more FOCUS payments, should I run the process again?
Yes, but you only need to load the new PBS Files and only after you are 100% sure you have downloaded all TA1/999/835-files from WellSky and loaded them into SpokeChoice.

What happens if I run Reset Stuck Claims before I loaded all PBS Files?
Technically, it wont hurt anything with the EDI Workaround process. However, if you run Reset Stuck Claims and then don't load new PBS Files or 835-files, you will be moving the claims paid/denied in the PBS Files and/or 835-files to READY which could cause you to resubmit duplicate claims. There is no need to panic, however you should try very hard not to do this.