Electronic data interchange, or EDI, is a regular part of the vocabulary for every home care agency that services clients who receive Medicaid or VA services. EDI is how you send your billing information in a HIPAA compliant manner to a billing clearinghouse for claim management. CareSmartz supports both 837P(professional) and 837I (institutional) claim files for many different clearinghouses and MCOs.
There are several steps that need to happen before you start processing your billing, so let’s take them one by one.
If you will be generating claim files electronically from the CareSmartz360 system, you will start in the Admin Settings>Agency>Billing Information.
First, select your Clearinghouse from the options at the top of the page. Then, indicate whether you file as a person or as a company and fill in the data in the text boxes.The Name of your company, must be the legal name of your company, not a d/b/a.Your NPI number, your tax type and ID, and your address are all required.You will need to add the extra 4 digits of your ZIP code. You can find those numbers at USPS.com if you’re not sure what they are.
In the next section of the page, you will need to add the Sender ID and Receiver ID that you receive from the clearinghouse or MCO.
The only required information in the Submitter Details is your phone type and phone number (no spaces or special characters).
That takes care of the back-end stuff.Now we need to set up the payer profiles for the companies you will be billing.
Hover over the Client module and click on Payers.
Click on +New payer in the top right corner of the screen.
In the Payer Details screen, select Company. Then start adding the name of the company in the text field. When you select from the drop-down, the Payer ID will auto-fill. You will need to select Veteran’s Affairs as the Type to create the 837I file.
Many clearing houses require the address of the payer be part of the EDI file, so please add it at the bottom of the page.
Once you save the payer, the next step is in the Payer profile, on the billing tab.
Scroll to near the bottom of the page where you will see “ICD10 HCPCS and Revenue Codes. Click on +Procedure Codes.
Select the Service Type from the drop down. Then enter the individual codes for the time increments required by this particular payer. Be sure to enter the codes in the REVENUE Codes for VA payers. Add the numbers in the field that corresponds with the units for which you bill.For example, if you bill in 15-minute increments, put the code in the box for 15 minutes, but put it in the box for Hourly if that’s how you bill.
You will need to add the numbers for all of the service types that you provide.
ALL of the payers for which you will be needing EDI files need to have the Payer ID and the Revenue Codes entered in the profile, or the EDI file will not be acceptable.
The next step is to set up the client profiles for any clients whose schedules will be billed using an EDI file. The important elements for EDI are on the
Claim Codes tab
On the main page, you need to select the “place of service” where the care will be provided. Home is selected by default; you only need to change it if the care is generally provided elsewhere.
The next step is on the Claim Codes tab.
When you start to enter the number, you will be presented with options from which to choose. Click the Add icon to add this code to this client’s assessment.Make sure you indicate which code is the primary code for the majority of the care you provide. Even if you only add 1 code, you will need to indicate that it is the primary diagnosis.
The Institutional Claim codes are required for clients who have VA payers.
Next, you need to configure the rates tab, so the correct insurance provider will get the bill.
Start by clicking on the rates tab. Because you already set up your payers, you will select +Existing Payer.
Enter the name of the insurance in the Company text field and click Search. Then, use the Select icon to select the correct payer.
This will open the Add Client Payer window.
Select “Primary” in the Rank field. Add the clieint's VA Member Number. Then, select the Payment Distribution. For VA payers, you will select the Client Authorization.
Add the client-specific details for the authorization and click save.
You can add another authorization for the same insurance if there is one.
Many clearinghouses require the Claim File Indicator Code, so it’s best to add it during the set up, so you don’t have to go back and add it later.
You can now also add the Group Name, Group Number, Insurance Type Code.
Once you have all the authorizations added, click the save button for the client payer.
Now, you’re ready to create schedules to be invoiced and turned into EDI files to submit to your MCO or your clearinghouse.
If you have set up the ICD codes and the institutional Claim codes, and you have configured the payers, all the necessary data will be in the schedules you create.
When you select the service type, you will see the authorization rate auto-fill in the bill type field. At the bottom of the schedule, you will see the diagnosis code information. From the basic schedule window, you can also adjust the fields if, for instance the place of service for a particular schedule will NOT be the regular place of service or if the primary diagnosis code for this visit is different from the pre-set primary code.
After the schedule has been created, the claim-related information which is associated with the schedule can be found in the schedule window > Claim info section. Agency users can make changes from the schedule window.
If you already have clients and schedules, you will need to do some work to add the necessary claim information to the schedules. You should contact the support team at CareSmartz for assistance with this.
That’s the end of the “set up” process! Next, just create your invoices like you usually do.If you’ve never created invoices in your CareSmartz360 system you can see the video: Accounting>Invoices for a step-by-step guide.
On the Finalized Invoice batch screen, you’ll see a “Generate EDI” icon.Just click the button, and the EDI file will generate.
If there is any missing information that is required to generate the claim file, the CareSmartz360 system will generate a report that shows exactly which information is missing so that the agency user can input the required information to successfully generate the EDI file.
You will see a screen that looks like this:
It shows you the schedule date, the client name, and the information that is not set up correctly. You can just go to the client profile or the payer profile and update the necessary information.
Once you have corrected the errors, you can click on the generate EDI icon again.
This will create a text file that you will see in the bottom left corner of your screen.
For most clearinghouses, you will need to save the file and then go into the website for the clearinghouse and upload the file.