ez-cap auto adjudication sanjay goel...client 1 - 20% of claims are auto adjudicated. many of these...

EZ-CAP Auto Adjudication

Sanjay Goel

Manager, Software Development

Doug Bell

Product Manager

Welcome!

What is Auto Adjudication?

Why Auto Adjudication?

EZ-Setup of Auto Adjudication for Auth and claims.

New features added in EZ-CAP v6.5.3

Questions?

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Hands Free with Auto Adjudication

• What is Auto Adjudication?• The automation of changing a record’s Status,

changing the data value or adding a new value to a record.

• Change Claim Status from 1 (Release to A/P) to 5 (A/P Hold).

• Change Authorization Status from 7 (Requested) to 1 (Approved).

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Why Auto Adjudication?

• Automation• Reduces human errors.

• Reduces manual checks and balances and lets the system do the work for you.

• More productivity.

• Bottom Line • Saves time and money.

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• Auto Adjudication Enhancements included in v6.5.3 will be reviewed at the end of this session.

Auto Adjudication – V6.5.3

Let’s Get Started

• Easy to setup (3 simple steps)

1. Create a Rule– Set, Description, Date

2. Set the Action to take place– Change Status

– Add Adjustment Code

– Add process Status Code

– Change Detail Net Pay

3. Criteria– What Data Element from the Auth or Claim record

will trigger the rule6

Authorization Auto Adjudication

Setup a Mammogram Rule-

1. Create a Set and the Rule for Mammogram– Enter a Set number, Description and date range

– Enter Rule Description and date range

– Unique Rule ID is assigned by the system

2. Set the Action to take place– Change Auth Status to a 1

3. Criteria

– Age Range

– Diagnosis Code

– Gender

– Provider Contract Type

– Service Code7

Authorization Auto Adjudication

Step1

Creating a Rule Set by specifying a Set #, Description and Date.

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Define the Rule specifying a Date and Description.

Authorization Auto Adjudication

Step2

Define the Action to take place

• Change Auth Status to 1 (Approved)

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Authorization Auto Adjudication

Step3

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Define the Criteria• What data element(s) will trigger the rule

Authorization Auto Adjudication

Turn on the feature in the Company Configuration

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Authorization Auto Adjudication

Sets may be assigned at -

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1. Company

2. Healthplan Contract 3. Option Master (HP/Option)

Authorization Auto Adjudication

What if sets are assigned at all 3 levels?

1. Company

2. Healthplan Contract

3. Option Master (HP/Option)

The system will always start looking at sets at the lowest level and move up -

3. Option Master (HP/Option)

2. Healthplan Contract

1. Company

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Authorization Auto Adjudication

Auth hits the Adjudication Rule and moves it to a Status 1.

Based on the criteria defined, the Action takes place.

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The matching Rule ID is stored in the column Auth Rule ID at the detail line grid.

Authorization Auto Adjudication

What do our clients say:

Client 1 - Reduction in manual work in approving authorizations.

Client 2 – 50% of authorizations do not require manual review.

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Claim Auto Adjudication

Setup PCP Encounter Rule

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1. Create a Set and the Rule for PCP Encounter

– Enter a Set number, Description and date range

– Enter Rule Description and date range

– Unique Rule ID is assigned by the system

2. Set the Action to take place

– PCP Encounter = ‘YES’ to move claim status to a 9 (Paid)

3. Criteria

– Not Required

Claim Auto Adjudication

Step1

Creating a Rule Set

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Define the Rule (enter a Date and Description)

Input Set, Description, Date

Claim Auto Adjudication

Step2

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Define the Action to take place PCP Encounters = YES The Claim Status will move to a 9 (Paid)

Claim Auto Adjudication

Step 3

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Define the Criteria• PCP Encounters means the claim is ‘from’ the member’s PCP,

adjusted for cap, and all lines are a zero pay.• No Criteria definition is needed. System already knows.• You do not need to use the Payment Process to release

Encounters, which reduces the claims waiting to be processed.

Claim Auto Adjudication

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Claim hits the Adjudication Rule and moves it to a status 9. Based on the criteria defined, the Action takes place.

Claim Auto Adjudication

What do our clients say:

Client 1 - 20% of claims are Auto Adjudicated. Many of these claims are to adjust the detail line to $0.00 and insert an Adjustment Code.

Client 2 – 100% of PCP Encounter Claims are automatically moved to a Status 9.

Client 3 – 65% (or 3,600 claims a day) are Auto Adjudicated.

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Auto Adjudication

Important and easy-to-use features -

Define Action and Criteria Query Builder style.

Define Ranges just like Benefit Matrix.

Adjudication Statistical Reports.

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Authorization Auto Adjudication

Adjudication Actions

UDF Fields – UDF #3 to UDF #20

Priority Status

Payment Status

Notes

Memos

Always Win in Scoring

Skip Adjudication if pend flag hit

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Authorization Auto Adjudication

• Auth Status

• UDF #3 through UDF #20 fields

• Account

• Case Exists

• Healthplan

• Option

• Request Category

• Certification Type

• Auth Service Type

• Auth Service Package

• Capitated

• Covered

• Patient Status

• Nursing Home Code

• Financial Responsibility

• All Diagnosis Codes

• Auth Details Exist

• Facility ID

• Rendering Provider Service Area same as PCP

• Rendering Provider Specialty same as PCP

• Provider LOB

• Requested Units

• Authorized Units

• Auth Record Type

• C.O.B.

• Member Condition Codes

• All Master and Detail Pend Codes

Most Used Adjudication Criteria

Authorization Auto Adjudication

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Auth Data ElementsService CodeDiagnosis CodePlace of ServiceAgeGenderHeader Net PayDetail Net PayPriority StatusService TypeAuth StatusUDF #1 to UDF #20AccountCase ExistsHealthplanOptionRequest CategoryCertification TypeAuth Service TypeAuth Service PackageCapitatedCoveredPatient Status

Auth Data ElementsNursing Home CodeFinancial ResponsibilityAll Diagnosis CodeBenefit Rule IDAuth Details ExistsReq'd UnitsAuth'd UnitsAuth Record TypeCOBMember Condition CodePend Codes

ProviderRequested Member's PCPRequested Provider IDRequested Provider ClassRequested Provider SpecialtyRequested Contract TypeRequested Vendor IDAuthorizing Member's PCPAuthorizing Provider IDAuthorizing Provider ClassAuthorizing Provider SpecialtyAuthorizing Contract TypeAuthorizing Vendor IDFacility IDRendering Provider Service Area same as PCPRendering Provider Specialty same as PCPProvider LOB – HMO InProvider LOB – HMO OutProvider LOB – PPO InProvider LOB – PPO Out

All Adjudication Criteria

Claim Auto Adjudication

Adjudication ActionsUDF Fields – UDF #1 to UDF #20

Deductible

Copay

Coinsurance

Populate Adjustment Value with Net Pay Value

Account

Notes

Memo

Negative Net Pay

Remove Existing Adjustment Code Values

Always Win in Scoring

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Claim Auto Adjudication

• Outcome Code

• Benefit Rule ID

• Claim Details Exist

• Financial Responsibility Code

• Contract Amount

• Allowed Amount

• Detail Net Pay

• All Diagnosis Codes

• Fee Set Exists

• Covered

• UDF Fields #3 to UDF #20

• Claim Record Type

• Case Exists

• Created By

• Provider Outside ID

• Account

• Rendering Provider Service Area same as PCP

• Rendering Provider Specialty same as PCP

• Member Condition Codes

• Employment

• Accident

• Other Accident

• Additional Insurance Code

• Member Service Area

• Healthplan

• Option

• Bill Type

• Admission Type

• Admission Source

• Inpatient Days

• Patient Status

• Facility ID

• Pend Codes (Detail)

Most Commonly Used Adjudication Criteria

Claim Auto Adjudication

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All Adjudication CriteriaClaim HeaderClaim StatusDiagnosis CodePlace of ServiceHeader Net PayEOB Indicator# of UnitsAuthorization ExistsPend Codes (Master)Outcome CodeClaim DetailDetail Line Net PayCapitatedService CodeModifier CodeQuantityService TypeProcessing Status CodeBenefit Rule IDClaim Details ExistsFinancial Responsibility CodeAllowed AmountDetail Net PayContract AmountAll Diagnosis CodeFee Set ExistsCoveredPend Codes (Detail)

ProviderProvider IDSpecialtyVendor IDProvider ClassContract TypePCP EncountersProvider LOB – HMO InProvider LOB – HMO OutProvider LOB – PPO InProvider LOB – PPO OutProvider Outside IDProvider Qual CodeAccountRendering Provider Service Area Same as PCPRendering Provider Specialty same as PCP

Claim Misc.UDF #1 to UDF #20Claim Record TypeCase ExistsCreated By

MemberAgeMember's PCPGenderCOBMember Condition CodeEmploymentAccidentOther AccidentAdditional Insurance CodeMember Service AreaHealth planOption

Hospital Data ElementBill TypeAdmission TypeAdmission SourceInpatient DaysPatient StatusFacility ID

Auto Adjudication Reports

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Auto Adjudication Reports for both authorizations and claims to view statistical data

This feature allows the user to see daily, weekly, monthly, or annual Auth/Claims volume and Adjudication Rates

Auto Adjudication or Workflow

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Which Comes First? Root Beer anyone?

• Auto Adjudication Rules are searched before Workflow Rules

Auto Adjudication Logic

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When a user clicks on the Save icon, the system performs Auto Adjudication.

Just like Benefits and Fee Schedules, data elements on the Authorization or Claim must match all values contained in a Rule.

Claim/Auth is pended when conflicting rules are hit.

Auto Adjudication Messages

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If a Claim is Edited that was previously Auto Adjudicated, the following message is displayed when the record is saved

V6.5.3 AA Enhancements

New claim data element ACTION items Encounters

Enables users to defined the criteria

Final Adjustment

Remove Existing Final Adjustment Code Values

Financial Responsibility

Replace Billed Amount with Contract Amount

Adjust Contract Amount Down to Billed Amount

Frequency Code

Populate Adjustment Value with Contract Value

Remove Capitated check mark from Claim Detail

V6.5.3 AA Enhancements

New claim data element CRITERIA items Service Header Date From

Service Detail Date From

HP LOB

Provider Payment Type

Provider Status

Adjustment Code Category

Service Type Change from P to H

Service Type Change from H to P

Date of Service Prior to Member’s From Date

Date of Service After Member’s To Date

V6.5.3 AA Enhancements

New claim data element CRITERIA items Multiple Specialties

Member Status

Member Patient ID

Provider UDFs

Sub Account

Carrier #

Locality #

V6.5.3 AA Enhancements

New Authorization data element ACTION items Final Adjustment Code

Remove Existing Final Adjustment Code Values

Financial Responsibility

Replace Usual Charges with Contract Amount

V6.5.3 AA Enhancements

New Authorization data element CRITERIA items Auth Action Header Date

Auth Action Detail Date

HP LOB

V6.5.3 AA Enhancements

New Features/Functionality Overlapping Rules

# #, ability to view conflicting rules

Master Rules

Similar to Benefit Rule Master Rules

Many new operator values

Modified logic when different rules are hit for different lines for changing status value

New Query Builder data elements

Other miscellaneous changes

New Rule sequence logic

Auto Adjudication Worksheet

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Start with a simple rule by defining the rule on paper Step 1

Creating a Rule Set :_________________

Description :_________________________________

Date :______________________

Define the rule :_______________________________

Step 2 Define the Action to take place

Change Status to : __________

Apply Adjustment Code: _______

Step 3

Criteria that will trigger the rule Service Code = ________________

All Diagnosis Code = ______________

Age > = __________________

Age <= ___________________

Set up the Rules in the system. Let the rule run for a week and monitor the output before adding more Rules.

EZ-CAP Auto Adjudication

Questions?

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