1

EC/EDI Provider Reimbursement Management

Managing HIPAA Transactions

Governmental and Private Insurance

Create, Transmit, Receive, Translate, Post and Review

270/271, 276/277, 837/835

Information Tool!

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PrefaceHave you had an opportunity that just slipped through your fingers, just because you didn’t take a little time out of your busy schedule to review something?

Well here is one of those opportunities!

Manigault & Associates, LLC is an EC/EDI Healthcare Software Solution Company, that designs, develops and implement software solutions, which not only save business processing time. We also;

1. Provides enhanced revenue management solutions.

2. Automated data entry, which speeds processing and eliminate errors.

3. Process and manage eligibility inquiry and response.

4. Support a number of software management systems.

5. Provides the highest level of customer support in the industry.

6. Create Third Party Solutions.

7. Find ways of getting things done.

Look at M&A as a road map to getting things done. When other software companies use the words; can’t, unable, unwilling or impossible, we use the words “yes we can”.

The most important aspects of M&A is our customer service record. We are committed to a simple premise;

Respond and Solve a Customer’s Request, Above All Else.

Take a look at the products, services and information included in this material and when you are ready, please give us a call.

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1. Front Cover

2. Preface

3. Table of Contents

4. Manigault and Associates Executive Summary

5. Thank you letter

6. Testimonial – Good Samaritan Hospital

7. Testimonial – Ventura County Medical Center

8. General System Schematics

9. 1. Electronic Remittance Advice Management Solution (ERA)

10. 1. ERA Main Menu

11. 1. ERA Download Menu

12. 1. ERA Print Report Menu

13. 1. ERA Standard ERA Report

14. 1. ERA Detail 1 of 2

15. 1. ERA Detail 2 of 2

16. 1. ERA Database Elements

17. 1. ERA Database Query 1

18. 1. ERA Database Query 2

1. Examples of Detail Reports

19. 2. Electronic Scripting Services (ESS)

20. 2. ESS Scripting Menu

21. 2. ESS Scripting Control and Activity Screens

22. 2. ESS Scripting Report Examples

23. 3. Eligibility Request and Response Solution (ERR)

24. 3. ERR Schematics

25. 3. ERR Desktop Screen Example 1

26. 3. ERR Desktop Screen Example 2

27. 3. ERR Main Server Screen

28. 4. Standalone Eligibility Request and Response Solution (SERR)

29. 4. SERR Summary

30. 4. SERR Operational Screen

31. 4. SERR Configuration Screen

32. 5. Electronic Eligibility Request and Response (270/271) Solution (ERR) [Planned Development]

33. 5. ERR Schematics

34. 5. ERR Design Structures

35. 6. Electronic Claim Developed (837) (ECD)

36. 6. ECD Schematics

37. 6. ECD Eligibility Examples

38. 6. ECD Claim Development Process

39. 7. Minor, Historical and New Project Descriptions

40. 8. Product System Requirements

41. 9. Standard Pricing and Return on Investments Analysis

42. 10. Historical Client and Vendor List

43. 11. M&A Contact Page

44. 12. M&A Eleven Year P&L Summary

45. 13. M&A Business Agreements (Non-Disclosure, Business Associate Agreement and Software License Agreements)

Table of Contents

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Manigault & Associates (M&A) is a California Based Limited Liability Software Company, which officially began operations March 9, 1999. M&A was created, due to ground work established by The Hospital Council of Southern California, COHR, Multi Hospital Purchasing Groups and The Healthcare EDI Study Group (HEDIC - June 1988).

We design, develop and implement automated data retrieval, translation, reporting and posting solutions, which eliminates the need for manual data entry and provides an array of Business Management Information Tools. M&A is currently made of 8 Associates, with over 140 years of health care systems experience. M&A also works with an array of Patient Accounting Systems, Healthcare Industry Group, Healthcare Standard Groups, Document Management Companies, Claims Processing Companies and Third Party Software Companies.

Major Products:

Product I : Electronic Remittance Advice (ERA) Solution, downloads, translates and reports on Medicare, Medicaid, Commercial Insurance and Collection Agency payments.

Product II : Electronic Scripting Service (ESS) Solution, post electronic information between dissumular computer systems.

Product III : Eligibility Request and Response Solution (ERR) from the desktop. This network driven system receives Medicare/ Medi-Cal Eligibility Request from a user, searches the Fiscal Intermediary (FI) system, matches the response to the PAS accounting codes and displays the proper code for the initial patient encounter.

Product IV : Standalone Eligibility Request and Response Solution (SERR). Single User , standalone, low cost version of ERR.

Product V: Electronic Insurance Request and Response (ERR) system which collects 270 file from Patient Accounting Systems (PAS) and sends back 271 file. If the payer is unable to receive and process a 270/271 file, the system reads the 270 file, logs on to the payer system, collects the required eligibility information, creates a 271 file and then sends the 271 file back to the PAS.

Product VI : Electronic Claim development Solution (ECD). This system creates 837 claim file for transmission to state agencies from standard claim processing systems

Other Products and ServicesSelf Pay Discount Policy Administration Pharmacy Bid Management (ANSI 840/843)

Adjudication Status Reporting Price Catalog and Supply Management (ANSI832)

Electronic Document Management Order Entry Management (ANSI 850/855)

72 Hour Rule Processing Resale Report Management (ANSI 867)

Disproportionate Share Projects

AB915 Projects

Paragraph 14 Projects

ACE Projects

EOB Denial Processing Projects

Professional Fee Management Project

Pharmacy System Management Projects

Patient Accounting System Conversions Projects

Eligibility Batch File Processing

Hundreds of Scripting Projects

Manigault & Associates, LLC Executive Summary

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Testimonial

ERAWe installed the Electronic Remittance Advice (ERA) Management Reporting system in 2004 at a cost of $995.00 installed and $225.00 per month for maintenance. We have recovered almost $700,000.00 in

our review of the; Last four years of ERA data.We use the ERM Reporting System to create our Medicare ERA Database to:

•Review outpatient line item data to uncover incorrect CPT/HCPCS coding, quantities, or missing codes (This effects reimbursement and compliance).•Reconcile transfer DRG payments.•Review the claims data sent to CMS vs. what is in our Hospital Information System (HIS) (i.e. improper use of modifier 59).•Compare HIS patient summary data to the database to see if we were appropriately for MSP (Medicare Secondary Payer) claims.•Query on DRGs that may have been down coded due to coder error ormissing chart documentation.•Run summaries on DRGs, SNF, and Rehabilitation accounts.

These bullet points represent a majority of what I use the database for.The Medicare information has proven invaluable to me over that last four years of working at Good Samaritan and Methodist Hospital.

Tood DerbishRevenue ManagerGood Samaritan Hospital Los Angeles, CA

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TestimonialERA, ERP and ARR

Q1. Medicare and Medi-Cal Eligibility System based on Historical Information:

A1.1  If the Medi-Cal Eligibility System was not in place we would have at least an 80% decline in accuracy.

A1.2. If incorrect codes were used due to coding errors there would be a 75% denial rate increase.

A1.3. There would be and increase of 3 FTE to correct and rebuild claims.

Q2. ERA postingA2.1  If manual posting was used an additional 4 additional FTE's would be required.

A2.2  Incorrect posting errors would increase by 20%

Q3. Specialized Reporting:  Immeasurable, M&A have been the only ones that were able to pull the information correctly.  When we've gone to the "experts" we've always had to call M&A. 

A3.1 AB915 24 hours savings Quarterly

A3.2 Paragraph 14 Project 24 hours saving Semi-Annually

A3.3 Disproportionate Share Project 15 hours savings Monthly

Holy Moly!

Karen Schneweis-SchmidtChief Hospital OperationsPatient Financial ServicesVentura County Medical Ventura, CA

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Remote Support

Health Care PayersHealth Care Provider

Manigault & Associates, LLC

A Simple way to Process, Identify and Manage

EC/EDI Health Care Transactions

Patient Accounting System

M&A Software

At Client Site

Medicare

Medi-Cal

Private

Outbound Inbound

270

837

271

835

Provider to Payer Payer to Provider

DatabaseEligibility

Claims

ERA

DatabaseSupply Management

users users users

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The Electronic Remittance Advice Solution was created in June of 1992 due to Federal regulations mandating the use the ANSI 835 as the means of receiving the Explanation of Benefit (EOB) for Medicare payments. This process has lead to the ERA product being presented in this narrative.

The ANSI 835 file replaces the paper based EOB by providing a standard means for coding and providing data elements such as; Patient Information, Service Date, Covered and Non Covered Charges, Billed Charges, Deductible, Coinsurance, Gramm Rudman and much much more.

This product was developed with the assistance of over 65 hospitals over the past 18 years and has processed well over 100 Billion Dollars in electronic transactions.

The System:

1. Downloads ERA files from Payer System.

2. Stores the raw ERA files

3. Translates the ERA files and moves the data into the ERA Database

4. Provides Standard Reports for Review (Attached)

5. Provides Access to Historical Data using MicroSoft Access TM

Included in this Product section are:

1. Menu Screen

2. Summary Report Descriptions

3. Medicare ERA Schematic

4. Actual Report Examples

5. Sample Database Elements

Electronic Remittance Advice

ERAProduct I

Narrative

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ERA

Main Menu

11

ERADownload Menu

12

ERAPrint Report Menu

13

ERA

Standard ERA Report

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ERA Remittance Reports Narrative Page 1 of 2

Remittance ReportsSeveral reports comprise the Remittance reports. All of the reports can be printed or viewed. Printing the reports sends one copy of the report to your default printer. The report does not appear on screen when it is printed directly. The exception is the “Mailback” report. The “Mailback” report appears on screen when printed directly.  Any report may be viewed. While viewing a report, the user may print the entire report, or selected pages of the report. The user may also choose to print multiple copies of the report and select how the multiple copies are sorted.

 

Standard Remittance AdviceThis report shows claim level information sorted by provider no, bill type and patient name with subtotals by bill type and a summary page for each provider.  The following fields are accumulated from the line items. This line item data can be seen in the bottom portion of the Supplemental Billing report. CoinsuranceDeductibleBlood DeductibleLab ChargesLab ReimbursementHCPCS AmountESRDInterestIME AmountASC Amount

Total Patient LiabilityPrimary Payer AmountNon Covered Charges Non Covered Charges - Contractual ObligationNon Covered Charges - Patient Responsibility If payment on line item is zero, the adjustment amount is accumulated into non covered charges. If the group code is ‘CO’, it is also accumulated into non covered contractual amount. If the group code is ‘PR’, it is also accumulated into non covered patient responsibility amount. The Contractual Adjustment amount is calculated as follows: Billed Charges – Net Reimbursement – Non Covered Charges – Total Patient Liability

Supplemental BillingThe Supplemental Billing report shows just one claim per page and consists of two parts. The top part shows claim level data as described under Standard Remittance Advice. The lower part shows each line item with adjustment amounts and codes indicating the reason for the adjustment. Additional adjustments are listed below the service line.

 

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ERA Remittance ReportsNarrative Page 2 of 2

Negative Reimbursement The Negative Reimbursement report, similar in form to the Standard Remittance Advice, only shows claims with a negative reimbursement

Zero ReimbursementThe Zero Reimbursement report, similar in form to the Standard Remittance Advice, only shows claims with a zero reimbursement.

 

Crossover (Medi/Medi) ReportThe Crossover report, similar in form to the Standard Remittance, only shows claims with a claim status code indicating a crossover.

 

Discharge DestinationThe Discharge Destination report, similar in form to the Standard Remittance Advice only shows claims with a patient status code of ‘2’.

 

Fiscal Year SummaryThe transaction statistics in the transmitted file convey totals by fiscal year and type of bill.The Fiscal Year Summary report summarizes the data of the daily transaction file by provider number, bill type and fiscal year.

 The Fiscal Year Summary Report shows the transaction statistics as sent in the daily transaction file. They convey subtotals for fiscal year within a bill type, totals by bill type and a summary by provider. NOTE: At this time the data sent by some Payors for noncovered charges and contractual adjustments are not correct.  A second version of the Fiscal Year Summary report is available which calculates those fields: Non covered charges = total charges – covered charges. Contractual adjustment = accumulated from claim level data. Your DMA Support representative will replace the uncalculated report with the calculated Fiscal Year Summary report upon request.

Several reports comprise the Remittance reports. All of the reports can be printed or viewed. Printing the reports sends one copy of the report to your default printer. The report does not appear on screen when it is printed directly.  Any report may be viewed. While viewing a report, the user may print the entire report, or selected pages of the report. The user may also choose to print multiple copies of the report and select how the multiple copies are sorted.

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ERA Database Elements(Small Data Sample)

Record: DETAIL Detail RecordField Name Field Description Col Len Type Dec Date Format

 A BPR16 BILLING CYCLE DATE 6 DT YYMMDDB TS301 POVIDER NUMBER 13 ANC CLP08 FACILITY TYPE CODE 2 AND CLP09 CLAIM FREQUENCY CODE 1 ANE NM101 IDENTIFIER CODE 2 ANF NM103 PATIENT LAST NAME 18 ANG NM104 PATIENT FIRST NAME INITIAL 1 ANH NM105 PATIENT MIDDLE INITIAL 1 ANI NM108 PATIENT NUMBER CHANGE 1 ANJ NM109 HIC NUMBER 19 ANK CLP01 PATIENT CONTROL NO 20 ANL CLP07 INTERNAL CONTROL NO 20 ANM DTM02 STARTING DATE 6 DT YYMMDDN DTM02 ENDING DATE 6 DT YYMMDDO LP03 CLAIM REPORTED CHARGES 11 DE 2P LX01 FISCAL PERIOD 6 ANQ MIA01 COVERED DAY 3 SIR NONCOVD NON-COVERED DAY 3 SIS DED DEDUCTIBLE 11 DE 2T COINS COINSURANCE 11 DE 2U BLDDED BLOOD DEDUCTIBLE 11 DE 2V NONCOV NON-COVERED AMOUNT 11 DE 2W CLP04 CLAIM PAYMENT AMOUNT 11 DE 2X GRAMRUD GRAM-RUDMAN DEDUCTIBLE 11 DE 2Y CONTADJ CONTRACTUAL ADJUSTMENT 11 DE 2Z PREFUN PATIENT REFUND 11 DE 2AA CLP10 PATIENT STATUS 2 ANAB INTEREST INTEREST AMOUNT 11 DE 2AC CLP02 CLAIM STATUS CODE 2 ANAD PRIPAY PRIMARY PAYER AMOUNT 11 DE 2AE MSPREIMB MSP PROV REIMB 11 DE 2AF MIA04 MEDICARE PRIMARY PAYMENT 11 DE 2AG MIA07 MSP PASSTHROUGH 11 DE 2AH MIA08 CAP PAY 11 DE 2AI CAS23 CLAIM DENIED/REDUCED 11 DE 2AJ CAS63 CORRECTION TO PRIOR CLAIM 11 DE 2AK CAS89 PROFESSIONAL FEES 11 DE 2AL CASA1 DENIED CHARGES 11 DE 2AM CASA2 CR CONTR ADJ 11 DE 2AN CASB3 COVERED CHARGES 11 DE 2AO ESRDNSUP ESRD NETWORK SUPPORT 11 DE 2AP MSPIND MSP INDICATOR 1 ANAQ MUDAYS MEDICARE UTILIZATION DAYS 3 SIAR MIA19 PROFESSIONAL COMPONENT 11 DE 2AS MIA05 REASON CODE 5 ANAT MIA20 REMARK CODE 5 ANAU MIA21 REMARK CODE 5 ANAV MIA22 REMARK CODE 5 ANAW MIA23 REMARK CODE 5 ANAX COINSD CO-INSURANCE DAYS 3 SIAY COINLT CO-INSURANCE LIFR TIME 11 DE 2AZ MIA02 LIFE TIME RESERVE DAYS 3 SIBA CLP11 DRG CODE 3 ANBB MIA16 DRG AMOUNT 11 DE 2BC DRG DRG AMOUNT (MIA04) 11 DE 2BD MIA06 DISPROPOTIONATE SHARE 11 DE 2BE MIA18 INDIRECT TEACHING AMOUNT 11 DE 2BF OUTLCD OUTLIER CODE 1 ANBG OUTLCA OUTLIER AMOUNT 11 DE 2BH OUTLDAY OUTLIER DAYS 3 SIBI MIA15 COST REPORT DAYS 3 SIBJ MIA17 CLAIM PPS CAPITAL OUTLIER AMT 11 DE 2BK FILL

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ERA Sample Database Query

Reason Codes (RAD), by Encounters and Total Charges

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ERA Sample Database Query

Common Procedure Terminology (CPT), by Encounters, Total Charges and Payments

CPT and Encounters sorted by Total Charges

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The Electronic Scripting Service was created in June of 1992 due to a request from Healthcare Facilities to reduce human posting errors related to manually entering ERA data into Patient Accounting Systems (PAS). The solution has grown to include hundred of applications and possibilities such as;

1. ERA posting into Patient Accounting System

2. Patient Accounting and Clinical System Conversions

3. Charge Master System Conversions

4. Admission Discharge and Transfer System

5. Pharmacy MARS and REFILL list Controls

6. Eligibility Request and Response System Control

7. Contract Management and Contractor License System Check

8. Any process where information from one system is used to upload to another system

The System connects to thousands of Applications used by healthcare providers. Each provides a unique Return on Investment (ROI) opportunity. The ROI is mesured in;

1. Time Saving

2. Reduced Full Time Employee (FTE) cost

3. Error reduction associated with human data activity

Included in this Product section are:

1. Same posting start menu

2. Sample of a posting control and activity screen

3. Posting report example

4. * Scripting is done in the background. Screens are designed based on client requirements.*

Electronic Scripting Service

ESSProduct II

Narrative

20

ESS

ERA Posting Menu Screen

21

ESS

Posting Control Screen

Posting Activity Screen

22

ESSPosting Report Examples

23

The Eligibility Request and Response Solution was created in June of 2000 due to a request from Ventura County Healthcare Agency CA and Henry Mayo Newhall Memorial Hospital CA, to assist in managing their insurance eligibility admission process. The system checks Medi-Cal Eligibility at the admission station, reads the response and applies the proper accounting codes for posting to the Patient Accounting System. This system eliminated human posting errors, which led to incorrect billing, which leads to rejected claims.

The system has grown to include Medi-Cal, Medicare and Private insurance.

The System uses proprietary M&A software with connections to Fiscal Intermediary system front ends which:

1. Collects the Request from the user’s desktop

2. Sends the request to The Payer

3. Receives the Response from The Payer

4. Matches the Response to a preprogrammed Algorithm linked to the PAS

5. Displays the Eligibility and posting information onto the desktop and in some cases post to the patient account.

Included in this section:

1. System Schematics

2. Desktop Examples

3. Server Example

Eligibility Request and Response Solution

ERRProduct III

Narrative

24

ERR

Eligibility Database

(User, time, info)

Desktops

Medicare

Medi-Cal

M&A Software

Patient Accounting System

Schematics

Private

25

ERRSimple Desktop Screen

An Example of an Eligibility Request Screen

An Example of an Eligibility Response Screen (as the user scrolls down)

      

26

ERR

An Example of an Eligibility Request Screen

An Example of an Eligibility Response Screen

27

ERRMain Server Screen

Medicare and Medi-Cal Access

28

The Standalone Eligibility Request and Response Solution was created in June of 2008 as a low cost single user solution for providers to request and collect Medi-Cal Eligibility directly form the desktop and code the response directly to their patient accounting system.

The system checks Medi-Cal Eligibility at the workstation, reads the response and applies the proper accounting codes for posting to the Patient Accounting System. This system eliminated human posting errors, which led to incorrect billing, which leads to rejected claims.

The System also allows for Share of Cost Spend Down

The System uses proprietary M&A software which:

1. Collects the Request from the desktop

2. Sends the Request Medi-Cal

3. Receives the Response from Medi-Cal

4. Looks up your billing code in a customizable MicroSoft Excel TM Spreadsheet

5. Displays your billing Code and the Eligibility Response from Medi-Cal

6. Stores the entire transaction into the Database (All aspects)

Standalone Eligibility Request and Response Solution

SERRProduct IV

Narrative

29

Executive Summary:

The web link below (Product) will download and install the INCLUSION Medi-Cal Eligibility Assistance Software.  Using your Medi-Cal User ID and password, the system provides an error free bridge between your Medi-Cal Eligibility Request and Response to your patient accounting system (PAS). 

Requirements: Valid Medi-Cal User ID and Password; Standard PC, Internet Links, Microsoft Excel TM.(System uses a simple Excel spread sheet to map to your PAS).

Features:Checks subscriber eligibility: real time, batch or historical and the ability to write down share of cost.

Benefits: This system will greatly reduce admission coding errors, which translates into less rejected claims due to subscriber coverage ineligibility. 

Cost:The system is being released as shareware until June 2009.  Projected single user license fee is $30.00 per month.

Conclusion:Please take a look at the software and tell us what you think or would like to have added.  If you would like to have features added, please get back to us before the shareware date expires.

Help:Easy to use online help reference material available through the software or directly on the web site.Product:http://www.m-allc.com/elv3_demo/mcal_el.msi

SERR

30

SERR

Operational Screen

31

SERR

Configuration Screen

32

The Electronic Eligibility Request and Response Solution was created in June of 2009 due to a request from Henry Mayo Newhall Memorial Hospital Los Angeles, CA to assist in managing their eligibility process as it relates to receiving and sending the 270/271 transactions.

The systems design is based upon the ARR system, which has been employed since 2000. The eligibility request is received as an ANSI 270 transaction instead of an user input. The request is then transmitted to the appropriate payer. If the payer’s system is unable receive a 270 file then the software will logon to the payer’s system, collect the response information, create an ANSI 271 file and upload the file to the Patient Accounting System.

The only transaction between the client and M&A is a 270/271 File.

The System:

1. Collects the 270 file from the Patient Accounting System

2. Matches the payer information from the 270

3. Sends the ANSI 270 file or logs on to the payer system

4. Collects the Response from the payer

5. Create a 271 file from the payer data

6. Uploads the 271 to the Patient Accounting System

7. Records the transaction into the a Database (All Aspects)

8. Waits for the next 270 file

Requirements:

Must have a user ID and Password for each payer system

In some cases direct access software may be required

Electronic Eligibility Request and Response (270/271)

ERRProduct V

Narrative

33

•Blue Cross

•Blue Shield

•CIGNA

•Healthnet

•MPHI

•Pacific Care

•United Healthcare

•Healthcare Partners

•Medicare

•Others using Clearing House

•Aetna

•Medi-Cal

Patient Accounting System M&A Software

Database

ERR

Provider Eligibility Request 270 >

< Payer Eligibility Response 271

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ERR

ISA*00* *00* *ZZ*P000000165 *ZZ*CMS * 090612* 1140*U*00401*0154

89028*0*P*:~GS*HS*P000000165*C MS*20090612*1140*999998001*X *004010X092A1 ~ST

*270*L10000296~BHT*0022*13*L10000296015*20090612*1140~HL*1**20* 1~NM1 *PR *2

*CMS*****PI*CMS~HL*2*1*21*1~NM1*1P*2**** **XX*9999913273~HL*3*2*22*0~ TRN

*1*L10000296015.MCR.1*9SHL000000~NM1*IL*1*FIRST*LAST*M***MI*999999999A~

REF*1L*999999999A~REF*SY*148185633~N3*100 N MAIN STR EET~N4* YOURTOWN

*US*99999~DMG*D8*19250728*F~DTP* 472*D8*20090612~EQ*47~SE*17*L10000296~

GE*1*489028001~IEA*1*015489028~

ISA*00* *00* *ZZ*PA VeriLink *ZZ*MEDITECH *090619*0646*U*00401*0006

79052*1*P*:~GS*HB*PA LA VeriLink*MEDITECH*20090619*0646*24642*X*001010Xd92ST*

271*V408927~BHT*0022 11*V408927*20090619*064616~HL*1**20*1~NM1*PR*2* MEDICARE

*****PI*1~HL*2*1*21*1~NM1*1P*2******FI *931213059~HL*3*2*22*0~TRN *2*V408927.MC

.1*9ACH000000~TRN*2*2147458565*3802245746~NM1*IL*1* LAST*FIRST*M ***MI*9999999

99A~N3*100 N MAN STREET~N4*YOURTOWN*US*999999999~DMG*D8*19230330*M~DTP

*307*D8*20090619~EB*1*IND**MA~DTP*307*D8*19880301~EB*1*IND**MB~DTP*307*D8*1

9890801~EB*K**47*MA **33***LA*60~EB*C**47*MA**29*1068~EB*F**47*MA **29 ***

DY*60~EB*A**47*MA**29*267**DY*30~EB*C**96* MB**29~DTP*348*D8*20040101~

MSG*Fecal blood scrn immunoassay~EB*D*IND**MB*Glaucoma scrn hgh risk diret********HC:

G0117~DTP*348*D8*19980101~MSG*Colon CA screen barium enema~EB*D*IND**MB*CA s

creen fecal blood test********HC:G0107~DTP*348*D8*19980101~MSG*CA screen flexisigmoid

scopea~E B*D*IND**MB*PNEUMOCOCCAL VACCIN******** HC:90732~DTP *348*D8

*19890801~MSG*PNEUMOCOCCAL VACCINE~E B*F*IND*67*MB**29***P6*8~EB*F*IND*

AD*MB**29*1840~DTP*292*RD8*20090101-20091231~EB*F*IND**MB*Physical and Speech

Therapy*29*1840~DTP*292*RD8*20090101-20091231~MSG*Physical and Speech Therapy ~EB*C

*IND*10***29***DB*3~DTP*292*RD8*20090101- 20091231~SE*101*V408927~GE*1*24642 ~IEA*1*000679052~

Example of ANSI 271 - Medicare

Example of ANSI 270 - Medicare

35

The Electronic Claim Development and ERA Management was created in June of 2008 in response to a request from The Ventura County Healthcare Agency because of a State requirement in the area of 837 claim file processing for Behavioral Health. The system creates an ANSI 837 Claim file from non standard Patient Accounting System and gives the newly created 837 file to the client for transmission to the state. The product also receives an ANSI 835 file from the state in order to provide unique number tracking

This product uses supporting tables and patient encounters to build and monitor claims and remittance advices. The product is was designed for Mental Health applications, but can be used for other types of encounters.

The system:

1. Receives Eligibility Request file from the Provider

2. Sends an Eligibility Batch Request file to the State

3. Receives an Eligibility Response file from the State

4. Sends the Eligibility Response to the Provider

5. Receives Supporting Tables and Claim files from the Provider

6. Create ANSI 837 Claim file and sends the file to the Provider

7. Provider Sends ANSI 837 Claim file to the State

8. Receive ANSI 835 ERA file

9. Translates the ERA file into the M&A relational database (or flat file)

Electronic Claim Development

ECDProduct VI

Narrative

36

ECD

Eligibility

Claim

ERA

Medi-Cal

M&A Software

Provider

Schematics

37

ECD Medi-Cal Eligibility Example

38

ECD Medi-Cal Claim Example

39

1. Self Pay Discount Policy Administration System (SPDP): Establishes and verifies charge guidelines for non insurance patients. The patient may apply for a healthcare service discount based upon their financial situation. The SPDP system queries all billed services for self pay discount status. The application services are automatically discounted based upon governmental standards.

2. Adjudication Status Reporting: Compares insurance charges to insurance payments to identify non-adjudicated encounters.

3. Electronic Document Management Project: Creates an electronic image of an ERA for storage and retrieval from Patient Accounting Systems

4. 72 Hour Rule Processing Project: Checks inpatient encounters against outpatient visits within the 72hour window.

5. Disproportionate Share Project: M&A software searches the ERA database for higher operating costs incurred in treating a large share of low-income patients.

6. AB915 Project: Supplemental Medi-Cal reimbursement for hospital outpatient services and adult health services.

7. Paragraph 14 Project:Reports (hospital financing waiver ensuring that low-income and uninsured Californians continue to have access to the essential health care services).

8. ACE Project: Periodically, upon client request, M&A writes off specific types of old claims.

9. EOB Denial Processing Project: Reviews the ERA files to review data patterns.These pattern can identify reasons for denied claims

10. Professional Fee Management Project: Identifies Charge areas by Professional Providers.

11. Pharmacy System Management Project: Real Time system which orders and print Pharmacy MARS, REFILL and other Schedule Reports

12. Patient Accounting System Conversions Project: Consulting and Software Development for Hospitals converting from one system to another

13. Eligibility Processing:Batch Processing system where M&A checks the Medi-Cal database for patient eligibility on a monthly bassis.

14. Scripting Projects: Any repetitive manual process that can be greatly improved using automated processes.

Minor Product Descriptions

Manigault & Associates, LLC

15. Pharmacy System Management Project: System used to received and award bids from pharmacy companies.

16. Price Catalog and Supply Management: System used to upload Price Catalogs from Distributors and  or Manufactures into Order Entry Systems.

17. Purchase Order Entry Management: System used to send Electronic Purchase Order to Distributors and or Manufactures.

18. Resale Report Management: System used to track Administrative Fee Payment from Distributors and Manufactures.

Historical Product Descriptions

19. ANIS 278 Physician Referral Certification (Patient Record)

20. ANSI 816 Membership Document

21. ANSI 834 Enrollment Document

Products under Development Review

40

Health Care Provider

Manigault & Associates, LLC

M&A Server

At Client Site

270

837

271

835

DatabaseEligibility

Claims

ERA

DatabaseSupply Management

Product System Requirements

Minimum Hardware:

Windows XP TM or Windows 2000 TM (Operating System)

1 Gigabyte RAM

100 Gigabyte of Online Storage

Software Requirements:

Patient Accounting System

PC Anywhere TM (Online support)

Microsoft Access TM (Database)

Internet Access and Dial Up Secure Access

Third Party Software Software provided by M&A

Scripting, Programming and Database Management

User Access Requirements:

User IDs and Passwords

Patient Accounting System

Payer(s) Electronic Systems

M&A Server

Standalone

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Manigault & Associates, LLC Standard Pricing and Return on Investment (ROI)

Estimates (Valid until March 31, 2010)

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Ventura County Health Care Agency, CA

Henry Mayo Newhall Memorial Hospital, CA

Torrance Memorial Medical Center, CA

Methodist Hospital Arcadia. CA

Good Samarian Hospital, CA

Kenneth Norris Cancer Hospital, CA

Buffalo General Hospital, MA

Children’s Hospital of Buffalo, MA

Millard Fillmore Hospital, MA

Catholic Healthcare West

Tenet Healthcare

Data System Group

Compulink Management Center

CPS Collections

Electronic Data Systems Corp

MedE America

MicroScript

Boston Software

Summit Healthcare System

HBO Systems

MediTech

First Coast

Keenan

Current and Historical Clients and Vendors List

Manigault & Associates, LLC

Additional Contact Information Available upon request

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Presents

An EC/EDI solution for managing your Business Office Functions

Eligibility, Claims and Remittance

Contact: David Manigault

1190 Alamo Pintado Road Solvang, CA 93463

Cell : 805-680-1306, Phone: 805-693-8229, Fax: 805-686-1888

Email:david.manigault@m-allc.com Web:http://www.m-allc.com

David Manigault – Founder/President/CEO

Neil Carman – Director of Technical Services

Johanna May – Director of EDI Translation Services

Andrew Clarke – Director of System Interface

Judy Anderson – Director of Administrative Services

Al Gately - Advisor

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M&A Eleven Year P&L with pre and post production activity

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M&A Business Agreements