TOPS Reference Manual

TOPS Contract and Claims

Inquiry

Reference Manual

TOPS Contract and Claims

Inquiry

Reference Manual

This manual was produced by UnitedHealthcare, Training & Development

All UnitedHealthcare specific written procedures, documents, records, work product, or manuals prepared by UnitedHealthcare shall be and remain the

property of UHC and shall be treated as confidential and proprietary information. UnitedHealthcare prohibits unauthorized use or distribution of

this material.

2003 by UnitedHealth Group

All rights reserved under the copyright laws of the United States of America.

All other product names are trademarks or registered trademarks of their respective holders.

Revision Date: August, 2005

UnitedHealthcare Training & Development Legal Statement

Please Read

UnitedHealthcare’s Training & Development (UHC T&D) uses real or live customer data in Production training materials and training scenarios. The purpose is to provide you with the knowledge, tools and experience to do your job as quickly, effectively and efficiently as possible. It is important that you understand this information is sensitive. You are responsible for ensuring that you use the information as permitted under this policy and Company information practices policies. During your training period, we will provide to you only the minimum amount of protected health information necessary for your particular training purposes. You may have access to Sensitive Information, including customers’ names, addresses, identification numbers, group numbers, and health information. This information may be provided to you in numerous formats including medical claims, enrollment forms, conversations with customers and several other scenarios. You may access or use this Sensitive Information for training purposes only. You may not access or use this Sensitive Information for any other purpose. You may not disclose this Sensitive Information to anyone other than your supervisor/manager or trainer as necessary to complete your training. You must return all impacted training materials to your trainer, as directed, at the end of your training period. Training materials containing sensitive information may not be removed from the premises, even for use at home. Please Note: You should always be very careful, whether in training or on the job, to collect, use, and disclose Sensitive Information only as permitted by law and in accordance with Company policies. If you are not sure whether you can collect, use, or disclose Sensitive Information in a specific situation, consult with your resources, including your supervisor, your Legal Services Department or the Compliance HelpLine. If in doubt -- don’t collect, use or disclose. Immediately report any information you have that Sensitive Information was improperly collected, accessed, used or disclosed to your supervisor, your Legal Services Department or the Compliance HelpLine.

August 2005 TOPS Contract and Claim Reference Manual Training & Development Table of Contents 7

TABLE OF CONTENTS

UNITEDHEALTHCARE TRAINING & DEVELOPMENT LEGAL STATEMENT...................................................................................................5

Please Read ............................................................................................................................................ 5

INTRODUCTION...........................................................................................11

Overview .............................................................................................................................................. 11

In This Manual .................................................................................................................................... 12

Using this Manual ............................................................................................................................... 14

SYSTEM BASICS .........................................................................................15

Introduction ......................................................................................................................................... 15

Signing On to TOPS............................................................................................................................ 15

Control Lines ....................................................................................................................................... 17

Keyboard Controls.............................................................................................................................. 18

Alternate Schemes............................................................................................................................... 20

Signing Off from TOPS ...................................................................................................................... 23

PREFERENCE ONLINE HELP .....................................................................24

Preference Overview........................................................................................................................... 24

Chapter Topics .................................................................................................................................... 24

Preference Volumes............................................................................................................................. 24

Accessing Preference Information ..................................................................................................... 30

ELIGIBILITY SCREENS................................................................................32

EPI Screen (Employee Policy Search) ............................................................................................... 33

CAI Screen (Customer Address) ....................................................................................................... 39

CEI Screen (Customer Eligibility)..................................................................................................... 42

MRI Screen (Medical Register) ......................................................................................................... 51

TOPS Contract and Claim Reference Manual August 2005 8 Table of Contents Training & Development

MDI Screen (Medical Dependent) ..................................................................................................... 64

HISTORY SCREENS.................................................................................... 77

AHI Screen (Abbreviated History) .................................................................................................... 78

MHI Screen (Medical History)........................................................................................................... 88

MNI Screen (Claim Number Register)............................................................................................ 103

MPI Screen (Medical Payment) ....................................................................................................... 107

RHI Screen (Revenue History Inquiry)........................................................................................... 114

ELECTRONIC DATA SCREENS ............................................................... 119

MEI Screen (Electronic Media Claim) ............................................................................................ 120

EDS 1 Screen (Electronic Data Screen 1)........................................................................................ 126



SCI/SDI Screen (Summary Check/Draft) ....................................................................................... 161

SFI Screen (Set Family) .................................................................................................................... 167

EDS 6.5 Screen................................................................................................................................... 171

NOTIFICATION SCREENS ........................................................................ 178

ARI Screen (Notification Records) .................................................................................................. 178

POI Screen (CCS/PARS Outpatient)............................................................................................... 185

PSI Screen (CCS/PARS Review)...................................................................................................... 191

PCI Screen (CCS/PARS Comments) ............................................................................................... 207

DLI Screen (CCS/PARS Outpatient TOPS Display) ..................................................................... 209

CMI Screen (Comments Medical) ................................................................................................... 215

PTI Screen (Personal Tracking Information)................................................................................. 218

INFORMATIONAL SCREENS.................................................................... 226

BCI Screen (Benefit Structure Comments)..................................................................................... 227

CCI Screen (COB Comments) ......................................................................................................... 231

August 2005 TOPS Contract and Claim Reference Manual Training & Development Table of Contents 9

FCI Screen (Freeform Comments) .................................................................................................. 237

PII Screen (Preexisting Investigator) .............................................................................................. 240

PROVIDER SCREENS................................................................................243

PHI Screen (Primary Care Physician History) .............................................................................. 244

PMI Screen (Provider Maintenance)............................................................................................... 248

PAI Screen (Provider Alpha Search)............................................................................................... 260

PRI Screen (Provider Association File)........................................................................................... 264

IPI Screen (IPA General Display).................................................................................................... 271

NAI Screen (Table of Notifications/Capitations/Withholds)......................................................... 280

NEGOTIATED RATES SCREENS..............................................................285

PPI Screen (PPO Provider) .............................................................................................................. 286

ETI Screen (Outlier/Exclusion Inquiry).......................................................................................... 306

FSI Screen (EPD Hard $ Schedule) ................................................................................................. 311

RCI Screen (Reasonable and Customary) ...................................................................................... 317

FXI Screen (Conversion Factor File) .............................................................................................. 323

PXI Screen (Room and Board Exception Table)............................................................................ 326

DPI Screen (DRG Carve-Outs)........................................................................................................ 332

DRI Screen (DRG Schedule) ............................................................................................................ 335

NXI Screen (Network Exception Inquiry) ...................................................................................... 340

SGI Screen (Surgical Grouper Inquiry).......................................................................................... 350

CRI Screen (Case Rate Inquiry) ...................................................................................................... 353

OCI Screen (Outpatient Rate) ......................................................................................................... 358

IRI Screen (Inpatient Rate).............................................................................................................. 371

MISCELLANEOUS SCREENS ...................................................................378

MEI Screen (Electronic Media Claim)............................................................................................ 379

IDI Screen (Individual Deductible).................................................................................................. 385

TOPS Contract and Claim Reference Manual August 2005 10 Table of Contents Training & Development

SCI/SDI Screen (Summary Check/Draft) ....................................................................................... 390

SFI Screen (Set Family) .................................................................................................................... 396

EDS 1 Screen...................................................................................................................................... 400

EDS 6.5 Screen................................................................................................................................... 408

APPENDICES............................................................................................. 416

Appendix A - CCS (PARS) Remark Codes..................................................................................... 416

Appendix B - Relationship Codes .................................................................................................... 418

Appendix C - Provider Types........................................................................................................... 419

Appendix D - Coverage Codes ......................................................................................................... 424

Appendix E - TOPS Screens Reference Sheet................................................................................. 426

Appendix F - Product Names ........................................................................................................... 430

Appendix G - Provider Flag Codes.................................................................................................. 433

Appendix H - Place of Service Codes............................................................................................... 436

Appendix I - Surgical Modifier Codes............................................................................................. 437

Appendix J - Specialty Codes ........................................................................................................... 438

Appendix K - Cause Codes ............................................................................................................... 445

Appendix I - TOPS Screen Flows..................................................................................................... 446

Appendix M - Market Type Values ................................................................................................. 451

GLOSSARY................................................................................................ 452

August 2005 TOPS Contract and Claim Reference Manual Training & Development Introduction 11

Introduction

Overview

The Online Processing System (TOPS) is a mainframe-based processing system that allows UnitedHealth Group to process claims throughout the United States

TOPS contains regions, called engines, in which data is stored. The engines include the following:

• ARCS Engine • Omni Engine • Bells Engine • Quark Engine • East Engine • Yogi Engine • North Engine • Zeus Engine • South Engine • XFile Engine • West Engine • King Engine • Central Engine • Dart Engine • Geo Engine • Foxx Engine • Myth Engine

Your office may work with information that is housed on just one engine. If so, you have access to that engine only.

However, your office may work with information that is on all the engines. If so, you will have seamless access, or access to all the engines.

Note on Confidentiality: Information in the TOPS engines discussed in this manual is taken from the actual production database of UNet. The data is confidential and should not be disclosed.

TOPS Contract and Claim Reference Manual August 2005 12 Introduction Training & Development

In This Manual

This manual contains the following chapters:

• System Basics This chapter includes descriptions of how to access TOPS from a Windows environment, how to sign on and off, use control lines, use keyboard controls, use alternate schemes, and other useful hints.

• Preference This chapter contains descriptions of the online help system, its volumes, its organization and components, and how to access help when you are in TOPS.

• Eligibility Screens This chapter contains descriptions of, procedures to use, and examples of those screens that help you access employee and dependent eligibility and policy information. The eligibility screens are EPI, CAI, CEI, MRI, and MDI screens.

August 2005 TOPS Contract and Claim Reference Manual Training & Development Introduction 13

• History Screens This chapter has descriptions of, procedures to use, and examples of those screens that contain historical information about claims information. The history screens are AHI, MHI, MNI, MPI and RHI.

• Notification Screens This chapter includes descriptions of, procedures to use, and examples of CCS (PARS), Notification information, Care Coordination, and Payout Control information screens. The notification (notification) screens are ARI, POI, PSI, PCI, DLI, CMI, and PTI.

• Informational Screens This chapter includes descriptions of, procedures to use, and examples of the freeform comments, COB comments, benefits comments, and preexisting comments screens. These screens are the BCI, CCI, FCI, and PII screens.

• Provider Screens This chapter includes descriptions of, procedures to use, and examples of the screens that contain provider information, such as provider demographics, tax identification numbers, IPA information, and contract information. The provider screens are PHI, PMI, PAI, PRI, IPI, and NAI.

• Negotiated Rates Screens This chapter includes descriptions of, procedures to use, and examples of the screens that contain participating provider rates, surgery rates, case rates, factors, DRG rates, and exception tables. These screens are the PPI, ETI, FSI, RCI, FXI, PXI, DPI, DRI, NXI, SGI, CRI, OCI and IRI.

TOPS Contract and Claim Reference Manual August 2005 14 Introduction Training & Development

• Miscellaneous Screens This chapter has descriptions of how to use and an example of the electronic claims screen, MEI, EDS 1, EDS 6.5 and three accounting screens: IDI, SCI/SDI, and SFI.

• Appendices The appendices include lists of codes, a TOPS screen reference sheet, and other items that you may need to quickly reference.

Using this Manual

If you are not familiar with the TOPS system, review the chapter on system basics and Preference, the online help system, before using TOPS.

If you are familiar with TOPS but need information about a particular screen, refer to the chapter containing that screen.

If you need to quickly access information about a code, control line, remarks, and so on, see the appendices of this guide, the reference aid, or Preference Online Help.

When you are reading about procedures in this guide, entries that you must make are in bold text. Variables appear as italics. If the text is bold and in italics, that entry is a variable.

August 2005 TOPS Contract and Claim Reference Manual Training & Development System Basics 15

System Basics

Introduction

This chapter contains information that helps you use TOPS, beginning with how to sign on. You also learn about keyboard controls, shortcuts, control lines, pop ups, hot keys, alternate schemes, and other useful tools.

In This Chapter

This chapter provides information about:

• Signing on and off of TOPS • Control lines • Alternate schemes

TOPS also has an online help system called Preference. See the following chapter for information about this system.

If you ever become locked out of the system, call UHC Security at 1-800-689-2883.

Signing On to TOPS

This table provides the steps to sign on to all the engines of TOPS.

Step Action Description

1 Open the appropriate emulator.

A prompt will appear for you to enter in the application name.

2 Type

TOPSSEA

3 Press the Enter key. A blank screen will appear.

TOPS Contract and Claim Reference Manual August 2005 16 System Basics Training & Development


4 Type

SEA1

5 Press the Enter key. The TOPS Seamless Engine Access menu will appear.

6 Select the option for the first engine (ARCS).

1

7 Press the Enter key. A blank screen will appear.

8 Type

SOI, your SSN

9 Press the Enter key. A security screen will appear.

10 Tab to the following fields and enter the appropriate information:

PASSWORD: (your TOPS password) FILM OFFICE NBR: 210 ADJUSTING OFFICE: 210SYSTEM: A (first letter of engine)

Note: The FILM OFFICE NBR and ADJUSTING OFFICE only need to be filled in on your initial login. They will be pre-filled from that point on. The engine you last signed on to will be displayed in the SYSTEM field upon accessing this screen.

11 Press the Enter key. In the lower left corner, the system will indicate “SIGN ON COMPLETE”.

12 Press the PA1 (Page Up) key.

The TOPS SEAMLESS ENGINE ACCESS main menu will appear.

13 Repeat steps 6-12 to sign on to each engine.

14 When all engines have been signed on to, type the option for Auto Routing: A

This will automatically route you to the appropriate engine to access the information you request.


Control Lines

Control lines are those entries you make at the top of the screen to send commands to the system. The commands allow you to:

• Access specific files • Return a particular type of system-formatted screen • Perform a specific processing function

All commands consist of two parts, a three-letter initial command (a transaction code) followed by a series of variable (the variable data) entries.

The transaction codes consist of two parts: the first two characters indicate the group and the last character indicates the system function.

Some examples of groups include:

• AR - Notification record • CC - Coordination of benefits (COB) comments • MH - Medical history • MP - Medical payment • PM - Provider maintenance

The system function codes are:

• I - Initial (always use when first accessing the screen) • B - Back (returns you to the previous page) • C - Calculate (instructs the system to input data to

determine benefits or other processing instructions) • N - Next (goes to next page) • P - Processing (updates the file with the new

information) • U - Update (updates any screen information with

unprotected fields) Note: You cannot use all of the system function codes on all screens.


The second part of the command consists of the variable data. Depending on the transaction, the variable data format can differ. However, the sequence of the variable data remains the same. Always separate each item by a comma; do not add a space after the comma. On some screens you can enter two commas, which instructs the system to ignore a field. Two or three commas can be placed after variable data anywhere in a control line to instruct the system to ignore the rest of the information in the control line. Examples of variable data include:

• Policy number • Employee Social Security number (SSN) • Patient name • Relationship code • Claim number • Provider SSN or tax identification number (TIN)

Note: A TOPS screens reference sheet is located in Appendix E.

Keyboard Controls

The keys that control your PC are dependent on the emulator you are using to access the mainframe computer. You may be able to view and change your keyboard mapping by using the options in your emulator. Check with system support personnel if you need assistance.


This table lists the keys you can use to perform tasks within TOPS.

Press This Key

To Perform This Task . . .

PA1 (Page Up)

Access the TOPS Main Menu

PA2 (Page Down)

Access pop-up help (if available) or go to Preference

Note: PA1 and PA2 Keys – If your keyboard has not been mapped differently, use Alt-Ins for the PA1 key and Alt-Home for the PA2 KEY.

F1 Access the Application Menu

F2 Exit the Expanded Provider Database (EPD) to return to TOPS.

F3 Access the Practice Review System (PRS)

F5 Access and exit the Document Archive and Retrieval System (TDARS)

F9 Access the Online Routing System (ORS)

F10 Access Consolidated Eligibility System (CES).

F11 Access Expanded Provider Database (EPD).

F12 Access a second TOPS window/move between two windows

TAB Move the cursor from field to field

Shift/Tab Move the cursor backward from field to field

Home Move the cursor to the top of the screen

Enter Submit information to the system

Reset (specific to emulator)

Reset keyboard


Alternate Schemes

When using alternate schemes to find a member using the EPI Screen, you need to know different identification criteria. In cases where you do not have this information, TOPS allows you to access these types of information through alternate schemes (or entries).

Enrollee Identification

To access enrollee information, you usually use the employee’s (or subscriber’s) SSN. Dependents use the employee’s SSN. There may be times, however, when you do not have the employee’s SSN. In these instances, you can use an alternate scheme to access an employee or dependent record.

To locate an enrollee when you do not have an SSN, complete the following steps of an alternate scheme:

1. Enter the first four letters of the employee’s last name.

2. Enter the first two numbers of the employee’s address.

3. Enter the two-letter state code of the employee’s state of residence.

4. Enter the first letter of the employee’s first name.


Note: Examples – The examples below show samples of how to display information using alternate schemes. These samples are for illustration purposes only. The names and addresses are fictitious.

This example illustrates the above procedure. With this information:

Joseph L. Frazier

513 Barnwood Drive

Adamsville, AL 35005

Make this entry:

FRAZ51ALJ

• If an employee’s last name has fewer than four letters, enter the letter of the employee’s first name. With this information:

Mary L. Hi

1108 Cherry Ave. S.

Lancaster, MN 56735

Make this entry:

HIMA11MNR

• If there is only one digit in the employee’s address, use that number and substitute the first letter of the city for the second digit. With this information:

Randolph G. Peterson

8 State Street

Marshfield, WI 54449

Make this entry:

PETE8MWIJ


If you do not have a street address number, substitute the first two letters of the city. With this information:

Randolph G. Peterson

1234 State Street

Anywhere, WI 54449

Make this entry:

PETEMAWIJ

Provider Identification

You can use alternate schemes to find a provider or facility using the PMI Screen. TOPS contains a tax identifier, either a SSN or federal TIN (Tax Identification Number) for a provider. When submitting a claim, providers often include their TIN.

Typically, when you search for information about this provider, you enter the tax identifier. When the tax identifier is not available, you can use an alternate scheme.

To locate a provider when you do not have a tax identifier, complete the following steps of an alternate scheme:

1. Enter the first three letters of the provider’s last name.

2. Enter the first letter of the provider’s first name.

3. Enter the first two numbers of the provider’s address.

4. Enter the two-letter state code of the provider’s state of residence.

The exceptions for a provider are identifical to the exceptions for an enrollee.

Dr. Harry Hanson

1234 State Street

Anywhere, WI 54449

Make this entry:

HANH24CA


Facility Identification

A facility has a TIN. Typically, it submits a claim with that TIN. If it does not, you can use an alternate scheme to access information about that facility.

The alternate scheme methods are basically the same as those used to locate a provider. However, you must enter the first three letters of the first word in the facility’s name and the first letter of the second word. With this information:

Marshfield Clinic

1000 N. Oak Ave.

Marshfield, WI 54449

Make this entry:

MARC10WI

Signing Off from TOPS

The procedure that follows describes how to sign off from TOPS.


1 Press the PA1 (Page Up) key.

The main menu to TOPS Seamless Engine Access appears.

2 Select the option for Logoff.

L

You have signed off.

3 Close your emulator.

TOPS Contract and Claim Reference Manual August 2005 24 Preference Online Help Training & Development

Preference Online Help

Preference Overview

Preference is an online, mainframe reference system that allows you to retrieve information. A good analogy for Preference is that of an encyclopedia. It consists of volumes that focus on given topics, which are easily accessible through your PC or CRT.

Chapter Topics

This chapter provides information on: • Preference Online Help within TOPS. • Locating relevant information in Preference.

The principle advantages of Preference over manuals or other forms of help are:

• Access to the most up-to-date information. • Access for everyone who has a PC or CRT. • Consistency in usage procedures, regardless of the

environment. • Applies to multiple U-Net systems. • Hot key and pop-up functions.

Preference Volumes

From within TOPS, you access Preference by pressing the PA2 (Page Down) key. If you first place your cursor in the Home position in TOPS by pressing the Home key, you will access the main screen of Preference after pressing the PA2 key. If your cursor is located within the screen of information in TOPS, you may access pop-up help (if available) or a volume within Preference (usually AIDS).

If you are not signed into TOPS, you must enter R999999999 and the volume title to access a volume within Preference.

August 2005 TOPS Inquiry Participant Guide Training & Development Preference Online Help 25

Example

The following example illustrates Preference’s main screen that displays the various volumes available in Preference.

If you have logged into TOPS, you can access the individual volumes in Preference by pressing the function keys listed or typing the volume title and pressing the Enter key. To access information about each volume, press the F11 key and follow the instructions.

The text that follows describes each volume, its title, and its function key.

AIDS - TOPS Processor Aids

This volume contains information that is available when paying or reviewing claims, answering customer calls, etc. Some of the major categories of information found in AIDS include codes, field values, processing guidelines, office information, OTS (Overpayment Tracking System), and warning and error messages.

Access the AIDS volume by pressing the F1 key.


SPI - Special Processing Instructions

This volume contains all provider specific SPIs. The SPIs include manual processing instructions for network providers when TOPS cannot automate calculations. To access an SPI, enter the provider’s tax identifier (without a prefix) or name as an index term.

Access the SPI volume by pressing the F2 key.

EOB - Explanation of Benefits

This volume contains remark codes, pend codes and form letters.

Access the EOB volume by pressing the F4 key.

MCG - Managed Care Guide

This volume contains information necessary to process claims for our managed care products. Included in this volume is utilization management, processing guidelines, eligibility information, negotiated reimbursement rates, provider information, and other network processing.

Access the MCG volume by pressing the F5 key.

MARKET - Market Biographic Information

This volume contains health plan specific information to assist when troubleshooting issues and resolving claim concerns. The topics include Market Specific General Information, Client Administrator by Plan/Policy, and CCS (PARS)/MetReview Care Coordination Contact List.

Access the MARKET volume by pressing the F6 key.


MCR (Group Volume) - Medical Claim Review

Note: As of February 20, 2000, the TMNGM, REIMB and CODING volumes were no longer updated. These volumes are available in Knowledge Library on the Frontier web site (http://kl/). The MCR 1 volume is the only information housed within the MCR volume.

DEL or DELIV Volume

This volume contains a list of all valid CPT-4 codes and HCPC codes. After you key a code at the index term prompt, Preference returns a description of the code and can include any of the following:

• Assistant surgeon covered • Starred procedure • Stand-alone code • McGraw-Hill values • Follow-up days • X-TIC network units • RBRVS units • Anesthesia time units • MCR referral instructions

Access this volume by pressing the F8 key.

STMAN - State Mandated Benefits Index

This volume includes an index of all state mandates and detailed information that applies to each state.


http://kl/


DIS – Group Volume

This volume contains documents specifically for Claims. Preference serves as the standard communication method to notify all claim offices of any new or revised processes, procedures, and system enhancements.

Each Claims Distribution release contains a cover sheet and a document. The cover sheet includes:

• Document reference number • Document title • Contact person • Implementation date • Staff, products, and systems affected by the release


TCC - Training Curriculum for Claim Handling

The TCC volume offers lessons for instructors and students on different aspects of handling claims (e.g., inpatient hospital, network basics, EMC, and claim completion).

Each lesson contains an instructor’s guide (to assist presenters) and a learner’s guide (for each enrollee of a class). You can use the curriculum for new hires, existing staff, or as a self-instructional class for those who need refresher training. There are additional lessons for those offices converting from IMCS to TOPS.


SYSPRB - System Problems

This volume is designed to be a method of documenting and reporting the system problems associated with a deliverable.



AARP

This volume is designed to be document AARP information.

Access this volume by pressing the F24 key (Shift + F12).

Other Volumes

There are other volumes that may be useful. Access these volumes by typing the volume name and pressing the Enter key.

• POLSPI - Special processing instructions by policy • STFILE - State mandated information for all states • PDI - Best practices for provider data integrity contract

loading • CASE 1 - Case installation procedures • OFFICE - Office specific information for processing • TRAIN - Training information • DELIV - Deliverable final documentation releases • HOWTO - How to use a group volume • SMCR-M - Standard Medical Claim Review training

manual • RX - Houses drug information • CSS - Brief overviews of the Customer Support Services

releases • CCG - IMCS to TOPS Case Conversion Implementation

Guide • AUTO - Audoadjudication (under development)


Accessing Preference Information

You may locate information in a volume by using the index term prompt. After you enter the topic or subject as an index term, the system searches the volume or all the volumes within a group volume. When you locate the appropriate subject or topic, enter an X in the field preceding the term(s) and press Enter. You will then access the information available on that subject.

You may also locate information by accessing the table of contents features within a volume by using the function keys as described on the volume menus. When you locate the appropriate subject or topic, enter an X in the field preceding the term(s) and press Enter. You will then access the information on that subject.

Preference Function Keys

Once you have accessed Preference, you have the option to use various keys as shortcuts. This table shows the keys that allow you to perform different actions.

This Key . . . Allows You to . . .

PA1 (Page Up)

Access the TOPS main menu.

F1 Accesses help.

F2 Toggles the menu off and on.

F3 Moves you back to a level which eventually exits Preference.

F7 Moves one page back.

F8 Moves one page forward.

Enter Sends information to the mainframe.


Pop-Up Help

To access pop-up help for a particular field on any screen, place the cursor anywhere on the field and press the PA2 key.

If pop-up help is not available, the system takes you directly to the Preference menu to search on your own.

To remove the help window, press the Enter key. You can continue to work as before.

You can access pop-up help for the following screens:

• MPI screen • MRI screen • ARI screen • PSI screen • ADI screen • PTI screen • CDI screen • TCI screen • IZI screen • IPI screen • FTI screen • FSI screen

TOPS Contract and Claim Reference Manual August 2005 32 Eligibility Screens Training & Development

Eligibility Screens

Overview

This chapter contains descriptions of, procedures to use, and examples of those screens that help you access employee and dependent eligibility and policy information. The eligibility screens are EPI, CAI, CEI, MRI, and MDI screens. Chapter Topics

This chapter provides information on:

• Enrollee searches. • Enrollee eligibility information for employees and

dependents.

August 2005 TOPS Contract and Claim Reference Manual Training & Development Eligibility Screens 33

EPI Screen (Employee Policy Search)

Overview

The EPI screen allows you to locate an enrollee’s record with only the employee’s SSN or with a policy number and a last name. For more detailed enrollee information, use the CEI screen.

Before You Work with This Screen

Before you work with the EPI screen, be aware that:

• The system can route you to this screen if it receives multiple hits on a social security number when you are using the MDI, MRI, or CEI screens.

• Each EPI screen can display information for up to six records. If more records exist, a message appears at the bottom of the screen indicating there are more. To access more records, press the Enter key or the F8 key.

Procedures

Follow the procedures on the following page to locate an enrollee’s policy number. The screen’s field descriptions follow the procedure and example.


Accessing the EPI Screen

Follow the steps below to access the EPI screen.

Step Action Result/Description

1 In the control line, enter EPI,, or EPI,S(SSN) or (Alternate Scheme)

2 Press the Enter key. If you entered in “EPI,,” you must enter a policy number and a last name and press Enter. If you entered an SSN or Alternate Scheme, the system displays the specified employee’s data.


Example

This example illustrates an EPI screen.

EPI Screen Field Descriptions

The following table lists the EPI fields and contains descriptions of each field.

Field This Field . . .

S Allows you to select a record from a multiple listing if you were routed from an CEI or MRI screen.

POLICY Contains the policy number of the specified enrollee.

LNAME Contains the enrollee’s last name.

12 CITY DR ANYWHERE

123456

123456

1234 ANY ST ANYWHERE

EPI,S123456789



ALT Indicates the enrollee’s alternate scheme or social security number (if an alternate scheme was used to access the screen).

SYS Indicates the claims system on which the claims are paid. The valid values are: COSM - COSMOS MET - IMCS TOPS Engine - Engine record is located on the TOPS system.

OFF Indicates the claim office location.

ADDR Contains the enrollee’s street address.

CITY Contains the enrollee’s city.

ST Contains the enrollee’s two-letter state abbreviation.

ZIP Contains the enrollee’s five- or nine-digit zip code.

EFF DT Contains the effective date of the enrollee’s policy. The format of this field is mm dd yyyy.



CAN DT Contains the expiration date of the enrollee’s policy. The format of this field is mm dd yyyy.


On CEI screen enterCEI,,S(SSN).

Does more than onepolicy exist for

Enrollee?

Select appropriatepolicy on EPI screen byplacing an "S" in Select

field.Yes

Enrollee's CEI record is displayed.

No

Access Enrollee'sclaim history? Enter "A" in Select field

to access AHI screen.

Accessemployee's register

information?

Accessdependent's

record?

AccessEnrollee's personal

physicianhistory?

Enter "M" in Select fieldto access MRI screen.

Enter "D" in Select fieldto access MDI screen.

Enter "P" in Select fieldto access PHI screen.

Yes

Yes

Yes

Yes

No

No

AccessEnrollee'sdeductible

information?

Enter "I" in Select fieldto access IDI screen.

Yes

No

No

Access Enrollee'sspecific claim?

Enter "S" in Select fieldto access MHI screen.

Yes

Enrollee's AHI record is displayed.

Enrollee's MRI record isdisplayed.

Enrollee's MDI record isdisplayed.

Enrollee's PHI record isdisplayed.

Enrollee's IDI record isdisplayed.

Enrollee's MHI record isdisplayed.

Access anotherclaim for Enrollee?

Enter "A" in R field toreturn to AHI screen.

Yes

Accessing Enrollee Information Viathe CEI Screen


CAI Screen (Customer Address)

Overview

The Policy Name and Address (CAI) screen displays all of the policyholder or customer mailing addresses. This screen is used to determine the policyholder name on EOBs and/or checks. It also includes the address the policyholder EOBs will be mailed to if the medical mail code on the MRI is other than A. This screen contains the following information: • Policy Name and Address Code • Policyholder’s full name • Name of contact person Before You Work with This Screen

Before you work with the CAI screen, be aware that:

• Each policy name and address contains a three digit numeric

PNA code used for multiple addresses. It is also found on the MRI screen.

• Up to 6 names and addresses can be listed on this screen, but there can be limitless entries.

If discrepancies are found, they need to be reported to the Case Installation Analyst for updating. Procedures

Use the following procedure to access the CAI screen. The CAI field descriptions follow the procedure and example.


Accessing the CAI Screen

Complete the steps in the following table to access the CAI screen. Step Action Result/Description

1 In the control line, enter CAI, (Policy #),(Reporting Code)

2 Press the Enter key. The system displays the PNA codes, name(s) and address(es) listed for the policy.

Example

This example illustrates a CAI screen.

CAC,123456,0001

1234 CITY RD ANYWHERE


CAI Screen Field Descriptions

The following table lists the CAI fields and contains descriptions of each field.


PNA CODE Policy name and address code. This is a three digit code beginning with 001 and continuing sequentially for as many names and address locations as necessary.

NAME Contains the policyholder’s name. The name entered in this field is used by TOPS to fill the “Benefit Plan Of” field on the EOB’s.

ATTN Contains an attention line to direct the EOB/check copies to a specific individual if appropriate.

ADDR Contains the street address of the policyholder.

CY Contains the city of the policyholder’s address.

ST Contains the state of the policyholder’s address.

ZIP Contains the zip code of the policyholder’s address.


CEI Screen (Customer Eligibility)

Overview

The CEI screen allows you to access CES (Consolidated Eligibility System) information. The system displays detailed eligibility data for IMCS and U-Net TOPS members. It also displays summarized eligibility information for COSMOS members. Information on the CEI screen includes:

• Enrollee and dependent's demographic data • Claim Office • Customer Service location • 800 telephone number • PCP’s MPIN and sequence number • Customer number for IMCS members • Group number for IMCS members • Plan code for IMCS enrollee • Suffix and account for U-Net TOPS members • Cap model • Division for COSMOS members


Before you work with the CEI screen, be aware that: If you work with claims processing, most information on the CEI screen comes from CES. The system makes certain modifications from TOPS policy information and IPA general data. Procedures

Use the procedure that follows to locate enrollee information. The screen field descriptions follow the procedure and example.


Accessing the CEI Screen

Follow the steps below to access the CEI screen.


1 In the control line, enter CEI,,S(SSN or Enrollee ID) or CEI,(Policy #, Group #, or Customer #),S(SSN or Enrollee ID)

2 Press the Enter key. The system displays the specified employee’s data.

Examples

This example illustrates a CEI screen for a TOPS enrollee.

1234567

CEC,123456,S123456789

1234 CITY ST PO BOX 1234

12345678001234567 8001234567

ANYWHERE


This example illustrates a CEI screen for an IMCS enrollee.

This example illustrates a CEI screen for a COSMOS enrollee.

CEC,123456,S1234567

1234 CITY DR

1234567 8001234567 1234567 8001234567

ANYWHERE

CEC,123456,S1234567

1234 CITY STANYWHERE


CEI Screen Field Descriptions

The CEI screen has three sections:

• Enrollee demographics Enrollee demographics are at the top left of the screen. The information includes the enrollee’s complete address the employer’s name (IMCS and TOPS members only), and policy telephone number (IMCS and TOPS) to which the enrollee should be directed.

• Claim office information (TOPS members only) Claim office information is at the top right of the screen. The information includes the claim payment office name, office number (pay location), engine, claim mailing address, and claims office telephone number (IMCS and TOPS).

• Enrollee-specific information This table lists the fields and provides descriptions of each enrollee-specific field in a CEI screen.


unlabelled (IMCS and TOPS)

Displays the policy telephone number which represents one of the numbers displayed on the enrollee’s card.

GRP# (IMCS and TOPS)

Contains the group number of the employer.

CUST# (IMCS and TOPS)

Contains the customer number of the employer.



unlabelled (IMCS and TOPS)

Displays the claims office telephone number .

unlabelled select field (TOPS)

Allows you to select a record and route to another screen with the following options: A - Accesses the AHI (Abbreviated History) screen for the enrollee. D - Accesses the MDI (Medical Dependent) screen for the enrollee. I - Accesses the IDI (Individual Deductible) screen for the enrollee. M - Accesses the MRI (Medical Register) screen for the enrollee. P - Accesses the PHI (Primary Care Physician History) screen for the enrollee.

FRST NME Contains the first name of each family enrollee. Only the subscriber’s information is shown for an enrollee on COSMOS.

RL Contains the two-letter relationship of the enrollee to the employee. See Appendix B for a list of valid relationship codes and descriptions.

BIRTH (TOPS & IMCS)

Contains the birth date of the enrollee. The format of this field mmddyy.



S (second) (TOPS & IMCS)

Indicates the one-digit gender of the enrollee. The valid values are: 1 - Male 2 - Female

PCP TIN & SFX (TOPS & IMCS)

Contains the provider’s one-digit prefix, a nine-digit tax identifier, and a three-digit suffix. The prefix is 1 if the tax identifier is the provider’s Social Security number and 2 if it is the Federal Tax Identification number. The suffix is the specific identifier for the provider under this particular TIN.

PCP NAME (TOPS & IMCS)

Displays the enrollee’s PCP name.

A M SS Unknown field.

Next line... unlabeled Plan & Reporting Codes (IMCS and TOPS)

Contains the codes that identify how a claim is paid.



unlabeled Indicates the current coverage effective date range for the enrollee. The format of this field is mmddyy.

unlabeled

Indicates the product name. See Appendix F for an explanation of product names.

C (IMCS and TOPS)

Contains the two-digit coverage code. See Appendix D for the list of valid coverage codes and descriptions.

unlabeled (TOPS)

Contains the following EBDS (TOPS) information: Coverage type (e.g., BASE, BMME, and CME). Base coverage set number MME/CME coverage set number Medicare coverage set number

unlabeled (IMCS and TOPS)

Contains the seven-digit market number.




Contains the two-digit market type used to identify the level of control in a network. The valid values for this field are: 00 - Default, or Wide Access or Blank 01 - Medicaid 02 - Medicare 03 - Worker’s Compensation (not used) 04 - Small Access 20 - Parallel Wide Access, Gatekeeper, Commercial 50 - Open Access, Commercial 51 - Medicaid Open Access 52 - Medicare Open Access 54 - Small Access 70 - Parallel, Commercial See Appendix M to see how market types are associated with the product lines.


Contains the provider’s MPIN number followed by a three-digit address indicator from EPD.

Next line... (IMCS and TOPS)

Contains the previous coverage information--plan and reporting codes, date range of coverage, product, and coverage code.



C (IMCS and TOPS)

Contains the one-letter identifier if coordination of benefits is necessary. The format of this field is Y/N.

H (IMCS and TOPS)

Contains the one-letter identifier indicating medical claims history exists. The format of this field is Y/N.

M (IMCS and TOPS)

Contains the one-letter identifier if Medicare is indicated. The format of this field is Y/N.

U (IMCS and TOPS)

Relates to medical underwriting. This field is not used.


Indicates the one-letter PCP selection, when applicable. The valid values for this field are: V - Voluntary choice A - Assigned choice

IPA (IMCS and TOPS)

Contains the following information: Enrollee’s five-digit IPA number


MRI Screen (Medical Register)

Overview

The MRI screen provides enrollee demographic and general benefit information. There must be an MRI record before the system can process claims. The screen contains the following information:

• Employee demographic information • Dependent information • Policy and coverage data


Before you work with the MRI screen, be aware that:

• There is a comment line below the control line. A letter(s) appears if certain kinds of comments exist for this Social Security number. Identify the comments by one of the following: - F - Freeform comments (located on the FCI screen) - C - COB comments (located on the CCI screen) - B - Benefits Structure comments (located on the BCI screen)

• Any information on the first line of the FCI screen also appears.

• To view a second address line, you may view the ESI (Employee Supplemental) screen. The control line format is the same as the MRI/MDI screen.

• An efficient way to access an MRI screen for an enrollee is to access the CEI screen and place an “M” in the Select field.

• Pop-up help is available for field descriptions on the MRI.

Procedures

Use the procedure that follows to access general information about an enrollee or their benefits. The screen field descriptions follow the procedure and example.


Accessing the MRI Screen

Complete the steps below to access the MRI screen.


1 In the control line, enter MRI,(Policy #),S(SSN) or (Alternate Scheme)) or MRI,,S(SSN) or (Alternate scheme

2 Press the Enter key. The system displays the specified enrollee’s data.

Example

This example illustrates the MRI screen.

MRI,123456,S12345689,,,


12345


MRI Screen Field Descriptions

The MRI screen consists of three sections:

• Enrollee demographics • Policy information • Enrollee-specific information

The enrollee demographic section follows the comment line and consists of two lines. The following table lists the MRI enrollee demographic fields and contains descriptions of each field.


unlabeled Contains the employee’s last name.

unlabeled Contains the employee’s street address.

MISC Contains any freeform comments that can vary from policy to policy.

unlabeled Contains the employee’s city of residence, two-character state code of residence, and five- or nine-digit zip code.

SSN Contains the employee’s nine-digit Social Security number. Note: This field is not always completed.

ID# Contains the employee’s company identification. Note: This field is completed only if the policy holder requires both the SSN and the ID# be reported.



DEC DT Contains the date that the employee died. The format of this field is mmddyy.

In the policy information section, there are three rows listed for the employee, spouse, and each dependent. The spouse and dependent coverage information appears in two lines of the specific enrollee section. For the employee, the “C - EE” line displays information regarding the current coverage, the “P1-EE” line displays information regarding the previous coverage, and the “P2-EE” line displays information regarding the coverage prior to the previous coverage. The table that follows lists the policy information fields and their descriptions.


POLICY Contains the employee’s policy number.

PLAN Contains the plan variation number.

REPT Contains the reporting code number.

CV Identifies the two-digit coverage code. See Appendix D for a list of valid coverage codes and descriptions.

EFF DT Indicates the effective date of the policy for that line. The format of this field is mmddyy.



CAN DT Indicates the cancellation date of the policy for that line. The format of this field is mmddyy and can be 999999 to indicate that the policy is active.

PNA Indicates if the policy enrollee has multiple locations. This field defaults to 001 if there is a single location. A member may have multiple locations due to a divorce and the member has the ex-spouse on the policy. This could occur if the divorce decree stipulated this and the two people are in separate locations.

MO Indicates the enrollee’s file location in QCARE. The format of this field is Y/N with Y indicating that the file is in QCARE.

E Indicates the eligibility update type. The valid values for this field are: M - Manual update D - TACS update

YR/DY/J-D Indicates the two-digit year, two-digit date, and one-character month in which a change in coverage or employment occurred.



CYCDT Indicates the last date in which a TACS update occurred. The format of this field is mm yy.

RC Lists the reason code for the YR/DY/J-D status or change in coverage or employment. The valid values for this field are: 01 - Furloughed 02 - Suspended 03 - Dismissed 04 - Resigned 05 - Disabled 06 - Leave of absence 07 - Deceased 08 - Retired 09 - Pregnancy

ST DT Indicates the status date. The format of this field is mmddyy.



RS Specifies the one-digit number used to restrict an enrollee’s file to limited access by the field office. The valid values for this field are: 0 or blank - No restriction 1 - Entire file is restricted 2 - Subscriber not restricted, a dependent(s) restricted 3 - A family enrollee restricted 6 - SCI transplant 7 - TCM transplant 8 - URN transplant

LOC Indicates the city and state in which the employee is employed.

PAY LOC 1 Contains the three-digit location in which the employee is currently paid.

PAY LOC 2 Contains the three-digit location in which the employee was paid before the current location.

YR Indicates the two-digit year used for salary, if applicable.

SAL Contains the current year’s salary, if applicable. Note: Some policies have deductibles that are dependent upon the salary of the subscriber.



DED/NC Contains the year’s calculated deductible. NC = Not Covered.

MMAIL Contains the one-character medical mail code.

DMAIL Contains the disability mail code consisting of four position indicators. First position: Indicates (Y/N) if a second address line exists that can be displayed on the ESI screen.Second position: Indicates (Y/N) if the address is a foreign address. Fourth position: Indicates the source of an address update: The valid values for this position are: M - Address update from enrollee P - Address update from post office E - Address update from employer

AUDIT Contains the last date that the file was manually updated. The format of this field is mmddyy.

This table contains the specific-enrollee information fields and their descriptions. The MRI screen contains lines for the employee and each dependent. Note: Dependent information is not updated after the policyholder has been canceled in CES.



FIRST NAME Contains the first name of the employee or dependent.

RL Contains the two-character relationship code of the enrollee to the employee. See Appendix B for a list of valid relationship codes and descriptions.

BTH DT Indicates the enrollee’s date of birth. The format of this field is mmddyy.

MD EFF Contains the enrollee’s effective date of coverage. The format of this field is mmddyy.

MD CAN Contains the enrollee’s cancellation date of coverage. The format of this field is mmddyy or 999999 (if active).

S Indicates the enrollee’s gender. The valid values for this field are: 1 - Male 2 - Female



C Indicates if coordination of benefits is applicable. The valid values for this field are: Y - The enrollee’s other insurance is the primary carrier. N - United HealthCare is the primary carrier for this enrollee.

M Indicates if Medicare benefits are applicable. The valid values for this field are: Y - Medicare is the primary carrier. Blank - United HealthCare is the primary carrier.

EFF DT Indicates the effective date of the other insurance or Medicare. The format of this field is mmddyy.

CAN DT Indicates the cancellation date of the other insurance or Medicare. The format of this field is mmddyy.



T Indicates Tax Equality and Fiscal Responsibility Act of 1982 (TEFRA) considerations. The valid values for this field are: 1 - Selected Medicare (United HealthCare benefits do not apply) 2 - Selected United HealthCare as primary carrier of benefits 3 - Selected Medicare with United HealthCare rider

R Indicates a one-digit restriction code. The valid values for this field are: 0 or blank - No restriction 1 - Individual restricted 2 - Individual restricted for payment update; history may be viewed 6 - SCI Transplant 7 - TCM Transplant 8 - URN Transplant

RET/ST Represents the retirement date or the date the student status is verified. The format of this field is mmddyy.



COBDT Indicates the date that the coordination of benefits was verified. The format of this field is mmyy.

U Indicates medical underwriting. The value of “A” indicates that the enrollee is on COBRA or eligible for extended benefits.

O Contains the one-character indicator as to which records and what information can be changed on the register. The valid values for this field are: C - Can change eligibility information for the dependent indicated (effective and cancellation dates). A - Can change the employee's first name and current cancellation date only.

P Indicates the enrollee level portability. Portability relates to the Health Insurance Portability Accountability Act of 1997 (HIPPA). The valid values for this field are: Y - Portability applies to a particular enrollee N - Portability does not apply to particular enrollee P - Portability applies. Research required to determine length of portability. Blank - Portability unknown



L Indicates if Late Entrant. The valid values for this field are: Y - Dependent enrollee meets Late Entrant criteria N - Dependent enrollee does not meet Late Entrant criteria Blank - Late Entrant criteria has not been determined.


MDI Screen (Medical Dependent)

Overview

The MDI screen displays specific information about each employee and the employee’s dependents. Information is displayed even if the dependent’s last name is different from the employee. This screen also contains:

• Relationship codes • Birth dates • Coordination of benefits


Before you begin working with the MDI screen, be aware that:

• There is a comment line below the control line. A letter(s) indicates if comments exist for this social security number. The one-letter identifiers are: - F - Freeform comments (located on the FCI screen) - C - COB comments (located on the CCI screen) - B - Benefits structure comments (located on the BCI screen)

• Any information entered on the first line of the FCI screen also appears in the comment line.

• To view a second address line, you may view the ESI (Employee Supplemental) screen. The control line format is the same as the MRI/MDI screen.

• An efficient way to access an MDI screen for an enrollee is to access the CEI screen and place a “D” in the Select field.

Procedures

Use the procedure that follows to locate an enrollee’s policy number. The screen field descriptions follow the procedure and example.


Accessing the MDI Screen

Complete the steps in the following table to access the MDI screen.


1 In the control line, enter MDI,(Policy #),S(SSN) or (Alternate Scheme) or

MDI,,S(SSN) or (Alternate scheme)

The system displays this information as you enter it.

2 Press the Enter key. The system displays the specified employee’s data.

Example

This example illustrates the MDI screen.

MDN,123456,S12345689,,,


12345


MDI Screen Field Descriptions

The MDI screen consists of three sections:

• Enrollee demographics • Policy information • Enrollee-specific information

The enrollee demographic section follows the comment line and consists of two lines. The following table lists the MDI enrollee demographic fields and contains descriptions of each field.


unlabeled Contains the employee’s last name.

unlabeled Contains the employee’s street address.

MISC Contains any freeform comments that can vary from policy to policy.

unlabeled Contains the employee’s city of residence, two-character state code of residence, and five- or nine-digit zip code.

SSN Contains the employee’s nine-digit Social Security number. Note: This field is not always completed.

ID# Contains the employee’s company identification. Note: This field is completed only if the policy holder requires both the SSN and the ID# be reported.



DEC DT Contains the date that the employee died. The format of this field is mmddyy.

In the policy information section, there are three rows listed for the employee, spouse, and each dependent. The spouse and dependent coverage information appears in two lines of the specific enrollee section. For the subscriber, the “C - EE” line displays information regarding the current coverage, the “P1-EE” line displays information regarding the previous coverage, and the “P2-EE” line displays information regarding the coverage prior to the previous coverage. The table that follows lists the policy information fields and their descriptions.


POLICY Contains the employee’s policy number.

PLAN Contains the plan variation number used to calculate the proper benefits for the enrollee.

REPT Contains the reporting code number used to calculate the proper benefits for the enrollee.

CV Identifies the two-digit coverage code. See Appendix D for the list of valid coverage codes and descriptions.

EFF DT Indicates the effective date of the policy for that line. The format of this field is mmddyy.



CAN DT Indicates the cancellation date of the policy for that line. The format of this field is mmddyy.

PNA Indicates if the policy enrollee has multiple locations. This field defaults to 001 if there is a single location.

MO Indicates the enrollee’s file location in QCARE. The format of this field is Y/N, with Y indicating that the file is in QCARE.

E Indicates the eligibility update type. The valid values for this field are: M - Manual update D - TACS update

YR/DY/J-D Indicates the year, date, and month in which a change in coverage or employment occurred.

CYCDT Indicates the last date in which a TACS update occurred. The format of this field is mm yy.



RC Lists the reason code for the YR/DY/J-D status or change in coverage or employment. The valid values for this field are: 01 - Furloughed 02 - Suspended 03 - Dismissed 04 - Resigned 05 - Disabled 06 - Leave of absence 07 - Deceased 08 - Retired 09 - Pregnancy

ST DT Indicates the status date. The format of this field is mmddyy.



RS Specifies the one-digit number used to restrict an enrollee’s file to limited access by the field office. The valid values for this field are: 0 or blank - No restriction 1 - Entire file is restricted 2 - Subscriber not restricted, a dependent(s) restricted 3 - A family enrollee restricted 6 - SCI transplant 7 - TCM transplant 8 - URN transplant

LOC Indicates the city and state in which the employee is employed.

PAY LOC 1 Contains the three-digit location in which the employee is currently paid.

PAY LOC 2 Contains the three-digit location in which the employee was paid before the current location.

YR Indicates the two-digit year used for salary, if applicable.

SAL Contains the current year’s salary, if applicable. Note: Some policies have deductibles that are dependent upon the salary of the subscriber.



DED/NC Contains the year’s calculated deductible.

MMAIL Contains the one-character medical mail code.

DMAIL Contains the disability mail code consisting of four position indicators. First position: Indicates (Y/N) if a second address line exists that can be displayed on the ESI screen.Second position: Indicates (Y/N) if the address is a foreign address. Fourth position: Indicates the source of an address update: The valid values for this position are: M - Address update from enrollee P - Address update from post office E - Address update from employer

AUDIT Contains the last date that the file was manually updated. The format of this field is mmddyy.


This table contains the specific enrollee information fields and their descriptions. The MDI screen contains lines for the employee and each dependent.


FIRST NAME Contains the first name of the enrollee.

RL Contains the two-character relationship code of the enrollee to the employee. See Appendix B for a list of the valid relationship codes and descriptions.

BTH DT Indicates the enrollee’s date of birth. The format of this field is mmddyy.

MD EFF Contains the enrollee’s effective date of coverage. The format of this field is mmddyy.

MD CAN Contains the enrollee’s cancellation date of coverage. The format of this field is mmddyy or 999999 (if active).



S Indicates the enrollee’s gender. The valid values for this field are: 1 - Male 2 - Female

C Indicates if coordination of benefits is applicable. The valid values for this field are: Y - The enrollee’s other insurance is the primary carrier. N - United HealthCare is the primary carrier for this enrollee.

M Indicates if Medicare benefits are applicable. The valid values for this field are: Y - Medicare is the primary carrier. Blank - United HealthCare is the primary carrier.

EFF DT Indicates the effective date of the other insurance or Medicare. The format of this field is mmddyy.



CAN DT Indicates the cancellation date of the other insurance or Medicare. The format of this field is mmddyy.

T Indicates TEFRA considerations. The valid values for this field are: 1 - Selected Medicare (United HealthCare benefits do not apply) 2 - Selected United HealthCare as primary carrier of benefits 3 - Selected Medicare with United HealthCare rider

R Indicates a one-digit restriction code. The valid values for this field are: 0 or blank - No restriction 1 - Individual restricted 2 - Individual restricted for payment update; history may be viewed 6 - SCI Transplant 7 - TCM Transplant 8 - URN Transplant

RET/ST Represents the retirement date or the date the student status was verified. The format of this field is mmddyy.



COBDT Indicates the date that the coordination of benefits was verified. The format of this field is mmyy.

U Indicates medical underwriting. A value of “A” indicates that the enrollee is on COBRA or eligible for extended benefits.

O Contains the one-character indicator as to which records and what information can be changed on the register. The valid values for this field are: C - Can change eligibility information for the dependent indicated (effective and cancellation dates). A - Can change the employee's first name and current cancellation date only.

P Indicates the enrollee level portability. The valid values for this field are: Y - Portability applies to a particular enrollee N - Portability does not apply to particular enrollee P - Portability applies. Research required to determine length of portability. Blank - Portability unknown



L Indicates if Late Entrant. The valid values for this field are: Y - Dependent enrollee meets Late Entrant criteria N - Dependent enrollee does not meet Late Entrant criteria Blank - Late Entrant criteria has not been determined.

August 2005 TOPS Contract and Claim Reference Manual Training & Development History Screens 77

History Screens

Overview

This chapter has descriptions of, procedures to use, and examples of those screens that contain historical information about claims information. The history screens are AHI, MHI, MNI, MPI and RHI.

Chapter Topics

This chapter includes information on:

• Abbreviated claim history for an enrollee. • Specific information on a claim. • Identifying information on a claim. • Claim number history for an enrollee.

TOPS Contract and Claim Reference Manual August 2005 78 History Screens Training & Development

AHI Screen (Abbreviated History)

Overview

The AHI screen provides a summary of medical claim payments for a specific enrollee and allows you to quickly locate a specific claim. This screen contains the following information:

• Dates of service • Processing dates • Provider charges • Paid amounts • Deductible information • Noncovered amounts • Remark codes

You can use a “modifier” to pull all claims submitted by a specific provider by using T (Prefix, TIN and NO Suffix) on the AHI Screen only. You can also use modifiers on the MHI Screen.

If you require more detailed information on a claim, you can access the correct MHI (Medical History) screen directly from this screen. Before You Work with This Screen

Before you work with the AHI screen, be aware that:

• When there are multiple AHI screens for an enrollee, the system shows the message, W759MORE RECORDS.

• To page forward to the next screen, press the Enter key. • To page back to the previous screen, type “B” over the

“N” in the control line and press the Enter key. • To begin paging forward again, type “N” over the “B.” • Each screen contains up to nine summary records of two

lines each. • An efficient way to access AHI for an enrollee is to access

the CEI screen and place an “A” in the Select field.


Procedures

Procedures are shown below for specific scenarios.

Procedure to View a Summary of All Claims for an enrollee

To view a summary of all claims in TOPS history for a specified enrollee, complete the steps in the following table.


1 In the control line, enter

AHI,,S(SSN),(First Name),(Rel) or AHI,(Policy#),S(SSN), (First Name),(Rel)


2 Press the Enter key. The system displays the specified enrollee’s claims history.

Procedure to View a Summary of All Claims for an enrollee from One Provider

To view a summary of all claims for one enrollee from one provider in the AHI screen, complete the steps in the following table.


1 Enter

AHI,(Policy#),S(SSN),(First Name),(Rel),T(Provider Prefix,TIN,Suffix)


2 Press the Enter key. The system displays the AHI summary record for that enrollee from that provider.

Note: This control line returns only those claims for the provider you indicate in the control line. If you add the provider suffix to the line, the system can narrow the search.


Example

This example illustrates a summary of all claims in TOPS history for a specified enrollee. The field descriptions for the AHI screen follow the examples.

_AHC,123456,S123456789,ALYSSA,CH,

1234 CITY ST ANYWHERE


Example

This example illustrates a summary of all claims for one enrollee from one provider.

AHI Screen Field Descriptions

This table lists the fields and provides descriptions of each field in an AHI screen.


S Allows you to select a claim record (MHI screen) from the AHI summary if you need more detailed information.

The only option is “S.”

AHC,123456,S123456789,ALYSSA,CH,T1234567890123




FST DT Contains the first date of service listed in the claim. The format of this field is mmddyy.

LST DT Contains the last date of service listed in the claim. The format of this field is mmddyy.

CHARGE Contains the total billed dollar amount that the provider submitted on the claim. The format of this field is n.nn.

PAID Contains the total dollar amount paid on the claim. The format of this field is n.nn.

DED Indicates both the dollar amount deducted from the claim payment and the deductible code applied to the procedure. The valid deductible codes are: • A - Appliances, nursing and therapy • B - Home health care

• D - Dental • E - Emergency illness or hospital extras/

emergency room • H - Deductible loaded from history • M - Major medical/calendar year deductible • O - Outpatient services • P - Prescriptions • R - Hospital room and board/confinement


Field This Field . . . deductible

• S - Surgery • T - Maternity • V - Vision • X - X-ray or lab • Y - Psychiatric

• 3 - Did not contact Care Coordination for outpatient procedures

• 7 - Did not contact Care Coordination; CCS (PARS) penalty

• 8 - Deductible for non-PPO facility

• 9 - No second surgical opinion obtained; CCS (PARS) penalty

N COV Notes the total dollar amount not covered under this claim, if applicable. A zero dollar amount indicates that all charges are covered.

RC Contains any two-digit remark or pend codes for this claim. You can have up to three remark or pend codes per claim. See Preference for specific code descriptions.

OV Notes any two-digit or one-character alphabetic override codes used in processing. You can have up to two override codes per claim. See Preference for specific code descriptions.



unlabeled Displays CP if the claim was for a capitated service. Capitated services not identified as encounters are processed through TOPS, an EOB is generated, and the records are sent to the reporting database.

Displays EN if this claim is an encounter which is a capitated service paid by an outside source (typically an IPA). These claim submissions are processed through TOPS, EOBs are suppressed, and the reporting database receives these records.

unlabeled--next line

Displays CV if the provider was a covering physician. This field is not used now.

unlabeled Notes the entity who received payment. P indicates payment was to the provider, while E indicates a payment to the employee. If an H appears in this field, check the MHI screen.

unlabeled Contains the name of the provider who submitted this claim. The field that follows can display the name of a second provider (or be left blank).

I Contains the unique, ten-digit inventory control

number (ICN) or film locator number (FLN) assigned to each claim.

PROC DT Contains the date that the system processed

the claim. The format of this field is mmddyy.


Procedure to View an MHI Screen for Detailed Information on One Claim

If you are reviewing the AHI screen and need to view the detailed history of a particular claim, complete the steps in the following table.


1 Type S in the select column of the record you want to access.

2 Press the Enter key. The system displays a limited MHI screen showing only the claim selected.


Example

This example illustrates how to view the detailed history of a particular claim.

Procedure to Return to the AHI Screen from an MHI Screen

To return directly to the AHI screen from the MHI screen, complete the steps in the following table. Type “A” in the R field below the control line. The system returns to the same spot on the AHI screen.


1 Enter A in the R field below the control line.

2 Press the Enter key. The system returns to the same spot on the AHI screen.

Enter an “S” in the S (Select) field on an AHI screen to view a specific claim on the MHI screen.

AHN,123456,S123456789,ALYSSA,CH,



Example

This example illustrates how to return to the AHI screen from the MHI screen.

AHN,123456,S123456789,ALYSSA,CH,


Enter an “A” in R (Return) field on an MHI screen to return to the AHI screen.


MHI Screen (Medical History)

Overview

The MHI screen provides a detailed listing of all processed and pending claims for a specific enrollee. Claims processing uses this screen when processing claims to identify duplicates and to make accounting adjustments. This comprehensive screen is especially useful when answering customer’s calls regarding claim status, date processing, benefits paid, etc. This screen contains the following information:

• Employee demographics • Deductibles • Diagnosis and procedure codes • Amounts for services claimed and paid • Provider demographics


Before you begin working with this screen, be aware that:

• The MHI screen contains a lot of information. All of the

information from the payment screen is in a “compacted” form in addition to individual and family deductible information.

• More than one claim can appear on the same MHI screen at one time. The claim information section of a claim identifies the end of a claim.

• When you reach the end of the history record, the system generates the message, “E065 NO MORE CLMS ON FILE.”

Procedures

Use the procedures that follow whenever appropriate. The MHI field descriptions follow the procedures and examples.


Accessing the MHI Screen Through the AHI Screen

There are several ways to access the history screen to obtain specific information. One way to access a specific claim is through the AHI screen. Complete the steps in the following table to access the MHI screen from the AHI screen:


1 Access the AHI screen for a specific enrollee.

Use the process to access the AHI screen described earlier.

2 Identify the claim on which you want detailed information.

3 Enter an S in the Select field.

4 Press the Enter key. The MHI screen for that claim appears.

Accessing Processed and Pending Claims

To display a detailed listing of all processed and pending claims in reverse chronological for a specific enrollee on the MHI screen, complete the steps in the following table.


1 In the control line, enter MHI,(Policy #),S(SSN),(First Name),(Rel)


2 Press the Enter key. The chronological claim history screen appears.


Example

This example illustrates the MHI screen.

Accessing Processed and Pending Claims with More Detail or Restrictions

To request additional information or restrict the amount of information displayed on the MHI screen, you can add modifiers to the control line. Enter modifiers at the end of the control line following the relationship of the patient. The following table lists the modifiers and the information displayed. These modifiers are used on MHI only.

MHB,123456,S123456789,ALYSSA,CH,0012345678


Entry of This Modifier . . .

Causes the System to

Display . . .

S COB benefit information in the message line.

C(claim #) All claims processed under that claim number.

(draft #) All services processed and paid under that draft number.

P Provider tax identification number and suffix for each service line in the message line.

R Date the claim was received in the processed date field.

I(ICN #) All services processed under the specific ICN.

F(FLN#) All services processed under the specific FLN.

ZI(ICN) PRS remark code for each service line under the specific ICN in the message line.

ZF(FLN) PRS remark code for each service line under the specific FLN in the message line.

BI(ICN) Provider’s name for the specific ICN in the message line.


Entry of This Modifier . . .

Causes the System to

Display . . .

BI(FLN) Provider’s name for the specific FLN in the message line.

(mm/yy) Services with the first and/or last date of service specified in the modifier.

A or A(draft #) or AC(claim#)

Provider’s name in the message line for the claim.

E or E(draft #) or EC(claim#)

Provider’s name in the P field.

DI(ICN) All services under the specific ICN.

DF(FLN) All services under the specific FLN.

A(mm/yy) Services with the first and/or last date of service specified in the modifier and the provider’s name.

K Whenever there is a line split of a service line, a control line modifier with a value of “K” needs to be entered before the ICN in order to see the next message; there will also be a message at the bottom of the screen specifying which line has been split. The bottom message will contain at least 2 line numbers but no more then 6 line numbers.


Example

This example illustrates how to use a modifier to request additional information or restrict the amount of information.

MHI,123456,S123456789,ALYSSA,CH,A03/97



MHI Screen Field Descriptions

The MHI screen is broken into three sections. The header section contains demographic and deductible information. The following table lists the fields and their descriptions in an MHI header section.

Line/Field This Field . . .

First line: FCI comments R

Displays information from the FCI screen. Appears only when the MHI was accessed from the AHI screen and is used to return to the page on the AHI screen.

Second line: Employee information CCS (PARS) waiver information

Displays the employee’s name and address.

Displays only when retrieved with a draft number modifier and appears after the employee’s zip code. The valid values are:

• Position 1: R - CCS (PARS) record rejected

• Position 2: S - Comments were reviewed

• Position 3: W - CCS (PARS) waiver

• T - TIN matched waived


Line/Field This Field . . . Third line: LFT PD LFT REM PAT # SPR HD

Displays benefits paid for the lifetime of this policy. Displays benefits remaining for this policy. Displays the provider’s patient number for this claim. Displays the semi-private room rate (for hospital claims only). Displays the hospital discharge code.

Fourth line: POL DD FM DD FM DT DD PER FROM mm/dd/yy TO mm/dd/yy

Contains the deductible dollar amount that the enrollee met at the time the claim was processed.

Contains the deductible dollar amount that the family met at the time the claim was processed.

Contains the date of the last deductible applied to the family deductible.

Contains the benefit period dates for the policy.



Fifth line: DX1/DX2 IC/IC2

YR

COB

RSV

COB RE

Contains the primary and secondary (if applicable) diagnoses codes for the displayed claim. Contains the procedure code(s) for inpatient hospital claims. Indicates the two-digit benefit year for the COB/Medicare Reserves. Indicates if there is coordination of benefits (Y/N). Lists the dollar amount saved because of other insurance. Lists the dollar amount not paid in full, or remaining expense, between the two carriers when COB exists.

Sixth line: CLAIM # DX CAUSE MCARE RSV MCARE RE

Enrollee’s claim number for diagnosis. Displays the diagnosis description. Displays the primary diagnosis and cause codes. See Appendix K for a list of valid cause codes and descriptions. Dollar amount saved because of Medicare. Lists the amount paid by Medicare for this claim.


The service line section follows the header section. Each service line contains two rows of information and there can be up to seven lines of services per claim.

Line/Field This Field . . . First line: PS SVC FST DT LST DT NBR OV P N RC CHAR NOT COV

Indicates the place of service. See Appendix H for a list of place of service codes and descriptions. Contains the medical code for the service performed. Contains the first date of service for the service line. The format for this field is mmddyy. Contains the last date of service for the service line. The format for this field is mmddyy. Contains the number of services for that service. Contains the two-digit or alphabetical character override code that forces the system to allow manual intervention in claims processing. See Preference for the specific code descriptions. Indicates who received the payment. A 2 indicates that the provider received the payment, while a 1 indicates the employee received the payment. Indicates which provider received payment. A 1 indicates that the primary provider was paid; 2 indicates that the secondary provider received payment. Contains any two-digit remark codes on the claim that represent a message on the EOB. See Preference for the specific code description. Lists the total dollar charge for the service line. Lists the dollar amount not covered for this service.



B CV DD (Cont’d.) D %

Lists the dollar amount covered as basic benefits. Lists the dollar amount applied to the basic deductible. Indicates the type of deductible code. Indicates the percentage coinsurance rate for basic benefits, which is usually 100 percent.

Second line: BP

S (first)

M D (first) D (second)

Lists the dollar amount paid under basic benefits after the coinsurance and deductible is calculated. Lists the dollar amount paid under the Supplemental Accident Benefit. Lists the dollar amount covered under the Major Medical or Comprehensive benefits. Lists the dollar amount applied to the Major Medical deductible. Contains the type of deductible code. The most commonly used values are:

F or 9 - Emergency room

G or 8 - PPO

H or 7 - CCS (PARS)

M - Medical care

R or 1 - Hospital room costs


Line/Field This Field . . . % P D (third) S (second)

Contains the coinsurance percentage rate for major medical benefits. Lists the dollar amount payable under the Major Medical Benefit after the coinsurance and deductible amounts are calculated. Lists the dollar amount paid from the credit reserve bank (COB or MCARE). Indicates if any penalty exists. The valid values are:

Y - Sanction the provider

W - Sanction the employee

The claim information section is after the last service line. This section contains two rows, which are usually highlighted in a different color to aid in identifying the end of a claim. The following table lists the fields and provides descriptions of each field in an MHI claim information section.

Line/Field This Field . . . First line: unlabeled D (mmddyy)

Identifies who received payment. P indicates the provider received payment, while an E indicates the employee received payment. This field also contains the provider’s prefix, nine-digit tax identifier, and suffix. The prefix is 1 if the tax identifier is the provider’s SSN and 2 if it is the federal TIN. The suffix is the specific identifier for the provider under this particular TIN. Contains the check’s draft number. Contains the date the claim was processed or last


Line/Field This Field . . . ADJ CH PD unlabeled

adjusted. Contains the identification number of the individual who processed the claim. Lists the dollar amount of the claim’s total charge. Lists the dollar amount paid for the claim. Displays EN if this claim is an encounter which is a capitated service paid by an outside source (typically an IPA). These claim submissions are processed through TOPS, EOBs are suppressed, and the reporting database receives the records.



Second line: ICN FLN

OFF S A

Contains the inventory control number for the claim. Contains the film locator number for the claim. Film Locator Number (FLN) is the number stamped on the patch card in the mailroom/DCC/RMO. The FLN is a 10-digit number made up of the following: First two digits – Year the claim was received. Third, fourth, fifth digits – Julian date the claim was received.

Sixth through tenth digits ar ethe sequential number assigned for clams received on any given day.

00 = Year 2000 032 Day = February 01 00123 Sequence Number = 123rd claim received for that year, julian date, claim office/RMO. A FLN is usually a unique number within one RMO. It may not be unique among all UHC RMOs. The image is then housed on IDRS where it can be retrieved using the FLN Filming Office Number. For these reasons, you need to know the Filiming Office Number and the FLN when obtaining a copy of a claim from IDRS.

Note: A complete listing of Filming Office Numbers can be located in PREFERENCE, Index Term, FLN Contains the numerical identifier of the office that processed the claim. Contains the policy suffix which consists of a one- or two-digit alphabetic designation that subdivides a policy number for reporting purposes, contractual purposes, or both. The last two digits contains the policy account number (01-99) used to administratively track claim and premium dollars on policies. A market number may precede the account number.


PRS Contains the PRS (Practice Review System) indicator. The valid values are:

Blank - Not processed by PRS; okay to process

M - PRS processed; pend to MCR

P - PRS processed; already pended to MCR by PRS

X - PRS processed; okay to process

A message line appears at the bottom of the MHI screen. This line contains messages generated when the claim was processed and other specific information regarding a claim.


MNI Screen (Claim Number Register)

Overview

The Claim Number History (MNI) screen displays all the claim numbers and diagnoses for all claims incurred by an enrollee, which are grouped by diagnosis code. This screen contains the following information:

• Claim number for a specific diagnosis • Treatment dates for a specific diagnosis • Last date a claim was processed • Claims that may be pended under a claim number

This screen is useful when you need to check two or more claim numbers for the same or related conditions. Before You Work with This Screen


• The first line of the MNI screen displays the first line of information from the FCI screen.

• There is one line for each claim number, which also contains the information detailed in the field descriptions.

Procedures

Use the following procedure to access the MNI screen. The MNI field descriptions follow the procedure and example.


Accessing the MNI Screen

Complete the following steps to access the MNI screen.


1 In the control line, enter MNI,(Policy #),S(SSN),(First Name),(Rel)

2 Press the Enter key. The system displays the claim numbers, diagnoses, cause, dates of service, last processed date, and dollar amount not paid on claim.

Example

This example illustrates the MNI screen.

MNC,123456,S123456789,CARRIE,EE,


MNI Screen Field Descriptions

Listed below are descriptions of the fields on the MNI Screen.


S Allows claims processing to select a claim record for processing. The only option is “S.”

CLM Claim number assigned to the diagnosis listed.

DIAGNOSIS Contains the description of the primary diagnosis for the claim number.

CAUSE Contains five-digit or character cause and diagnosis code for the claim number. First character is cause code, and remaining digits or characters indicate the ICD diagnosis code. The valid cause code values are:

• A - Accidents

• O - General sickness

• 1 - Psychiatric

• 2 - Normal maternity

• 3 - Emergency illness

• 4 - Routine

• 5 - Complications of pregnancy

• 6 - Alcoholism and drug addiction

START DT Indicates the first date of service for any claims processed using this claim number. The format of this field is mm/dd/yy.



END DT Indicates the last date of service for any claims processed using this claim number. The format of this field is mm/dd/yy.

PROC DT Indicates the last date a claim was processed using this claim number. The format of this field is mm/dd/yy.

RE Indicates the dollar amount of remaining expenses. (The dollar amount that was not paid.)

Note: This does not indicate out-of-pocket expenses.

ES Is not in use.

P Indicates if claims are pended under this claim number. The format of this field is Y/N, with Y indicating that claims are pended.


MPI Screen (Medical Payment)

Overview

The MPI screen is where claims are actually processed and paid (when the claim does not auto adjudicate). This screen contains the following information:

• Claim header information • Service line information

Procedures

Use the procedures that follow whenever appropriate. The MPI field descriptions follow the procedures and examples.


Accessing the MPI Screen


1 In the control line, enter MPI,(Policy #),S(SSN),Patient Name, Relationship Code, Claim Select, FLN, TIN


2 Press the Enter key. Information on the screen is disiplayed.

Example

This example illustrates the MPI screen.

Header Information: First Seven Lines

Service Line Information

MPC,123456,S123456789,SUSAN,EE,C002,I0084957120,2593254669 C - *CFCI/ACPD INFO FN 6/94 C3S TR –- - SMITH 1202 E SHELL POINT ROAD RUSKIN FL 33570 --- P1 --------------- P2 --------------- F/I - CCR .00CRE 165.33 M – TC ----- -- DED1 33.86 PD 010195 123195 MCR .00 MRE .00 P – CS 07890 ABD PAIN D 7890 ----- ----- ----- ----- I ---- ---- ---- Pt# ----------------- DC – SP ---- -- SUR -- -- D --- DR ---------- PRS - ---- PS SVC FST DT LST DT NBR OV P N RC CHARGE NOT COV B CV DD D % -- ------ ------ ------ -- -- - - -- ----- -- ----- -- ----- -- ---- -- -- -- BP ----- -- S ---- -- M ----- -- D ---- -- D -- % --- P ----- -- C ----- -- S -- ------ ------ ------ -- -- - - -- ----- -- ----- -- ----- -- ---- -- -- -- BP ----- -- S ---- -- M ----- -- D ---- -- D -- % --- P ----- -- C ----- -- S -- ------ ------ ------ -- -- - - -- ----- -- ----- -- ----- -- ---- -- -- -- BP ----- -- S ---- -- M ----- -- D ---- -- D -- % --- P ----- -- C ----- -- S -- ------ ------ ------ -- -- - - -- ----- -- ----- -- ----- -- ---- -- -- -- BP ----- -- S ---- -- M ----- -- D ---- -- D -- % --- P ----- -- C ----- -- S -- ------ ------ ------ -- -- - - -- ----- -- ----- -- ----- -- ---- -- -- -- BP ----- -- S ---- -- M ----- -- D ---- -- D -- % --- P ----- -- C ----- -- S WW1243NPP/Y/1013 01/01/95, W1275PCP = 2-593254669-011,W 01/01/95,W161 P1- 2-


MPI Screen Field Descriptions

The MPI screen is broken into three sections. The header section contains demographic information. The following table lists the fields and their descriptions in an MPI header section.

Line/Field This Field… (First line)

Displays information found on the first line of the FCI screen.

TR Transaction code field (used for accounting purposes).

Second line:

Displays the employee’s last name and complete address.

Third line:

PARS Waiver Field. Valid values are: Position 1 – R = Reject PARS record Position 2 – S = Comments reviewed Position 3 – W = Waived; T = TIM match waived.

P1 and P2

Provider address or addresses.

F/I Fund Indicator Override.

CCR COB Credit Reserve Bank indicator.

CRE COB Credit paid on the claim being processed.

M Member Indicator Override.

TC (fourth line) Total charge of the bill being processed.

DED 1 Amount that has been applied to the deductible for the year.

PD Benefit period for the policy (usually January through December).

MCR Medicare Credit Reserve Bank indicator.


Line/Field This Field…

P Provider Indicator Override

CS (Fifth line) The primary diagnosis code preceded by the cause code of the illness. Next to this field the system displays a word description of the diagnosis. In the blank space next to the word description, the Benefit Specialist may enter in additional description if necessary.

D Displays the primary diagnosis code and allows the capability of inputting four more secondary diagnosis codes.

I This field has three sections used for inpatient claims where surgeries were performed. They indicate the surgical codes that were not performed.

PT# The provider's patient number for the billed expense.

DC Discharged indicator (inpatient claims only).

SP Semi-private room rate per day (inpatient claims only).

SUR Month and day the surgery was performed.

D DRG code. DR Draft number of the claim, displayed only

when an accounting adjustment is being done.

PRS PRS indicator, if PRS processing applies. Valid values are: X – PRS processed, ok to process. P – PRS processed, pend to MCR. M – PRS processed and already pended to MCR by PRS. Blank – Not processed by PRS, ok to process.


The service line section follows the header section. Each service line contains two rows of information and there can be up to five lines of services per claim.

Line/Field This Field… First line: PS SVC FST DT LST DT NBR OV P N RC CHAR

Indicates the place of service. . Contains the medical code for the service performed. This field will be Revenue Codes (facility) or CPT-4/HCPCS Codes (professional). Contains the first date of service for the service line. The format for this field is mmddyy. Contains the last date of service for the service line. The format for this field is mmddyy. Contains the number of services for that service. Contains the two-digit or alphabetical character override code that forces the system to allow manual intervention in claims processing. See Preference for the specific code descriptions. Indicates who received the payment. A 2 indicates that the provider received the payment, while a 1 indicates the employee received the payment. Indicates which provider received payment. A 1 indicates that the primary provider was paid; 2 indicates that the secondary provider received payment. Contains any two-digit remark codes on the


NOT COV B CV DD D %

claim that represent a message on the EOB. See Preference for the specific code description. Lists the total dollar charge for the service line. Lists the dollar amount not covered for this service. Lists the dollar amount covered as basic benefits. Dollar amount applied to the basic deductible. Indicates the type of deductible code. Indicates the percentage coinsurance rate for basic benefits, which is usually 100 percent.

Second line: BP

S (first)

M D (first) D (second)

Lists the dollar amount paid under basic benefits after the coinsurance and deductible is calculated. Lists the dollar amount paid under the Supplemental Accident Benefit. Lists the dollar amount covered under the Major Medical or Comprehensive benefits. Lists the dollar amount applied to the Major Medical deductible. Contains the type of deductible code. The


% P C S (second)

most commonly used values are:

F or 9 - Emergency room

G or 8 - PPO

H or 7 - CCS (PARS)

M - Medical care

R or 1 - Hospital room costs Contains the coinsurance percentage rate for major medical benefits. Lists the dollar amount payable under the Major Medical Benefit after the coinsurance and deductible amounts are calculated. Dollar amount paid out from the reserve bank for the service line. Indicates if any penalty exists. The valid values are:

Y - Sanction the provider

W - Sanction the employee Last line The last line of the MPI Screen is the

message line. This displays edits/warnings received when processing the claim as well as other specific information regarding the claim.


RHI Screen (Revenue History Inquiry)

Overview

The RHI Screen can be used when the claim was not submitted electronically and the processing date is over 60 days. The claim can be reviewed online the way claim was originally keyed in on the EDS screens (prior to processing). Accessing the RHI Screen

To access the RHI, you must enter one of the following control lines:

• RHI,POLICY,SSN,PAT,Rel,Claim Select,ICN,Draft number • Returns only claim(s) with this ICN number Examples of RHI Control Lines:

Policy # S+SSN Patient Relationship Claim Select ICN

Draft number

RHI,123456,S123456789,James,EE,C001,I0303859812,0005672374


RHI Screen Field Descriptions

Field Description LAST NAME Employee’s Last Name STREET ADDRESS

Employee’s Street Address

CITY Employee’s City ST Employee’s State ZIPCD Employee’s Zip Code DX1 The primary diagnosis code used for the claim(s)

displayed. DX2 – DX9 The secondary diagnosis codes used for the claim(s)

displayed. IC1 – IC6 Procedure codes, (for inpatient hospital bills only). CLAIM # The claim number under which the expense was

processed. DX The literal description of the diagnosis. Example:

Allergy. CAUSE The primary diagnosis code preceded by the cause

code. The values for a cause code are; • A = Accident • 0 = General Sickness • 1 = Psychiatric • 2 = Normal Pregnancy • 3 = Emergency • 4 = Routine Care (Preventive) • 5 = Complication of Pregnancy • 6 = Alcohol/Drug Abuse. Note: Claims with Cause Code 1 or 6 will be routed to UBH (United Behavior Health) for processing.

DOS FROM Displays the first date of service for claim. DOS TO Displays the last date of service for claim. REV Revenue Code for services being rendered. PROC Procedure Code for services being rendered. DOS The date health care services were provided to the

covered person. UNITS The number of times a service with the same CPT

or HCPCS code is provided per day by the same physician or non-physician.


Field Description OV The override code used to force the system to allow

"manual" intervention in the processing of the claim. Some of the more common override codes are; 01-suspect duplicate, 02-Medical Claim Review (MCR) and

Reasonable & Customary (R&C) edits. May also be used to clear most ADJ DET (adjuster determined) edits.

07-Investigate COB 13-Eligibility edits plus ALL lower override

codes. This edit is to be used with CAUTION and ONLY when absolutely necessary as it impacts downstream reporting

A complete list of Override Codes are listed in the Knowledge library

RC The remark code number entered during claim processing that displays a corresponding message on the EOB. Some of the more common override codes are; • D1-Physician Negotiated Rate • D2-Facility Negotiated Rate • 29-Charges over Reasonable & Customary

(R&C) • B9-System generated copay applied Complete instruction on how to review the Remark Codes are listed in the Knowledge library

CHARGE The total charge for that service line. NOT COV The amount that is not covered by the policy master

for this service line. ALLOW This field will give you the total allowable for each

service line entered.


Field Description COMP Compatibility Indicator

Valid Values are: N - Non-compatible D – Discount P - Per Diem L - Lump / case LB - Both Lump / case and Per Diem LP – Both Lump / case and

PM Pay Method –displays an indicator that when the agreement is to pay contracted rates regardless of the billed charges. Valid Values are:

A - Pay the contracted rate always, on a detail line basis.

Blank - Pay the lessor of the contracted rate or 100% of charge, on a detail line basis.

CRV Carve Out indicator - A decision to purchase separately an additional service that typically is a component of that benefit plan. Example: an HMO may "carve out" the behavioral health benefit and select a specialized vendor to supply these services on a stand-alone basis.

EXC Exclude Outlier indicator - OutLier new name -( was Exclusion from stop) – displays one or more compatibility indicators that indicate the I-Rate lines are excluded from OutLier processing. Y = Yes, excluded from Outlier Blank = Not excluded from Outlier

GRP ASC Grouping Number P The TIN and suffix for the provider of service. D The draft number for the claim. This is assigned to

the claim when it is processed. The draft number will be used when looking up a check.

ADJ The "adjuster" number identifying the processor of the claim.

CH The total charge of the processed claim. PD The total benefit amount paid for the processed

claim.


Field Description ICN The Inventory Control Number is automatically

assigned to the claim. FLN The Film Locator Number for the processed claim. OFF The office where the claim was filmed. A The suffix for the policy. PRS A code to indicate that PRS processing applies.

Values: X - PRS processed, okay to calculate

benefits. P - PRS processed pend to Medical Claim

Review (MCR). M - PRS processed and pended to MCR by

PRS. Blank - Not processed by PRS, okay to

calculate benefits. SP Detail line level split indicator; a value of Y means

the line has been split; if line is not split use value of N; field to be right-justified (HCFA Non-OPS claims will not have a split indicator).

United HealthCare TOPS Inquiry Participant Guide 9/00 Training & Development Notification Screens 119

Electronic Data Screens

Overview

This chapter has descriptions of how to use and examples of the electronic claim screens, including MEI, EDS1, EDS2, EDS3, EDS6.5 and EDS9/ACS.

TOPS Contract and Claim Reference Manual August 2005 120 Notification Screens Training & Development

MEI Screen (Electronic Media Claim)

Overview

The MEI screen provides access to electronic claims received by the claim office. This screen lists a summary of the claims received electronically and their current status.

The provider of the services, software vendors, clearinghouses, and billing services submit claims into an electronic media system. They then go through the Practice Review System (PRS) and autoadjudication. Claims that do not autoadjudicate are held in a queue for manual processing. Claims are then brought up from the queue into TOPS where they are processed.

Claims should be released for further processing or completion within three to four days after they have been received. If claims are not processed during this timeframe, the claim office should be notified.

The MEI screen contains the following information:

• Policy • Name • Document Control Number assigned to the claim • Service dates • Dollar amount claimed • Claim status



Before you work with the MEI screen be aware that:

• Claims from this screen should be processed or complete within three to four days. If not, contact the claims office.

• If a claim processes under a different inventory control number (ICN) than the one under which it was pre-keyed, there was a clerical error in the original keying. The ICN number should not change unless there was a correction.

• The search is quicker if you know the employee’s social security number.

• To return to the TOPS system from the MEI screen keep pressing the F1 key and choose TOPS or press the key representing the Clear Screen function.

Procedures

Use the procedure that follows to determine if a claim has reached the claims office, even if it is not yet entered in the system. The screen field descriptions follow the procedure and example.


Accessing the MEI Screen

Complete the steps below to access the MEI screen.



MEI,S(SSN)


2 Press the Enter key. The system displays policy, patient name and relationship, and claim information.

Example

This example illustrates an MEI screen.

S123456789


MEI Screen Field Descriptions

The following table lists the MEI field descriptions.


unlabeled Julian date

Displays the current year and Julian date.

unlabeled calendar date

Displays the current calendar date.

OFFICE Displays the office number of the operator logged into the system.

EMPLOYEE ID NUMBER

Displays the SSN of the employee.

O Allows the entry of option codes that are used by claims processors.

POLICY Displays the employee’s policy number.

NAME Displays the first name of the patient.

REL Displays the code that describes the relationship of the patient to the employee.

DCN Displays the document control number assigned to the claim when entered into TOPS.

SUF Displays the document control number suffix.



TAX ID 1 Displays the tax identification or social security number of the servicing provider.

TOTAL CHG Displays the total billed charge on the claim.

OFF Displays the claims office number.

SVC DATES Displays the range of dates that services were performed.



STAT Displays the status of the claim. The valid values are:

• (Blank) - Not processed

• APAY - Autoadjudicated

• APND - Auto pended

• CLSD - Auto closed

• DLTD - Deleted

• HMO - HMO queue

• MPAY - Manually paid

• MPND - Manually pended

• PROC - Processing queue

• RJCT - Rejected

• RSLV - Resolved

• SEND - Send back queue

• SMRT - Smarts queue

• TRAN - Transferred

• UNID - Unidentified queue

• UBSH - USBH queue

• PRS - PRS


EDS 1 Screen (Electronic Data Screen 1)

Overview

The acronym EDS means Electronic Data Screen.

There are two types of EDS 1 screens:

One type displays data from providers who bill on HCFA 1500 forms (referred to as non-hospital claims).

The other displays claims from providers who bill on UB-92 forms (referred to as Hospital claims on EDS 1, although this is misleading since other provider types can bill on an UB-92, not just hospitals).

The EDS1 screens are used to review the specific services that had been submitted from a provider (CPT-4 codes, Revenue codes, etc.). The EDS 1 screen will enable you to research the services rendered to a patient on a claim before it becomes fully auto-adjudicated. That is, you can see details that reflect exactly how the provider billed us, where the claim has not yet been through the TOPS Front End programs that 'translate' some data to a TOPS compatible format. You can also see that same data after it has been subjected to 'translations'. This can be useful in a number of different situations, which will be explained below. The EDS 1 screen is often though of as the ‘before front end' and 'after front end' picture of the claim. The information on the left-hand side of the screen is the 'before' picture, the information on the right hand side of the screen is the 'after' picture.

Business Purpose:

The majority of claims come to UNITEDHealthGroup via ‘EDI’ (Electronic Data Interchange) or they arrive as a paper claim form that is then scanned or keyed into the Front End Production system. EDI or scanning of paper claims is collectively referred to as ‘electronic’ claims. The data on all of the EDS screens will be available until the claim is processed (paid or denied). Once the claim has been processed, the information will remain available for viewing for 60 days. If the information is needed beyond the 60 days, it will need to be reviewed in TDARS or iDRS. You may retrieve a copy of the Electronic/Paper UB92 or Electronic/Paper HCFA-1500 (you


will need to separately read TDARS and iDARS manuals to see how the claims appear in these systems and how to access them).

Please note claims that have been keyed directly into the TOPS Payment screen (MPI screen) by a claim processor are not available in EDS. Very few claims are keyed this way, however. If you need to access a claim that was direct keyed to an MPI (it wasn't scanned, it didn't arrive via EDI), the only way is to view the actual information submitted by the provider in iDRS.

The EDS 1 screen is used primarily to research the services rendered to a patient by a provider. The EDS 1 screen will display information on:

The patient information such as name, date of birth, relation to insured

Medical procedure(s) performed (CPT-4 Procedure Code, HCPCS and/or Revenue Codes)

Diagnosis coding ICD-9 Diagnosis Code, DRG

Charge amounts Based on each service rendered and Total Claim

Dates of service

System-generated edits: PF8 additional procedure lines, PF7 for Previous lines. Note: Don’t confuse this with the edits that the claim processor receives such as SPI warning messages etc., these can be found on the bottom of the MPI Screen.

The provider’s name and address and Tax Identification number from the information support EDS 3 Screen. (Often the middle initial of the physician is on this screen, this information will help to determine which provider should be selected when similar names are on the provider files.)

Whether attachments are present such as operative report, progress report etc.

As previously mentioned, there are two types of EDS 1 screens: Non-Hospital bill types for claims submitted on HCFA 1500 and Hospital (meaning, hospital, outpatient facility or ancillary


providers) bill types for claims submitted on UB-92. For the most part, the patient information such as name, SSN, DOB, RL etc. are the same on both types of screens. However, the non-hospital EDS 1 screen has fields for Referring Physicians, CPT, and Procedure codes. The Hospital EDS 1 screen has Attending Physician, DRG (assigned by the hospital) and Revenue codes. The Attending Physician is the name of the doctor who saw the patient at the hospital.

Professional CSS/ DLA’s will typically use the EDS 1 to review the services indicated on a claim for which the provider of service is billing. The Professional DLA will use this screen when working the EMCCF Claim Resolution Process. The Professional CSS will use this screen when trouble shooting an issue on a claim. The scenarios indicated below are some examples when the Professional CSS or DLA would use this screen.

To verify the dates of service on the claim to review what PPI rate tables the claim should be processing against.

Determine the physician status (par vs non-par) at time of service and also to identify correct rate on EPD Fee Schedule.

To view the place of service that the services where rendered. This is helpful when trying to trouble shoot a service that is contracted based on location of service.

It is important to remember the EDS 1 will show the before and after picture of the claim. However, it is the Medical Payment Screen (MPI), which indicates the final coding and payment for the claim.

Hospital CSS/DLA’s typically use the EDS 1 screen to review the services indicated on a claim for which the provider of service is billing. The Hospital DLA may use this screen when working the EMCCF Claim Resolution Process. The Hospital CSS may use this screen when trouble shooting an issue on a claim. The scenarios indicated below are some examples when the Hospital CSS or DLA would use this screen:


To verify the dates of service on the claim to review what PPI rate tables the claim should be processing against.

To verify the length of admission to see if a case rate is applicable.

To view the procedure(s) performed, this is especially helpful when working the EMCCF claim resolution queue and the claim-processing center did not give PIM enough information.

To review if the facility billed with a DRG number for the inpatient claim. This is helpful when a CSS is reviewing a claim issue where the provider states the incorrect DRG number was paid. The CSS will review the DRG number billed by the facility on the EDS 1 screen and review what the system assigned DRG based on diagnosis and procedure on the MPC screen.

When working the EMCCF claim resolution queue for fee schedule issues if the claim office did not indicate what the problem was, the EDS 1 can be used to review the procedure code and the number of units billed to investigate the rates indicated on the fee schedule. Accessing the EDS 1 Screen

There are several ways to access the EDS screen, including entering through the MEI screen (also known as the EMC status screen). Note: Make sure you sign on to office 210 and access the TOPS 'Bells' engine.

When the MEI screen is displayed, select the appropriate claim and then type the number '1' in the 'O' field. The EDS 1 screen for that claim will be displayed.

If the claim does not come up in EDS, it was keyed manually and all information from the claim will be shown on the Medical Payment Screen (MPI). This screen can be used to verify if the correct benefit was used during payment calculation. To retrieve a claim from MPI, you must have the policy number, SSN, Insured’s first name, relationship, and Inventory Control Number (ICN).


The EDS 1 Screen Physician Shown below is an EDS 1 screen for a HCFA 1500 submission.

Directly below the provider's address, you will see any system-generated edits such as "press PF8 Key for additional lines" or "press PF7 key for previous lines".

The next screen field (NXT SCR) is located on all EDS screens and the ACS (ACS or EDS9) screen. It is used to toggle between the paperless screens as well as between UNET and the paperless screens.between UNET and the paperless screens.

After all the service lines you will find the provider's name, the account number that the provider uses for the patient, and the provider's address, Tax ID number or SSN, and phone number

Tax ID number can be used to verify if EMCCF information was keyed correctly.


EDS 1 Screen Field Descriptions (Non-Hospital)

Shown below are descriptions of the fields on the EDS 1 screen.


ICN Inventory Control Number (10 digits). This number is unique to each claim. The ICN number was created to give each claim in UNet, regardless of what engine it is paid on, a unique number. This number is also used to pull up a specific claim for a member. Suffix: When the claim has been split into multiple claims, the ICN suffix indicating on which UNET/TOPS payment screen this service line will be displayed.

An example of multiple suffixes is: ICN=I0145439871 01

Suffix

SSN Social security number of the member based on the eligibility selection. The nine-digit number is preceeded by S.

PAT Patient’s first name. This information is used to identify the specific patient when multiple members appear under the insured. The first name will help you narrow down the selection you need to inquire on.

RL Code indicating patient’s relationship to the insured. Valid Values are:

♦EE - employee ♦ SP - spouse ♦ CH - child ♦ SC - stepchild ♦ ST - student ♦ HC - handicapped CH ♦ RR - retired employee

♦ SS - Surviving Spouse

♦ NB - New Born ♦DP - Domestic Partner



DOB Patient’s date of birth, displayed in month, day, year (MM/DD/YYYY) format.

NXT SCR Used to enter code that will take you to the next screen. Valid entries are listed below. MPC or “A”= UNET calculated payment screen

for this ICN MRI or “F” = UNET Medical Family/Dependent

Register for this ICN MNI or “C” = UNET Claim Number Register for

this Individual AHI or “H” = UNET Abbreviated History for this

individual EPI or “E” = UNET Employee/Policy Screen

(SSN look up only) 1 = EDS 1 Screen for either UB92 or HCFA bill 2 = EDS 2 Screen for either UB92 or HCFA bill 3 = EDS 3 Remark Screen for either UB92 or

HCFA bill 9 = EDS 9 (ACS) Screen for either UB92 or

HCFA bill N = Next Claim in queue Q = Change the queue set up S = MEI selection screen R = Work completed, Releases claim from

queue. Johnstown PIM is the only PIM region to use this.

U = Update fields that allow processor update. FCI = The UNET Freeform Comments Inquiry

Screen will be returned CCI = The UNET Coordination of Benefits

Comments Inquiry Screen will be returned BCI = The UNET Benefit Structure Comment

Inquiry Screen will be returned CMI = The UNET Comments Medical Inquiry

Screen for the patient will be returned RET = The UNET pended screen will be

returned • Axx = UNET calculated screen for z specific

ICN suffix (xx= ICN suffix to be calculated) POL Policy number used to determine the calculation

rate on the Medical Payment Screen (MPI). A policyholder’s number relates to benefits provided from their employer.



REF Name of the referring physician.

TC Total Charge or the total amount of billed charges from the provider. The TC field on the EDS 1 screen may differ from the UNet payment screen due to the claim having multiple ICN Suffixes. Multiple suffixes mean that the provider submitted one claim, but TOPS system split the charges into multiple claims. If the TC field does not mirror the amount indicated on the EDS1 screen, the claim has been split into multiple ICN Suffixes for processing.

AMT PD This field shows the amount the patient paid at the time of the visit. (Co-Pay, etc.). The field located next to the amount paid identifies whether or not the pricing screens, coinsurance and if there is a discrepancy with the information appearing on this screen verses the (MRI) Medical Register screen. Valid Values are: P = if there is a pricing screen for this claim.

The pricing screen relates to the calculated benefits that the adjuster create when processing claims

C= whenever there is other insurance on the EDS2 screen

A= whenever the claim and MRI street address does not match for example if the patient’s is a student away at college. The address may be different.

A This field indicates whether a claim was received with additional information or attachments (operative report, progress notes, etc.).

This field will only be used when the claim was received via paper. When the claim is either scanned or keyed into the front-end production system to go through the EDI process, a code will indicate if additional information is attached.

HP AD Hospital admission date, if applicable. This field can be used to verify dates of service.

DC Hospital discharge date, if applicable. This field can be used to verify dates of service.

OI ALL If the patient has Other Insurance, this field will indicate the carrier’s allowed amount.



Note: The EDS 2 screen has the other insurance carrier information

OI PD Other insurance carrier’s paid amount, if any.

1 2 3 4 These fields indicate the patient’s diagnosis that is associated with the services rendered. Field 1 is the Primary Diagnosis. Fields 2-4 are the secondary diagnoses.

FROM Beginning date of the service rendered on the service line. All dates must be entered in month, day, year (MMDDYY) format.

TO End date of service rendered for the service line.

POS This field indicates the place of service code for the service line. When a claim is received electronically or keyed into EDI, a two-digit numerical American Medical Association (AMA) code is displayed in this field to represent the setting of where services were rendered. The numerical code will be translated as the claim goes through the Front-End Conversion Process. This is where the system changes the two digit numerical code to the corresponding two-digit UNet alpha code. The UNet alpha code will be displayed in the PS field on the EDS 1 and on the MPI screen. The most common valid values are:

AMA DESC UNET 11 Office OF 12 Home HM 21 Inpatient Hosp. IH 22 Outpatient Hosp. OH 81 Independent Lab IL

For a complete list of valid AMA and UNET place of service codes, go to Preference; AIDS Volume: M-Index of Place of service codes. Note: This is helpful when trouble shooting a service that is contracted based on where the service is rendered. You would compare the UNet place of service code to the appropriate rate table, which would allow the rate to be defined.

PROC This field indicates the procedure code reported by the provider for the service line. It is a field on


Field This Field . . . the non-hospital EDS1 screen and it will contain a CPT-4 procedure code or a HCPCS. This is the information that has been submitted by the providers electronically prior to the TOPS PRS logic.

M1, M2 The procedure code modifiers(s) reported for the service line. A modifier provides the means by which the reporting physician can indicate that a service or procedure has been altered by some specific circumstances but not changed in its definition or code. Some of the most common modifiers that NDM would see are the following: 80 – Assistant Surgery 26 – Professional component 22- Unusual Procedural Service 50- Bilateral Procedure

Additional information on modifiers can be located:

1. In the CPT Book in Appendix A 2. Knowledge library: Operational

Processes:Claim-Customer Service;UNET specific coding.

This field is especially important to verify if the provider of service is rendering Surgeons service vs. Anesthesiologist services or if the service is for professional component vs. the Technical component.

T The type of service indicator for the procedure code. Some of the most common ype of service codes are: 1 – Medical Care 2 – Surgery 3 – Consultation

A complete list is located in Preference volume “AIDS” (F1)

NBR Number of services/units rendered for the specific procedure code indicated and dates (1 office visit, 2 allergy injections, etc.).

DX This field indicates the primary diagnosis for the service line. An individual can go to a doctor for


Field This Field . . . multiple diagnoses on one date of service and receive multiple services. The diagnosis on the line is specific to the service being rendered.

CHARGE The service line charge amount will display information keyed from provider prior to PRS logic.

SX Suffix: When the claim has been split into multiple claims, the ICN suffix indicating on which UNet/TOPS payment screen this service line will be displayed.

PS This field indicates the “after” picture of how UNet/TOPS system had converted the place of service originally submitted by the provider as found on the left side of the EDS 1 Screen. This will play a key role in how the claim will sort to a Service Type on the PPI Rate Table The most commonly used values that are: IH =Impatient Hospital OF = Office AT = Alcohol Treatment HS = Hospice BC= Birthing Center OH =Outpatient Hospital IL = Inpatient Lab RX = Pharmacy SA = Substance Abuse CL= Clinic AS = Ambulatory Surgery HM = Home OL=Outpatient Lab CF= Convalescent Facility

There are one of two ways in which a valid UNet Place of Service Code appears on the Medical Payment Screen (MPC).

If claim is Smart Total Bill Keyed (STBK): The Front-End Keyer (FEK) will enter the two digit numerical code listed on the claim into the system. The claim will then go through the Front-End Conversion Process where the system changes the two digit numerical code to the appropriate two digit UNet alpha code. If claim is Manually Keyed: The Benefit Specialist


Field This Field . . . will enter the valid two digit UNET alpha code for the Place of Service listed on the claim.

Note: The two digit numerical code, from the claim, can only be used when claims are Smart Total Bill Keyed (STBK), otherwise the appropriate alpha code must be entered.

SVC This field indicates the services after the UNet/TOPS system has run the services through PRS. The codes indicated in this column may vary from the information the provider originally billed (as found on the left side of the EDS1). An example of this would be when the provider billed for two CPT-4 codes for procedures rendered, the system sent the claim through PRS. The PRS logic found one code that more accurately describes the service rendered, the new code would be indicated

CHARGE The field will indicate the charges submitted on the claim. If PRS logic does not bundle or change the coding. If the codes were affected during the PRS process the charges may be different.

- - - The PRS code for that line. This field identifies whether the claim was affected during the Front-End processing , specifically, PRS logic. If the system determined that codes needed to be bundled or charges were not covered you will see an indicator here. Valid values are: U= unchanged by PRS A= added by PRS R= rejected by PRS AC= added by PRS to change the charge or

unit amount RC= rejected by PRS to change the charge or

unit amount RR= rejected or rebundled by PRS Q= a question line by PRS

D Physical description of the service rendered and any line level information. This is a system-generated field; the descriptions of the value codes are located within the UNet database.


The EDS 1 Screen Hospital An illustration of a EDS 1 screen is shown below for a UB 92 submission.

ICN 0311111217 SSN S1234567890 PAT CxxY RL CH DOB 0xxx19xx NXT SCR _____ POL 1xxxx2 ATT PHY Mxxxx ROxxxxxxx TC 3434.00 AMT PD A FROM 0xxxxx THRU 0xxxxx NR OI ALL OI PD DRG 000 L DRG AMT SPR 611.00 MC:D C --- V3000 V053 ------ ------ ------ ------ ------ ------ ------ ADM V3000 RM REVE RT/DYS DESC DYS/UT HCPC/MD DATE CHARGE SX PS SVC CHARGE 0171 309.00 NURS/NEWBORN 0002 --------- 0000 618.00 01 IH NB171 618.00 0270 MS/GEN CLS 0001 --------- 0608 5.00 01 IH MISC 342.25 0300 LB/GEN CLS 0001 --------- 0608 47.00 01 0391 BLD ST/PRC AD 0001 --------- 0608 82.00 01 0471 DIAG AUDIOLOG 0001 --------- 0608 80.00 01 0636 RX/DETAIL COD 0001 --------- 0608 .25 01 0723 LABOR/DEL CIR 0001 --------- 0608 128.00 01 0001 GENL TOTL CHG 0002 --------- 0000 960.25 01 PROV NAME Kentucky Hospital ACT V0xxxxxx63 1 xxx xxxxxxx xxx xxx xxxxxx, xx xxxxx 2xxx4xxx27 TIN 06xxxxxx4 PROV NAME GREAT PLAINS MEDICAL CTR ACT 01012xxx6 601 WEST LEOTA NORTH PLATTE, NE 69103 3085349310 TIN 470662290 ----------------------- (Message Line) -------------------------------------


EDS 1 Screen Field Descriptions (Hospital)



ICN Claim’s Inventory Control Number (10 digits). (See field description for non-hospital screen)

SSN Social security number of the member based on the eligibility selection. (See field description for non-hospital screen)

RL Code indicating patient’s relationship to the insured. Valid Values are:





NXT SCR Used to enter code that will take you to the next screen. (See field description for non-hospital screen)

POL Policy number used to determine the calculation rate on the Medical Payment Screen (MPI). A policyholder’s number relates to benefits provided from their employer.

ATT PHY Hospital attending physician.

TC Total Charge or the total amount of billed charges from the provider. (See field description for non-hospital screen)

AMT PD Amount paid, if applicable. (See field description for non-hospital screen)

FROM Date the patient was admitted to the hospital.

THRU Date the patient was discharged from the hospital.



NR Negotiated Rate Indicator: Appears on claims that pass through the Front End with an OI, OIM, or OIMEDI line (other insurance information). Valid Values are:

NR=Y When the keyer identifies the prime allowable.

NR=D When other lines on the same claim have "Y" in this field

NR=S When the frontend derives the prime allowable.

NR =Spaces When no NEG RATE display will be present.

OI ALL Other insurance allowable. (See field description for non-hospital screen)

OI PD Other insurance carrier’s paid amount, if any. (See field description for non-hospital screen)

DRG This field indicates the Diagnosis Related Group (DRG) Number from the facility. Note: This is not the system assigned DRG based on diagnosis, procedure code etc. The system assigned DRG can be found on the MPI screen. Diagnosis Related Group 1st three bytes - DRG code 4th byte - LIER indicator

L = Inlier H = Outlier

This field is especially helpful when investigating a claim where a provider is stating that they billed for DRG 123, but UHC paid for DRG 456.

SPR Semi Private Room rate. This is only indicated on bill that contains room and board rates.

MC This field shows the amount the patient paid at the time of the visit. (Co-Pay, etc.). The field directly located next to the amount paid identifies whether the payment made was related to the co-insurance or deductible requirements of the policy. The dollar amount if applicable will be entered next to the corresponding field.



Medicare information D = Medicare deductible C = Medicare coinsurance

Indicators will also appear: P = pricing screen associated with this claim C = other insurance information is on EDS2 A = claim address and MRI address do not

match - - - - - - There are nine six-byte fields for diagnosis codes

associated with the claim. These are located under the DRG field.

REVE This field indicates the revenue codes submitted electronically for the services rendered.

RT/DYS If an inpatient revenue code of 100-219 is indicated, this field should indicate the rate from the hospital.

DESC Description of revenue codes, displayed by the system.

DYS/UT This field indicates the Days or Unit information that was submitted electronically for the revenue code indicated.

HCPC HCPCS codes from the claim. A HCPCS code is a method for coding supplies, materials, injections and services performed by health care professionals. There are three levels of codes within the HCPCS coding system.

Level I CPT codes Level II National codes Level III Local codes

MD HCPC code modifiers(s) reported for the service line. A modifier provides the means by which the reporting physician can indicate that a service or procedure has been altered by some specific circumstances but not changed in its definition or code. Some of the most common modifiers that NDM would see are the following:

80 – Assistant Surgery


Field This Field . . . 26 – Professional component 22- Unusual Procedural Service 50- Bilateral Procedure

Additional information on modifiers can be located: 1. In the CPT Book in Appendix A 2. Knowledge library: Operational

Processes:Claim-Customer Service;UNET specific coding.

This field is can be used to verify if the provider of service is rendering Surgeons service vs. Anesthesiologist services or if the service is for professional component vs. Technical component.

DATE Revenue code date of service. Multiple visits for the same type of service may or may not have taken place. This may be helpful to review when the provider indicates they billed for two visits and received reimbursement incorrectly (for example, received reimbursement for just one visit).

CHARGE Charge amount for the revenue code and description as it is shown on the claim.

SX When the claim has been split into multiple claims, the ICN suffix indicating on which UNET/TOPS payment screen this service line will be displayed.

PS This field indicates the “after” picture of how UNet/TOPS system converted the place of service originally submitted by the provider as found on the left-hand side of the EDS 1 Screen. This will play a key role in how the claim will sort to a Service Type on the PPI Rate Table. Valid values are; IH =Impatient Hospital OF = Office AT = Alcohol Treatment HS = Hospice BC= Birthing Center OH =Outpatient Hospital IL = Inpatient Lab RX = Pharmacy SA = Substance Abuse Center CL=Clinic CF= Convalescent Facility AS = Ambulatory surgical center HM = Home OL=Outpatient Lab

SVC This field indicates the services after the UNet/TOPS system has run the services through


Field This Field . . . PRS. The codes indicated in this column may vary from the information the provider originally billed (as found on the left side of the EDS 1 screen). An example of this would be when the provider billed for two CPT-4 codes for procedures rendered, the system sent the claim through PRS. The PRS logic found one code that more accurately describes the service rendered, the new code would be indicated. This is the Service code that will carry to MPI screen.

CHARGE The field will indicate the charges submitted on the claim, if the PRS process does not bundle or changed to coding the charge amount will appear the same as when the claims was built. If the codes were affected during the PRS process the charges may be different. This is the charge amount that will carry to MPI screen for the PS/SVC Code(s).

PROV NAME This information is from the EDS 3 screen which is the support screen for Provider/Facility demographic information.

ACT Patient account number assigned by the facility. Up to 20 characters can be displayed with only 17 passing to UNet.

PROVIDER’S ADDRESS

Provider’s address and telephone number. This information is from EDS 3, the support screen for Provider/Facility demographic information.

TIN Provider’s tax identification number. This information is for the EDS 3 screen, which is the support screen for Provider / Facility demographic information.



Overview

This screen provides additional information on the patient, the insured, secondary coverage, accidental injury, and incidentals. If the patient has dual coverage, one being the primary and another being the secondary, the secondary or coinsurance covered amounts will be displayed on this screen. The EDS 2 screen also displays Medicare rejections or crossover amounts.

The EDS 2 screen is often thought of as a support screen for the claim being considered. This screen can be utilized to show physical locations of patient and providers. This screen provides specific dates for illness, and accident occurrences. The EDS 2 screen also provides detailed information on the other insurance information if applicable. Other insurance information includes coverage dates, company name, location and policy number.

Claims that are related to automobile accidents or employment can be identified on this screen. The first date the patient visited the provider is listed. If the patient is partially or totally disabled, the date range will be shown. If the patient is able to return to work, this information may also be listed on EDS 2.

For HCFA 1500 claim submissions, this screen supplies the Coordination of benefit (COB) allowable and patient disability information. For UB-92 submissions, this screen supplies the admission hour, type; source and a list of other physicians listed on the UB 92 bill. When applicable, the NY Surcharge will appear on this screen. The EDS2 screen can be used to identify when large provider ancillary groups that are paid to certain addresses based on the place of service location. The EDS 2 screen can be used to retrieve data that has been submitted electronically or manually entered for claim resolution. The UB-92 EDS 2 screen slightly varies form the HCFA 1500 EDS 2 screen. For example, ICD-9 procedure codes that were performed on the patient during the admission will appear; therefore this information will affect the way a claim will look on the EDS 2 screen.


The following information will be displayed on the EDS 2 screen: For HCFA 1500 & UB92 Claim Forms ♦ The patient information such as name, date of birth, relation to insured ♦ The insured information, which may different from the patient if other insurance, is presence. ♦ Information such as insured name, coverage dates and policy number for other insurance coverage. ♦ Medicare crossover amount and non-covered charges will be presence. ♦ The indication of whether the claim was related to patients employment and or disability. ♦ The covering dates for the disability charges. UB-92 Claim Forms Only ♦ Diagnosis coding (ICD-9 Diagnosis Code, DRG) ♦ Medical procedure(s) performed (CPT-4 Procedure Code, HCPCS and/or Revenue Codes) ♦ Submitted DRG coding (system assigned DRG located on MPC screen) ♦ NY surcharge if applicable ♦ Dates of service Accessing the EDS 2 Screen

You can access the EDS 2 screen directly from the MEI screen. When you are on the MEI screen (also known as the EMC Status screen), select the appropriate claim and then type the number 2 in the O field. EDS 2 will be displayed for that claim. Note: If the claim does not appear in the EDS 'queue' because it was keyed manually, all of the information for such a claim will appear or can be accessed on the Medical Payment screen (MPI


A sample EDS 2 screen is shown below.

This screen was designed to provide additional information on the patient, the insured, other coverage, accidental injury and incidentals.

Other insurance information will be displayed, if applicable.


EDS 2 Screen Field Descriptions



ICN Inventory Control Number (10 digits). This number is unique to each claim. The ICN number was created to give each claim in UNet, regardless of what engine it is paid on, a unique number. This number is also used to pull up a specific claim for a member. Suffix: When the claim has been split into multiple claims, the ICN suffix indicating on which UNET/TOPS payment screen this service line will be displayed. An example of multiple suffixes is: ICN=I0145439871 01 Suffix



REL Code indicating patient’s relationship to the insured. Valid Values are:




DOB Patient’s date of birth, displayed in month, day,


Field This Field . . . year (MM/DD/YYYY) format.
















ICN suffix (xx= ICN suffix to be calculated) FLN Each claim received at UnitedHealth Group is

given a Film Locator Number. The FLN is 10 digits and is comprised of the Julian Date and the order the claim was received. It helps to control 'first in, first out' inventory management.


Field This Field . . . An FLN is frequently assigned to a 'batch' of claims that has arrived at the same time. It does not uniquely identify the claim (more than one claim can have the same FLN).

On the EDS9 screen, the FLN (10 digits) is followed by a 2-digit UFE indicator. The UFE indicator is followed by the 3-digit Document Control Center (number) or DCC. The DCC is essential for understanding if the original claim is located in TDARS or iDRS. While the UFE indicator and DCC do not have field names on the EDS9, they appear in this area and will be described here.

FLN: The FLN is 10 digits and is comprised of the Julian Date and the order the claim was received. • First two digits = year the claim is received

at UnitedHealthcare. • Third, fourth, fifth digits = Julian date

(corresponding month and day of the calendar year in sequential order) a claim is received at UnitedHealthcare.

• Sixth through tenth digits = the sequential number assigned for claims received on any given day

Example: FLN: 000010002 where:

00 equals the year, 2000 001 = the first day of the year (i.e. 001 is January 1st) 00002 = Image number (sequential number,

system assigned) UFE Indicator – Two two digits telling you how many claims are associated with that FLN. DCC: Document Control Center (#) • Numbers in the range 969-999 represent

claims that arrived to UHG via EDI. • Numbers in the range 100-800 represent

claims that arrived at UHG via paper and were scanned or directly keyed by our keying


Field This Field . . . vendors.

Claims with a DCC between 969 - 999 can be found in TDARS. TDARS will show the claim details as billed and sent in by the provider.

Claims with a DCC of 100-800 can be found in iDRS. iDRS will show the claim information "as billed by the provider". (When you look at these claims on the EDS screens, however, you will see how the keying vendor keyed the data, not how the provider originally billed it. This is important to understand when you are troubleshooting a situation).

The TOPS EDS screens will display all claims that arrived via EDI, scanned paper claims or keyed paper claims.

Note: More Information • Vendor keyed claims can be found in

TDARS as well through the 'FLN KEY' function (this would be typed in the 'ENTER REPORT ID' field). This would only be necessary if you suspect a vendor keying discrepancy and wish to verify it. In PIM, we recommend use of iDRS to verify exact details billed by the provider.

• After scanned claims are electronically scanned in, they are reviewed by a keying vendor to identify possible discrepancies.

• If you need to understand if the particular claim you are working on was a scanned paper claim or EDI or keyed vendor claim, you should refer to the PAPLESS field in this documentation.

PAT: FST/MI The first name of the patient from UNET Medical Register (MRI) screen. This information is used to identify the specific patient when multiple members appear under the insured. The first name will help you narrow down the selection you need to inquire upon.

LAST Patient’s last name.

SEX Code indicated sex of the employee or dependent indicated on the corresponding line. M = Male; F =


Field This Field . . . Female.

DOB The patient's date of birth, displayed in month, day, year (MM/DD/YYYY) format. The date of birth is from block 2 Paper HCFA 1500 or box 3 on electronic HCFA 1500, block 2 Paper UB 92 or box 3 on electronic UB 92 submissions.

ADR Code indicating whether the address on the paper claims or electronic submission is different from the address that was returned on the Front End. Y = Yes; Blank = No.

INS: SSN Social Security Number of the member based on the eligibility selection. This information is used to access the Insured’s information when researching an EMCCF.

INS: Name Insured’s plan name.

GROUP NO On secondary claims, the carrier’s allowed amount will be shown in this field.

EMPR On secondary claims, the other carrier’s paid amount is shown in this field.

EMP Employment indicator. Y = Yes; N = No; Blank = Not on Claim.

EMP RL Patient’s relationship to the employee.

ST Code indicating whether the patient is a full-time college student. Y = Yes; N = No.

OOTHER INSURANCE INFO 172 OR SPOUSE EMPR

These fields will contain any information on other insurance keyed in on the front-end, such as: addresses, spouse's other insurance information, etc. If the OI field is not completed or the value = N, the system will generate a message indicating that there is NO OTHER INS.

CONDITION RELATED

Indicators for possible work related injury, auto accident, or emergency room services.

LB Code (Y or N) indicating whether lab work was performed outside of the doctor’s office. Y = Yes; N = No.

INS ADDRESS

Insured’s address.

ASG BEN Y = Patient/Member authorizes insurance company to issue claim payments directly to the provider. N = Patient/Member does not authorize the insurance company to issue claim payments


Field This Field . . . directly to the provider.

DATE This field indicates the first date that symptoms such as illness and accident occurred and the last menstrual period if applicable. Valid values are: I - Illness A - Accident L - Last Menstrual Period

TAX Total tax charged, if applicable.

DISC Discount information, if applicable.

NY SURCHARGE

Information related to New York Surchage, of applicable.

DATE FIRST CONSULTED

Dates the patient first consulted this physician or facility for treatment.

DATES TOTAL DISABILITY

Dates (from and to) that the patient was totally disabled.

DATES PARTIAL DISABILITY

Dates (from and to) that the patient was partially disabled.

DATE RETURN WORK

Dates patient is able to return to work.

MC: ASG Y or 2 = Pay provider. Provider agrees to accept Medicare’s allowable amounts for services rendered. N or 1 = Pay employee. Provider does not agree to accept Medicare’s allowable amounts for services rendered. Allowable amounts should be based on limiting charge.

PD Medicare paid amount from the EOMB

DED Medciare Part B deductible. If no Part B deductible is identified on the claim, this field will be blank.

COINS Medicare coinsurance from the EOMB.

NC/REJ Medicare not covered/rejected amounts from Medicare Remittance Advice statement.

PAT RESP Patient responsibility from the EOMB. Note: Patient responsibility will display only when there is an amount equal to or greater than 0; if patient responsibility is 0, the PAT RESP field will


Field This Field . . . be blank. CSS or DLA won’t use.

XOVER CARRIER

Medicare carrier abbreviation (four characters). The Medicare carrier will display for Medicare crossover and electronic Part B claims.

REF TIN Tax identification number of referring physician. This field can be used to identify who the referring physician is when the information has been omitted from the claim form.



Overview The EDS 3 screen can be used to view provider’s demographic information and tax identification numbers. The EDS 3 is also considered to be a support screen for the claim being considered. The EDS 3 screen can be divided into two sections. The first section of the screen gives you the information needed to identify the claim (ICN, SSN PAT, etc.). The remaining fields give basic provider information as it was keyed. The EDS 3 screen:

contains the servicing providers demographic information as billed

identifies which tin suffix combination was selected for claims payments

routes and identifies which EMCCF queue the provider may have been routed to for further research.

The EDS 3 screen for UB and HCFA submission is exactly the same. Indication whether the claim was keyed by a vendor or electronically submitted will be located in the SOURCE field The REM field will house any remarks keyed by NEIC/CFE/DEIS during submission of the claims. The EDS screen provides data to support the provider algorithm logic. The algorithm logic determines which provider will be selected. The claim data received goes through a series of matching combinations. Once the fields are matched, for example the servicing name, billing name, or organization name the system will then select the appropriate servicing provider. Provider Selection Flow:

Claim keyed or received from electronic vendor If Keyer (STBK) selects the provider, EDS 3 will show

STBK for source. If Keyer did not select the provider, the claim is routed to EPD for possible selection.

If electronic vendor and EPD could not select the provider, the electronic claims route to smarts queue. If smarts queue resolver selects provider, claim is routed back though auto adjudication. If no provider selected in smarts queue, claim routes to the resolver. If STBK, EPD or Smarts Queue could not select the provider, then the


claim will route to a resolve for review and possibly sent to NDM-Johnstown.

On UB-92s and HCFA forms, there are specific areas for a provider to indicate his name and tax identification number (TIN) or social security number (SSN). However, invoices come in a variety of formats. It may be a little more difficult to locate the provider on these forms. Generally, the provider name, address, and TIN/SSN will be together. A Smart Total Bill Keyer typically selects the provider suffix for auto routed claims. If the keyer is unable to determine the correct provider, the selection of a provider may be bypassed and the claim processor is responsible for selecting the correct provider.


Accessing the EDS 3 Screen

You can access the EDS 2 screen directly from the MEI screen. When you are on the MEI screen (also known as the EMC Status screen), select the appropriate claim and then type the number 3 in the O field. EDS 3 will be displayed for that claim. Note: If the claim does not appear in the EDS 'queue' because it was keyed manually, all of the information for such a claim will appear or can be accessed on the Medical Payment screen (MPI). Shown below is a sample of the EDS 3 screen.

You may encounter claims for which you suspect an incorrect provider was selected. You can verify the provider selection by using EDS 3.

Tells you what Tax ID and Suffix will be used for processing.

This bill was submitted electronically based on the source code of EMCE.





ICN Inventory Control Number (10 digits). This number is unique to each claim. The ICN number was created to give each claim in UNet, regardless of what engine it is paid on, a unique number. This number is also used to pull up a specific claim for a member. Suffix: When the claim has been split into multiple claims, the ICN suffix indicating on which UNET/TOPS payment screen this service line will be displayed. An example of multiple suffixes is: ICN=I0145439871 01 Suffix



REL Code indicating patient’s relationship to the insured. Valid Values are:






















ICN suffix (xx= ICN suffix to be calculated) FLN Each claim received at UnitedHealth Group is

given a Film Locator Number. The FLN is 10 digits and is comprised of the Julian Date and the order the claim was received. It helps to control 'first in, first out' inventory management.

An FLN is frequently assigned to a 'batch' of


Field This Field . . . claims that has arrived at the same time. It does not uniquely identify the claim (more than one claim can have the same FLN).

On the EDS9 screen, the FLN (10 digits) is followed by a 2-digit UFE indicator. The UFE indicator is followed by the 3-digit Document Control Center (number) or DCC. The DCC is essential for understanding if the original claim is located in TDARS or iDRS. While the UFE indicator and DCC do not have field names on the EDS9, they appear in this area and will be described here.

FLN: The FLN is 10 digits and is comprised of the Julian Date and the order the claim was received. • First two digits = year the claim is received

at UnitedHealthcare. • Third, fourth, fifth digits = Julian date

(corresponding month and day of the calendar year in sequential order) a claim is received at UnitedHealthcare.

• Sixth through tenth digits = the sequential number assigned for claims received on any given day

Example: FLN: 000010002 where:

00 equals the year, 2000 001 = the first day of the year (i.e. 001 is January 1st) 00002 = Image number (sequential number,

system assigned) UFE Indicator – Two two digits telling you how many claims are associated with that FLN. DCC: Document Control Center (#) • Numbers in the range 969-999 represent

claims that arrived to UHG via EDI. • Numbers in the range 100-800 represent

claims that arrived at UHG via paper and were scanned or directly keyed by our keying vendors.


Field This Field . . . Claims with a DCC between 969 - 999 can be found in TDARS. TDARS will show the claim details as billed and sent in by the provider.

Claims with a DCC of 100-800 can be found in iDRS. iDRS will show the claim information "as billed by the provider". (When you look at these claims on the EDS screens, however, you will see how the keying vendor keyed the data, not how the provider originally billed it. This is important to understand when you are troubleshooting a situation).

The TOPS EDS screens will display all claims that arrived via EDI, scanned paper claims or keyed paper claims.

Note: More Information • Vendor keyed claims can be found in

TDARS as well through the 'FLN KEY' function (this would be typed in the 'ENTER REPORT ID' field). This would only be necessary if you suspect a vendor keying discrepancy and wish to verify it. In PIM, we recommend use of iDRS to verify exact details billed by the provider.

• After scanned claims are electronically scanned in, they are reviewed by a keying vendor to identify possible discrepancies.

• If you need to understand if the particular claim you are working on was a scanned paper claim or EDI or keyed vendor claim, you should refer to the PAPLESS field in this documentation.


SCI/SDI Screen (Summary Check/Draft)

Overview

The SCI and SDI screens display payment information regarding a specific summary check. A summary check is a check that can have multiple patient(s) benefits applied to it. If this screen is filled with data, a summary check has or will be issued. The SCI and SDI screens contain identical information. Use this screen when a caller, particularly a provider, cannot match the check received to a claim submitted and does not have an EOB or has not received a check for a claim submitted.


Before you work with the SCI/SDI screen, be aware that:

• You can access the SCI/SDI screen by accessing a specific claim and then change the transaction code.

• If you know the check number, use the SCI screen to access payment information.

Procedures

Use the procedures that follow when you need to access information about a payment. The field descriptions follow the procedures and example.


Accessing the SCI/SDI Screen Using a Check Number

Complete the steps below to access payment information.



SCI,(Check #)


2 Press the Enter key. The system displays the summary information.

Accessing the SCI/SDI Screen From the MHI Screen

You can also access this screen from the MHI screen by completing the steps below.


1 On the AHI screen, access a specific enrollee’s claim by entering S in the Select field before the claim you want to view.


2 Press the Enter key. The enrollee’s specific claim is displayed.

2 In the control line in the MHI screen, enter SDI

The system overwrites the MHI on the control line.

2 Press the Enter key. The system displays the summary information for that specific draft number.


Accessing the SCI/SDI Screen Using a Draft Number

You can also access the screen using a draft number by completing the steps below.



SDI,(Policy #),S(SSN),(First Name),(Rel),(Draft #)



Example

This example illustrates an SCI/SDI screen.

SDC,123456,S123456789,ALYSSA,CH,0012345678

S123456789 S123456789


SCI/SDI Screen Field Descriptions

This table lists the SCI/SDI field descriptions.


CHK NO Contains the two-letter prefix and ten-digit check number on the summary check.

CHK AMT Contains the total dollar amount of the summary check.

TR Contains a two-character code that indicates a change in the claim’s disposition.

OV Contains the one-character override code that forces the system to allow manual intervention to process the claim.

RC Contains the two-character remarked code used during processing of the claim.

PROC DT Indicates the date when adjustments were made to the claim or check. The format of this field is mm dd yy.

CHECK ISSUE DT

Indicates the date when the check was issued. The format of this field is mm dd yy.

S Allows you to enter S to go to the MHI screen.

WARN OV Contains the override code that forces the system to allow manual intervention in order to process the line.



POLICY NUMBER

Contains the policy number under which the claim was paid.

EMPLOYEE ID

Contains the employee’s nine-digit Social Security number.

PATIENT NAME

Contains the first name of the patient.

RL Contains the two-character relationship code of the enrollee to the employee.

DRAFT NO Contains the number of the draft.

PAID AMOUNT

Contains the dollar amount paid to a provider for a corresponding claim.

REISSUE Contains information used for accounting purposes.

ALTERED DATA

Allows you to alter data if you need to make an adjustment.

comments lines

(See note.)

Note: The following two messages can appear in the lower left corner of the screen:

• “NOT SUMMARY CHECK,” which indicates that the check and payment should have been sent out within two business days of the processing date.


• “SUMMARY CHECK NOT ISSUED,” which indicates that this check will be sent out as part of a summary check, but the check has not yet been issued. As of 8/14/95, the issue date is based on the following schedule:

Release Day of the Week

First Letter of Provider’s First Name

Monday A, B, C

Tuesday D, E, F, G, H

Wednesday I, J, K, L, M

Thursday N, O, P, Q, R

Friday S, T, U, V, W, X, Y, Z, and all nonalpha


SFI Screen (Set Family)

Overview

The SFI screen displays specific types of benefits and tracks plan limits for lifetime and yearly maximums. It also displays specific types of deductibles or penalties applied. Before You Work with This Screen

Before you work with the SFI screen, be aware that:

• The SFI consists of three screens. To view the second and third screens, press Enter and the next screen will be displayed. This procedure will cycle you through all the screens.

Procedures

Use the procedure that follows when you need to locate enrollee maximums and family deductible information. The field descriptions follow the procedure and example.

Accessing Lifetime and Yearly Maximums and Family Deductible Information

Complete the steps in the table below to access an enrollee’s maximums and a family’s deductible information for the current and previous year.



SFI,(Policy #),S(SSN),(First Name),(Rel)


2 Press the Enter key. The system displays the specified enrollee’s maximums and a family’s deductibles.


Examples

This example illustrates the first page of an SFI screen.

SFN,123456,S123456789,ANDREA,EE,


SFI Screen Field Descriptions

The SFI screen contains two sections:

• Individual maximums section • Family deductible section

This table lists and describes the fields in the individual maximums section. Information is displayed for the current and two previous years. Each year contains two rows of information.


AUDIT Displays the last date that information transferred to this screen.

Row 1: YR/PD

Indicates the year and the total benefit dollars paid for each type of benefit for the current year. The benefit types include Medical, Vision, Early Retirement, Retirement, Psychiatric Confinement, Psychiatric Nonconfinement, Psychiatric Combined, Alcohol and Drug Confinement, Alcohol and Drug Nonconfinement, Alcohol and Drug Combined, and Out-Of-Network Medical.

Row 2: ADJ

Displays the amount that was paid for each type of benefit plus any adjusted amount.

This table lists and describes the fields in the family deductible section. This section only lists the current and previous year deductible information. Each “DED +(letter)”represents a different deductible that was applied with the information listed in the following table.



DED YR/NO IND

Indicates the year and number of family members that the deductible had been applied. The types of deductibles are: DED M - Medical care deductible DED R - Hospital room and board deductible DED P - Prescription deductible DED G - PPO deductible DED 4 - (Unassigned) DED H - CCS (PARS) deductible DED V - Vision deductible DED Y - PPO deductible DED E - Hospital extras or emergency illness deductible DED 5 - (Unassigned) DED S - Surgery deductible DED 6 - (Unassigned) DED O - Outpatient services deductible DED B - Home health care deductible DED C - Midyear change deductible DED F - Second surgical opinion deductible

DED AMOUNT

Displays the amount of deductible that was applied for the family.

CO IND Displays the number of family members that had carryover from the previous year.

CO AMT Displays the amount of carryover for the family.

DED SAT DTE

Displays the date that a deductible has been applied.


EDS 6.5 Screen

Overview The EDS 6.5 is the Revenue Detail Institutional EDS Screen. The purpose of the EDS 6.5 is to review and allow processors to make any necessary adjustments to the updateable fields in order to calculate the correct allowable amount on the new EDS 6.5 screen. The new screen should be used in any situation the service line data being changed by the user does not match the original data from the physician/ provider. Accessing the EDS 6.5 Table: Access to new EDS 6.5 screen is accomplished utilizing ’OPN’ in the ‘A’ (Action) field of the EDS6 screen.

A new value ‘OPN’ will be added to the existing EDS6 (Institutional) ‘A’ (Action) field. When ‘OPN’ is entered in the action field of the existing EDS6 screen the new EDS 6.5 screen will be returned and will display the details associated with the applicable UNET Service line. Shown below is a sample of the EDS 6.5 screen.

(0) ----5---10---15---20---25---30---35---40---45---50---55---60---65---70---75---80 (1) ICN XXXXXXXXXX XX SSN XXXXXXXXXX PAT XXXXXXXXXX RL XX POL XXXXXX NXT SCR _____ (2) DOS FROM ------ DOS TO ------ BYPASS HISTORY - (3) IC1 ---- IC2 ---- IC3 ---- IC4 ---- IC5 ---- IC6 ---- (4) DX1 ----- DX2 ----- DX3 ----- DX4 ----- DX5 ----- DX6 ----- DX7 ----- (5) DX8 ----- DX9 ----- (6) (7) A REV CPT/HCPC DOS NBR CHARGE NOT COV OV RC ALLOWED CI R PM C EXC GRP (8) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (9) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (10) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (11) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (12) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (13) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (14) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (15) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (16) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (17) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (18) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (19) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (20) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (21) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (22) (23) PROV TIN/SX ---------- --- PAT ACCT -------------------- (24) MESSAGE LINE


EDS 6.5 Screen Field Descriptions

Field Description ICN This field indicates the 10-digit Inventory

Control Number. This number is unique to each claim. The ICN number was created to give each claim in UNET regardless of what engine it is paid on a unique number. No other claim will have the same number. This number is also utilized to pull up a specific claim for a member. A unique number 10-digit number assigned to each claim as it goes through TOPS Front End processing.

Suffix: When the claim has been split into multiple claims, the ICN suffix indicating on which UNET/TOPS payment screen this service line will be displayed. An example of multiple suffixes is:

ICN=I0145439871 01 ……………………Suffix

SSN Social Security Number of the member based on the eligibility selection The employee social security number from UNET Medical Register (MRI) screen This information is used to access the Insured’s information when researching an EMCCF.

PAT Patient’s first name The first name of the patient from UNET Medical Register (MRI) screen This information is used to identify the specific patient when multiple members appear under the insured. The first name will help you narrow down the selection you need to inquire on.


Field Description NXT SCR This field will allow the user to enter data to

advise the system of the next screen to access. Valid codes are listed below: MPC or “A”= UNET calculated payment screen for this ICN MRI or “F” = UNET Medical Family/Dependent Register for this ICN MNI or “C” = UNET Claim Number Register for this Individual AHI or “H” = UNET Abbreviated History for this individual EPI or “E” = UNET Employee/Policy Screen (SSN look up only) 1 = EDS 1 Screen for either UB92 or HCFA bill 2 = EDS 2 Screen for either UB92 or HCFA bill 3 = EDS 3 Remark Screen for either UB92 or HCFA bill 9 = EDS 9 (ACS) Screen for either UB92 or HCFA bill N = Next Claim in queue Q = Change the queue set up S = MEI selection screen R = Work completed, Releases claim from queue. Johnstown PIM is the only PIM region to use this. U = Update fields that allow processor update. FCI = The UNET Freeform Comments Inquiry Screen will be returned CCI = The UNET Coordination of Benefits Comments Inquiry Screen will be returned BCI = The UNET Benefit Structure Comment Inquiry Screen will be returned CMI = The UNET Comments Medical Inquiry


Screen for the patient will be returned RET = The UNET pended screen will be returned Axx = UNET calculated screen for z specific ICN suffix (xx= ICN suffix to be calculated) This field is utilized to tell the system what screen you want to access next. The most commonly used screens in NDM are: 1 = EDS 1 Screen for either UB92 or HCFA bill 2 = EDS 2 Screen for either UB92 or HCFA bill 3 = EDS 3 Remark Screen for either UB92 or HCFA bill 9 = EDS 9 (ACS) Screen for either UB92 or HCFA bill

DOS FROM The beginning date of the service rendered on the service line. All dates must be entered as month, day & year (mmddyy).

DOS TO The end date of the service rendered for the service line.

BYPASS HISTORY

Bypass history.

IC1 – IC6 Procedure codes (for inpatient hospital bills only).

DX1 Primary diagnosis code used for the claim displayed.

DX2 – DX9 Secondary diagnosis code or codes used for the claim displayed.

A Action

REV Revenue codes submitted electronically for the services rendered.

Field Description

CPT/HCPC Service/Procedure code.


DOS Date of service, displayed in month, day, year (MM/DD/YYYY) format.

NBR The number of services performed for that service code. (i.e., indicates number of days inpatient (facility), may indicate number of units (professional).

CHARGE Charges submitted on the claim.

NOT COV Amount not covered by the policy master for this service line.

OV The override code used to force the system to allow "manual" intervention in the processing of the claim. Some of the more common override codes are: 01-suspect duplicate, 02-Medical Claim Review (MCR) and Reasonable & Customary (R&C) edits. May also be used to clear most ADJ DET (adjuster determined) edits. 07-Investigate COB 13-Eligibility edits plus ALL lower override codes. This edit is to be used with CAUTION and ONLY when absolutely necessary as it impacts downstream reporting A complete list of Override Codes are listed in the Knowledge library http://kl/content/operational%20processes/claim-customer%20service/unet%20claim/override%20codes.doc

RC The remark code number entered during claim processing that displays a corresponding message on the EOB. Some of the more common override codes are; D1-Physician Negotiated Rate D2-Facility Negotiated Rate 29-Charges over Reasonable & Customary (R&C) B9-System generated copay applied Complete instruction on how to review the Remark Codes are listed in the Knowledge library http://kl/content/operational%20processes/claim-customer%20service/unet%20claim/remark%20codes.doc

Field Description ALLOWED The allowed is the amount we will consider after all non-

covered amounts have been subtracted. The allowed then

http://kl/content/operational processes/claim-customer service/unet claim/unet history screens.doc





is the basis for the deductible and coinsurance calculation

CI Compatibility Indicator- displays a one-two character indicator that identifies the processing that will be governed by the I-Rate line. Valid values are: D= discount or factor processing P= per diem processing L= all inclusive lump/case rate processing LB= all inclusive lump/case rate and per diem processing N= incompatible processing LP= all inclusive lump/case rate and POC processing CP = Floor $ amount and POC processing (with or without CAP)

R A rule defines how services will be processed, inclusive of the handling of billed units from the claim. The Valid Values are: C=Case Rate (Includes Miscellaneous) V=Per Visit (Excludes Miscellaneous) T=Per Visit (Includes Miscellaneous) U=Per Unit R=Carve-out S=Step Rate (Excludes Miscellaneous) P=Step Rate (Includes Miscellaneous)

PM Pay Method code that indicates when the agreement is to pay contracted rates regardless of the billed charges. The Valid values are: A = Pay the contracted rate always, on a detail line Basis. B = Pay the lesser of the contracted rate or a percent of charge, on a detail line basis. Blank = The system pays the lesser of the contracted rate or 100% charge, on a detail line basis.

Field Description C A decision to purchase separately an additional service

that typically is a component of that benefit plan. Example: an HMO may "carve out" the behavioral health benefit and select a specialized vendor to supply these services on a


stand-alone basis.

EXC Excluded Outlier Indicator. Y = Excluded from outlier

GRP Group version.

PROV TIN/SX

The TIN and suffix for the provider of service.

PAT ACCT The provider's patient number for the billed expense


Notification Screens

Overview

This chapter includes descriptions of, procedures to use, and examples of CCS (PARS) notification information, Care Coordination, and Payout Control information screens. The notification screens are ARI, POI, PSI, PCI, DLI, CMI, and PTI. Chapter Topics

This chapter includes information on: • Notification records for an enrollee. • Specific information on notification.

ARI Screen (Notification Records)

Overview

The ARI screen displays notifications for services. The system transfers these notifications from the Care Coordination System (CCS) (formerly used was Patient Authorization Review System - PARS) to TOPS. This screen has the following information:

• Enrollee information • Notification dates • CPT codes covered • Physician/Facility information • Comments


Before you work with the ARI screen, be aware that:

• The system displays an abbreviated listing of notifications for services. If you need more detailed information, select a record to display the POI/PSI (outpatient/ inpatient) screen, which is more detailed than the ARI screen.

• If you process claims, you may be automatically routed to the ARI screen.

August 2005 TOPS Contract and Claim Reference Manual Training & Development Notification Screens 179

Access Enrollee's ARI

Enrollee's ARIrecord displayed

View Notificationdetail?

Enter an "M" in theSelect field before theNotification to view.

POI outpatientNotificationdisplayed?

POI Notificationdetail displayed.

Access claimcomments onNotification?

Enter "C" in thesecond Select field

before the Notification.

Enrollee's PCIrecord displayed

Access DLIto see how

Notification used inTOPS

payment?

Enter an "M" in thesecond Select field

before the Notification.

DLI recorddisplayed.

Enter an "M" in thefirst Select field to

return to ARI screen.

POI screendisplayed.

Enter an "M" in theSelect field to return to

POI screen.

Yes

No

Yes

Yes

Yes

No Enrollee's ARIrecord displayed.

PSI inpatientNotification detail

displayed.

Access claimcomments onNotification?

Enter a "C" in theSelect field.

Enrollee's PCIrecord displayed

Enter an "M" in theSelect field to return to

ARI

No

Yes

No

Accessing Enrollee'sNotification Information


Procedures

Use the procedure that follows to access the ARI screen. The ARI screen field descriptions follow the procedure and example.

Accessing the ARI Screen

Complete the steps in the following table when you need to access the ARI screen.


1 Enter

ARI,(Policy#),S(SSN),(First Name),(Rel)


2 Press the Enter key. The system displays any notifications for the policy and enrollee you specified.

Example

This example illustrates the ARI screen.

MHB,123456,S123456789,ALEK,EE,


ARI Screen Field Descriptions

The following table lists the ARI screen fields and descriptions.


NO VALID RECORD

Indicates whether any notification records exist for a particular individual. If you process claims, you can select this field by entering an “S” to return to the MPI screen.

S Allows you to select a record or move to the detailed record. This is a CCS (PARS) select field. The valid values are:

M - Route to the POI/PSI (outpatient/ inpatient) screen for additional review.

S - Route to the payment screen (MPI) and use this record in payment (claims processor).

N Indicates the line number from the TOPS payment being processed.

FNAME Contains the first name of the enrollee who has received the notification.

RL Indicates the two-letter relationship code of the enrollee to the employee.

See Appendix B for a list of the valid relationship codes and descriptions.

DX Contains the notification diagnosis code.


Field This Field . . . A/D Contains the notification code to

accept or deny the notification. The valid codes for this field are:

• A - Acceptance

• D - Denial

CPT Contains the service code that was reviewed for the notification.

M Indicates whether more than one CPT code was covered. The format of this field is Y/N, with Y indicating that more than one service was covered.

ADM/EFF Indicates the admission or effective date of the notification.

DSG/CANC Indicates the discharge or cancellation date of the notification.


Field This Field . . . PD Indicates if claim was processed using the

CCS (PARS) notification record. The valid values for this field are:

• Y - The CCS (PARS) record was used in TOPS.

• N - The CCS (PARS) record was not used in TOPS.

• X - This is a TOPS only record.

RC Contains a two-character CCS (PARS) remark code. See Preference for additional information on the specific remark codes.

CARE GIVE Indicates the type of provider approved to perform the specific service.

PROV TIN/ SUFF

Contains the physician/facility's nine-digit tax identifier preceded by a one-digit prefix and followed by a three-digit suffix. The prefix is 1 if the tax identifier is the provider’s Social Security number and 2 if it is the Federal Tax Identification number.


Field This Field . . . UNITS H/D/V Indicates the type and number of units covered

for the service. The valid values for this field are:

• H - Hour

• D - Days

• V - Visits

• U - Units

C Indicates whether this record contains any freeform comments. The valid values for this field are:

• Y - Comments are available on the PCI screen.

• N - There are no comments.


POI Screen (CCS/PARS Outpatient)

Overview

The POI screen provides the detailed notification records for referral and service notifications given to physicians by Care Coordination. This screen contains the following information:

• Enrollee information • Physician/facility and notification identification • CPT codes • Dates of service • Units approved


Before you work with the POI screen, be aware that: • To access a specific record, enter “M” from the ARI screen

into the select field of the record for which you want more detail.

• The search for information is quicker if you know the enrollee’s Social Security and policy numbers.

Procedures

Use the procedure that follows when you need to access the POI screen. The POI screen field descriptions follow the procedure and example.


Accessing the POI Screen

Complete the steps below to access the POI screen.


1 Access the ARI screen for a specific enrollee.

Use the process to access the ARI screen as described earlier.

2 Enter an M in the S (Select) field before the notification you wish to view.

3 Press the Enter key. The system displays the appropriate screen for the notification requested--POI screen for an outpatient notification or PSI screen for an inpatient notification.

Example

This example illustrates the POI screen.

POC,123456,S123456789,ANDREA,EE,


POI Screen Field Descriptions

The POI screen consists of two sections. The first section contains the header information and the second section contains the service information. The table that follows lists the POI fields and their descriptions for the header information.


First line: S TIN # CPT AUTH #

Allows you to enter “M,” which returns you to the ARI screen. Displays the approved physician/facility's prefix, nine-digit TIN, and three-digit suffix. Indicates the first three digits of the covered service. Displays the ten-digit notification number assigned to the review.

Second line: EE PT REL

Contains the employee’s name. Contains the patient’s name. Contains the two-character relationship code of the patient to the employee.


Field This Field . . . Third line: SEX DOB TOPS PT TOPS REL LST UPDT DT

Indicates the patient’s gender. Indicates the patient’s date of birth. Contains the patient’s name from the MRI. Contains the two-character relationship code of the patient as it appears on the MRI. Indicates the last update date.

Fourth line: DX CPT

Lists up to two diagnosis codes that were reviewed for services. Lists the service code(s) that were reviewed or approved from the CCS (PARS) record.

The table that follows lists the POI fields and their descriptions for the service information.


S Allows you to specify what action to take in your data search. The valid values for this field are: • S - Select this POI as the appropriate

notification (claims processing) • R - Reject this POI because it is not the

notification needed (claims processing) • M - Move to the DLI screen for this

notification • C - Routes you to any claim comments

CPT Contains the CPT code being approved.


Field This Field . . . EFF DT Indicates the date on which the covered

covered can begin. The format of this field is mm dd yy.

CANC DT Indicates the date on which the covered service should conclude. The format of this field is mm dd yy.

Note: There is a seven-day window applied before the beginning date and after the cancellation date of the notification.

CARE Indicates the type of provider covered to provide the service.

SSO This field is not used.

RC Displays the two-character CCS (PARS) remark code that indicates how the claim should be paid. See Appendix A for a list of valid CCS (PARS) Remark Codes.

UNITS Indicates the number of service units that were covered.

REM UNITS Indicates the number of covered service units remaining.


Field This Field . . . H/V/D Contains the one-character type of service

units (hours, visits, days, or units).

FREQ Indicates the frequency of the covered services.

PS Indicates the two-character covered place of service. See Appendix H for a valid list of place of service codes and descriptions.

COM Indicates if any comments exist for a specific record. The format of this field is Y/N, with Y indicating that comments exist.


PSI Screen (CCS/PARS Review)

Overview

The PSI screen is a system-generated screen containing the Care Coordination review data from CCS (PARS) for inpatient facility medical services. This allows you to retrieve and view information from the CCS (PARS) file online. This screen indicates whether Care Coordination has been contacted when required for inpatient confinements and procedures. If there is a penalty applied to a hospital or surgery charge, this screen is helpful in determining if the penalty was applied appropriately. It indicates the date Care Coordination was contacted. Before You Work with This Screen

Before you work with the PSI screen, be aware that:

• To access a specific record, enter an “M” from the ARI screen into the select field of the record for which you want more detail.

• The system changes the transaction code in the control line from PSI to PSC if only one record exists; it changes from PSI to PSN if multiple records exist.

• The search is quicker if you know the Social Security and policy numbers of the enrollee.

Procedures

Use the procedure that follows to access the PSI screen. The PSI screen field descriptions follow the procedure and example.


Accessing the PSI Screen

Complete the steps below to access the PSI screen.


1 Access the ARI screen for a specific enrollee.

Use the process to access the ARI screen as described earlier.

2 Enter an M in the S (Select) field before the notification you wish to view.

3 Press the Enter key. The system displays the appropriate screen for the notification requested--POI screen for an outpatient notification or PSI screen for an inpatient notification.

Example

This example illustrates the PSI screen.

PSC,123456,S123456789,RICHARD,SP,


PSI Screen Field Descriptions

The following table lists the PSI screen field descriptions.


CCS (PARS) INFO S

Allows you to select a record and route to another screen. This is a CCS (PARS) Select field. The valid values are:

M - Route to the ARI screen.

C - Route to the PCI screen.

S - Route to the payment screen and use this record in payment. (Claims processor)

R - Return to the payment screen, but do not use this record (noncompliance). (Claims processor)

CLM CMNTS Indicates if there are claim comments for this specific inpatient notification. The valid values are:

N - No

Y - Yes



TIN Displays the nine-digit physician’s Social Security or Tax Identification number or a facility’s Tax Identification number. The one-digit prefix indicates the type of tax identifier. The valid values are:

1 - Social Security number

2 - Tax Identification number A three-digit suffix follows the first ten digits and gives a provider unique identification under this TIN.

AUTH # Displays a unique notification number which has been assigned to the CCS (PARS) record.

EE Displays the first and last name of the employee.

PT Displays the first and last name of the patient.

REL (first) Indicates the two-letter relationship code of the enrollee to the employee. See Appendix B for a list of valid relationship codes and descriptions.



SEX Contains the patient’s gender. The valid values are:

1 - Male

2 - Female

DOB Contains the patient’s date of birth. The format of this field is mm dd yy.

PT Contains the first name of the patient.

REL (second)

Indicates the two-letter relationship code of the enrollee to the employee. See Appendix B for a list of valid relationship codes and descriptions.

REV # Contains the CCS (PARS) review number for that specific episode of care.

STAT Contains the one-character hospital review status of the patient. The valid codes are:

C - Completed review for claim payment

P - Care Coordination review complete (no longer in use for new reviews)

X - Review incomplete/interim hospital bill



ADMTP Contains the two-character type of admission as determined by Care Coordination. There are four positions. The valid codes for positions one and two are:

SC - Scheduled admission

UR - Urgent admission

ER - Emergency admission

OH - Outpatient hospital

RN - Pregnancy

SN - Preadmission pregnancy/notification within 24 hours

LN - Late notification*

CO - Consultation*

AR - Avoided review

PR - Patient refuses

NR - Nonreviewed

RR - Retrospective review

OF - Office review Valid values for positions three and four are:

M - Medical

S - Surgical

OB - Obstetrics

EM - Emergency medicine

ER - Emergency admission

UR - Urgent admission

CP - Complicated pregnancy

PS - Psychiatric

SA - Substance abuse

CO - Consultation

MD - Physician

HS - Hospital

PT - Patient

P1 - Provider informant

PH - Policyholder



• 03 - General information on program or services

• 04 - Delayed contact

• 05 - Physician uncooperative

• UC - Uniformed client

*In most cases, TOPS automatically pays these admission types as not obtained or noncompliance.

DX Contains up to two ICD diagnosis codes.

CPT Contains up to two CPT procedure codes.

SSO Contains two positions for a one-character code which indicates if Care Coordination requires a Surgical Second Opinion (SSO) for the two procedures listed in the SSO CPT fields. The valid values for these fields are:

• R - SSO required

• O - SSO not required

• S - SSO suggested



STAT Contains two positions for the one-character status of the SSO. The valid values for these fields are:

W - Waived by Care Coordination

X - SSO not obtained

Y - SSO obtained and confirmed

O - SSO not required

N - SSO obtained, nonconfirmed

DRG Contains the DRG code assigned by Care Coordination.

REV DT Contains the date Care Coordination initially reviewed the case and a determination was made on the CCS (PARS) file. It can also indicate when Care Coordination was contacted.

ADL CPT Displays up to four additional CPT codes.

FAC Contains the name of the facility.

PHYS REQD

Contains the date the physician requested the patient be admitted.

The format of this field is mm dd yy.



DCHG Contains the date the physician requested the patient be discharged.


NBR Contains the number of days the physician requested the patient be confined.

LST UPDT DT

Contains the date of the last review.


APPD ADM

Contains the date of admission approved by Care Coordination. The format of this field is mm dd yy.

DCHG Contains the date of discharge approved by Care Coordination.


NBR Contains the two-digit number of days approved by Care Coordination for the confinement.

APPD POS

Contains a code for the approved place of service for the CCS (PARS) notification.

ACTL ADM

Contains the actual date of admission.




DCHG Contains the actual date of discharge. The format of this field is mm dd yy.

NBR Contains the two-digit actual number of days the patent was confined.

RMK CODES

Contains the CCS (PARS) claim remark code. This informs the claims office on particular remarks pertinent to the CCS (PARS) review.

CM Contains the two-character Case Management status code from Care Coordination. The valid values for this field are:

RF - Referred to Case Management

AC - Accepted by Case Management

NI - Case Management has reviewed but will not be following the case.

TOPS INFO WAIVER

Is filled from the TOPS payment with a “W” when the CCS (PARS) penalty has been waived.

DX1 Contains the ICD code from the TOPS payment.

DRG Contains the DRG code derived in TOPS payment.



PAYMNT FST DT

Contains the first date of hospital confinement paid on TOPS. The format of this field is mm dd yy.

LST DT Contains the last date of hospital confinement paid on TOPS. The format of this field is mm dd yy.

NBR Contains the number of inpatient hospital days paid on TOPS.

TRX Contains the transaction code used if an automated adjustment was performed on TOPS.

RC Contains the remark code entered on TOPS to explain payment or nonpayment of the hospital confinement. See Preference for additional information or specific remark codes.

CHG Contains the total dollar charge considered in claim payment on TOPS.

PD Contains the total dollar amount paid in claim payment on TOPS.



SURG DT Contains the date of surgery as entered on TOPS claim payment. The format of this field is mm yy.

FST DCN Contains the first document control number paid on TOPS.

LST DCN Contains the last document control number paid on TOPS.

N/C NBR Contains the number of days noncovered in claim payment on TOPS.

N/C Contains the total dollar amount of noncovered charges on TOPS claim payment.

NOBT% Contains the percentage of the penalty coinsurance for nonnotification of Care Coordination for a confinement.

NOBT DD Contains the deductible for nonnotification of Care Coordination for a confinement.

TIN Contains the provider’s prefix, TIN, and suffix from TOPS claim payment.



AGREE Contains the CCS (PARS) agreement code form the TOPS policymaster. The valid values for this field are:

Y - Yes, CCS (PARS) must agree

N - No, CCS (PARS) does not have to agree

SSO

Contains the one-character SSO obtained/ confirmed indicator from TOPS claim payment. The valid values for the first position in this field are:

O - SSO obtained

N - SSO not obtained The valid values for the second position in this field are:

C - SSO was confirmed

N - SSO was not confirmed

PROC Contains the CPT procedure code from the TOPS payment for which the SSO was obtained.

DT Contains the date from the TOPS payment that the SSO was performed. The format of this field is mm dd yy.



CHG Contains the dollar amount charged for the SSO procedure from the TOPS payment.

PD Contains the dollar amount paid for the SSO procedure from TOPS payment.

DCN Contains the document control number under which the SSO was paid on TOPS.

SSO NOBT N/C

Contains the dollar amount of SSO charges which were not covered in TOPS claim payment.

NOBT% Contains the percentage of the penalty coinsurance for nonnotification of Care Coordination for a mandated procedure or the penalty coinsurance for not obtaining an SSO on a mandated procedure on TOPS.

NOBT DD Contains the dollar deductible for the penalty coinsurance for nonnotification of Care Coordination for a mandated procedure on TOPS.

TIN Contains the SSO provider’s prefix, TIN, and suffix.

PPO Contains the PPO association or PPO arrangement number from TOPS.

N Contains a “Y” if the PPO was not obtained at the time processing had occurred.



RC Contains the two-character remark code used for SSO processing in the TOPS payment. See Preference for additional information or specific codes.

UPDT Contains the date of claim payment on TOPS. The format of this field is mm dd yy.

TIME Contains the time the claim was paid on TOPS.

OFF Contains the three-digit TOPS office number where the claim was paid.

DX Contains up to two ICD codes used in the TOPS claim payment for SSO processing.

CPT Contains up to two CPT codes used in the TOPS claim payment for SSO processing.

TOPS 20/30 ADJST

The following fields contain information if the claim has been adjusted.

DX1 Contains the adjusted ICD diagnosis code from TOPS.

DRG Contains the adjusted DRG code derived from TOPS.

PD Contains the adjusted amount of payment from TOPS.



OV Contains the override or adjustment codes entered on TOPS.

RC Contains the remark code used for adjustment on TOPS.

SSO Contains the adjusted SSO indicator. The valid values for this field are:

Y - Yes

N - No

PROC Adjusted CPT procedure code on TOPS.

PD Adjusted amount paid for SSO procedure.

RC Remark code used in SSO adjustment on TOPS.

UPDT Contains the date of the adjustment on TOPS.

TIME Contains the time of the adjustment on TOPS.


PCI Screen (CCS/PARS Comments)

Overview

The PCI screen provides an avenue of communication between you and Care Coordination for communicating any additional payment information regarding a notification. The system batch feeds comments from CCS (PARS) every night. Before You Work with This Screen

Before you begin working with the PCI screen, be aware that: • You cannot update the PCI screen in TOPS. • You can only access the PCI from the POI/PSI screen.

Procedures

Use the procedure that follows to access the PCI screen. The PCI screen field descriptions follow the procedure and example.

Accessing the PCI Screen

Complete the steps below to access the PCI screen.


1 Access a record on the PSI or POI screen.

Use the procedure to access the POI or PSI screen as described earlier.

2 Enter

C in the Select field on the PSI or second Select field on the POI.

The system displays any freeform comments that exist for the specified enrollee.

3 Press the Enter key. The system displays any claim comments that exist for that specific POI/PSI.


Example

This example illustrates the PCI screen.

PCI Screen Field Descriptions

The PCI screen consists of blank lines; subsequently, there are no field descriptions. What the screen contains varies from record to record and is determined by those adding the comments. You can only view freeform comments entered by others.

PCI,123456,S123456789,ALEX,EE,0000123456


DLI Screen (CCS/PARS Outpatient TOPS Display)

Overview

The DLI screen indicates how the notification has been used for processing claims on TOPS. The screen contains the following information:

• CPT codes • Dates of service • Claim comments notation • Units covered • Provider information • Billed and paid dollar amounts

Use this screen to troubleshoot claims that require notifications. Before You Work with This Screen

Before you work with the DLI screen, be aware that:

• You need to access the DLI screen from the POI screen by typing an “M” in the second select field before a specific notification.

• The search process is quicker if you know the policy and Social Security numbers.

Procedures

Use the procedure that follows when you need to access the DLI screen. The DLI screen field descriptions follow the procedure and example.


Accessing the DLI Screen

Complete the steps below to access the DLI screen.


1 Access a notification on the POI screen.

Use the procedure to access the POI screen as described earlier.

2 Enter an M in the second S (Select).

3 Press the Enter key.

The system shows how the TOPS system used the CCS (PARS) notification for this enrollee.

Example

This example illustrates the DLI screen.

DLC,123456,S123456789,ALEK,EE,


DLI Screen Field Descriptions

The DLI screen combines information from CCS (PARS) and TOPS systems in one location. The S, or select, field (at the top left corner of the field) functions in the same manner for both systems. Within this field, you can specify how to proceed in your data search. The valid options for this screen are:

• S - Select this notification (claims processing) • R - Reject this notification (claims processing) • M - Move to the POI screen • C - Routes you to the claim comments, if any

Information from the CCS (PARS) system appears at the top of the screen. The following table lists the CCS (PARS)-related DLI fields and their descriptions.


CPT Contains the CPT code that was covered.

CARE Indicates the type of medical provider who was covered to render the service.

EFF DT Indicates the date on which the service covered can begin. The format of this field is mm dd yy.

CANC DT Indicates the date on which the service covered should conclude. The format of this field is mm dd yy.

Note: There is a seven day window applied before the beginning date and after the cancellation date of the notification.



UNIT Contains the number of service units that were covered.

CLM CD Displays the two-character CCS (PARS) remark code that indicates how the claim should be paid. See Appendix A for a list of valid CCS (PARS) remark codes and descriptions.

REM UNTS Indicates the number of covered service units that remain.

H/V/D Indicates the one-character type of service units (hours, visits, days, or units) covered.

FREQ Indicates the frequency of the covered services.

POS Contains the covered place of service. See Appendix H for a list of place of service codes and descriptions.

COM Indicates if there are any comments for a specific record. The format of this field is Y/N, where Y indicates that comments exist.


Information from TOPS appears at the bottom of the screen. The following table lists the TOPS-related DLI fields and their descriptions.


CPT Contains the CPT code used to process the claim.

FST Indicates the first date of service for the claim. The format of this field is mm dd yy.

LST DT Indicates the last date of service for the claim. The format of this field is mm dd yy.

SUF Contains the physician/facility's three-digit suffix used when the claim was processed.

CHARGE Indicates the dollar amount charged for the service.

PAID Indicates the dollar amount paid for the service.

UNITS Indicates the number of units “used” when the claim was processed.

OFF Contains the claim office location where the claim was processed.



RC Contains the TOPS remark code used when the claim was processed. See Appendix A for a list of valid CCS (PARS) Remark Codes.


CMI Screen (Comments Medical)

Overview

The CMI screen provides an avenue of communication between the Care Coordinator and the field office for communicating any special processing instructions (SPIs) or negotiated contracts for long-term care cases. It is a freeform screen with unlimited pages that are displayed in date order. This screen is specific to an individual family enrollee while the FCI (freeform) screen is specific to a family.

The information on this screen consists of objective medical information on the status of a claim.


Before you begin working with the CMI screen, be aware that:

• Screen update capability is limited to these users: - MCR nurses who document objective medical information on the status of a claim. - Care Coordination nurses who document payment instructions and negotiated rates for long-term care. - Home office MCR nurses who review all HO reviews, including appeals and standard file review. The appeals procedure for HO reviews specifically includes CMI documentation. - MCR benefit specialists who are educated through nurse instruction for appropriate documentation regarding the claim. - National Transplant Unit which documents information on transplant cases.

• When a CMI record exists, TOPS generates the message, W1459 CMI REC EXISTS. The customer service representative should access the CMI screen and review the comments.


Procedures

Use the procedure that follows when you need to access the CMI screen. The CMI screen field descriptions follow the procedure and example.

Accessing the CMI Screen

Complete the steps below to access the CMI screen.


1 Enter

CMI,(Policy#),S(SSN), (First Name),(Rel)


2 Press the Enter key. The system displays any freeform comments that exist for the specified enrollee.

Example

This example illustrates the CMI screen.

CMI,123456,S123456789,CHELSEA,CH,



CMI Screen Field Descriptions

The following table lists the CMI fields and their descriptions.


DATE Contains the date that the comments were entered. The format of this field is mm dd yyyy.

COMMENTS Contains any freeform comments regarding special processing instructions or information.

NAME Displays the enrollee’s last name.

ADDR Displays the enrollee’s address.

CITY Displays the enrollee’s city of residence.

ST Displays the enrollee’s two-character state of residence.


PTI Screen (Personal Tracking Information)

Overview

The PTI screen contains information about predetermination of benefits. It also gives information about Medical Claim reviews for a specific individual’s claim. This screen contains:

• Patient demographics • Dates of service • Data for diagnosis and services rendered • Allowable data • Comments


Before you work with the PTI screen, be aware that:

• The search is quicker if you know the enrollee’s Social Security and policy numbers.

Procedures

Use the procedure that follows to look for information about predetermined benefits or Medical Claim reviews. The PTI screen field descriptions follow the procedure and example.


Accessing the PTI Screen

Complete the steps in the following table when you need to access the PTI screen.



PTI,(Policy#),S(SSN),(First Name),(Rel)


2 Press the Enter key. The system displays any relevant records for the specified enrollee.

Example

This example illustrates the PTI screen.

PTI,123456,S123456789,ALEK,EE,


PTI Screen Field Descriptions

The PTI screen consists of four sections:

• Enrollee Specific section • Additional Visits section • Discount section • Other Information section

The following table lists the PTI field descriptions in the Enrollee Specific section.


DEACTIVATE Allows entry of a deactivation code so the record is not used in payment. The valid values for this field are:

D - Deactivate (do not use in payment).

Blank - Use in payment.

MCR SSN Displays the Social Security number of the individual who last updated this record.

LAST UPDATE DATE

Indicates the date of the record’s last update. The format of this field is mm dd yyyy.

USED IN PYMT

Indicates if this record was used in payment. The valid values for this field are:

Y - Used in payment.

N - Not used in payment.

FOR DATES Gives the beginning and end dates of service


Field This Field . . . to which the record pertains. The format of this field is mm dd yyyy.

PROVIDER TIN

Contains the physician/facility’s one-digit prefix, a nine-digit tax identifier, and a three-digit suffix. The prefix is 1 if the tax identifier is the provider’s Social Security number and 2 if it is the Federal Tax Identification number. The suffix is the specific identifier for the physician/facility under this particular TIN.


The following table lists the PTI field descriptions in the Additional Visits section.


TYPE Contains the up to six-character type of service for this record. The valid values for this field are:

Chiro

Psych

Podiat

Therap

Vision

Speech

Other

CPT/HCPCS

Contains CPT codes for services being rendered.

ALLWD UNITS

Contains allowable number of units for diagnosis.

DYS/VST HOURS

Contains the approved amount of days, visits, or hours that MCR determines are covered.

ALLOWED PER WEEK

Contains the number of units that MCR determines are covered per week.

RMNG UNITS

Indicates the number of units that remain.

DENY/ REFER EXCESS

Contains a one-character indicator to a claims processor to deny or refer to MCR. The valid values for this field are:

D - Deny

R - Refer to MCR

RC Contains the two-digit remark code to use if the DENY/REFER field is D.


The following table lists the PTI field descriptions in the Discount Information section.


SUB CHG

Contains the submitted charge dollar amount.

ALLOW Contains the allowed charge dollar amount.

TYPE BILL Contains the type of bill submitted. This field accepts any two-character alpha or numeric combination (e.g., TB - total billed).

SVCS DISCOUNTED

Contains the six-character services which were discounted.

The following table lists the PTI field descriptions in the Other Information section.


DIAGNOSIS Contains the ICD diagnosis code.

PRV TYPE Contains the two-character provider type code that indicates the type of physician who rendered the other diagnosis. See Appendix C for a list of valid provider type codes and descriptions.



PRE-D Indicates whether this is a predetermination. The valid values for this field are:

Y - Yes

Blank - No

DRUGS ALLOWED/ DENIED

Indicates whether the drug(s) should be allowed. The valid values for this field are:

A - Allowed

D - Denied

RC Indicates the two-digit remark code to use if the drug(s) is denied. See Preference for the specific code.

IV SVCS ALLOWED/ DENIED

Indicates whether IV services should be allowed. The valid values for this field are:

A - Allowed

D - Denied

RC Indicates the two-digit remark code to use if IV services are denied. Refer to Preference for the specific code.



COMMENTS Allows freeform comments for any claims entered in the screen. Comments should relate to procedures in this record, predetermined medical conditions, or medical supplies.

TOPS Contract and Claim Reference Manual August 2005 226 Informational Screens Training & Development

Informational Screens

Overview

This chapter includes descriptions of, procedures to use, and examples of the freeform comments, COB comments, benefits comments, and preexisting comments screens. These screens are the BCI, CCI, FCI, and PII screens. Chapter Topics


• Enrollee comments (COB, benefits, medical, and freeform).

August 2005 TOPS Contract and Claim Reference Manual Training & Development Informational Screens 227

BCI Screen (Benefit Structure Comments)

Overview

The BCI screen allows you to document and track an enrollee’s special benefits with limitations or maximums that the system is unable to track. This screen tracks these types of benefits:

• Chiropractor visits that must be manually tracked • Occupational therapy visits • Physical therapy charges • Routine care

- Well woman exams - Mammograms - Pap smears - Well child exams, immunizations, etc.

• Care approved by United Behavioral Health • Rental versus purchase information for durable medical

equipment • Drug allowances • R&C for chemotherapy • Transplant Unit information (uses the last four lines of

the BCI to document transplant information) • Other policy specific benefits which are not automated

This screen contains the following information: A description of benefits

• Claim number • Dates of service • Claimed and paid dollar amounts • Comments


Before you begin working with the BCI screen, be aware that:

• Only one screen is available. • The screen is enrollee specific.


Procedures

Use the procedure that follows when you need to access an enrollee’s special benefits. The BCI screen field descriptions follow the procedure and example.

Accessing the BCI Screen

Complete the steps below to access the BCI screen.



BCI,(Policy#),S(SSN),(First Name),(Rel)


2 Press the Enter key. The system displays any freeform comments that exist for the specified enrollee.


Updating the BCI Screen

Complete the steps in the below to update the BCI screen.


1 Access the BCI screen for a specific enrollee.

Use the procedure to access the BCI screen described earlier.

2 Enter appropriate information as described in the following BCI field descriptions.

3 Change the transaction code from BCI to BCU.

4 Press the Enter key. Saves the benefit comments.

Example

This example illustrates the BCI screen.

BCI,123456,S123456789,MARIE,EE,



BCI Screen Field Descriptions

The following table lists the BCI field descriptions.


BEN DES Type of benefit the comments are about.

CLM Claim number used for claim payment for this benefit.

DX Contains the primary diagnosis on the claim.

FRM First date of service on the claim. The format of this field is mmddyy.

TO Last date of service on the claim. The format of this field is mmddyy.

CHARGE Dollar amount charged for the claim.

NBR Number of services on the claim.

PAID Dollar amount paid for the claim.

MISC Any freeform information on the benefit.

NAME Contains the enrollee’s last name.

ADDR Contains the enrollee’s address.

CITY Contains the enrollee’s city of residence.

ST Contains the enrollee’s two-character state of residence code.


CCI Screen (COB Comments)

Overview

The CCI screen serves as a repository for information on other insurance or relevant coverage for an employee and his or her dependents. This screen contains the following information:

• Other insurance demographic information • Dependents covered under the other insurance • Dates • Benefits • Comments Customer service representatives and benefit specialists find this screen useful in researching coordination of benefits. Procedures

Use the procedures that follow when you need to work with the CCI screen. The CCI screen field descriptions follow the procedures and example. Accessing the CCI screen

Complete the steps below to access the CCI screen.


1 Enter

CCI,(Policy#),S(SSN)


2 Press the Enter key. The system displays any freeform COB comments that exist for the specified enrollee.

Documenting COB Information

Complete the steps below to document COB information:



1 Access the CCI screen. Use the procedure to access the CCI screen described above. The system displays any freeform COB comments that exist for the specified enrollee.

2 Change CCI to CCU.

3 Type any applicable COB information.

The system displays what you enter.

4 Press the Enter key twice. The system saves the comments you just entered.


Example

This example illustrates a CCI screen.

CCI Screen Field Descriptions

The CCI screen has three sections:

• Other Insurance contains information about the insurance and employer.

• Benefits contains any special instructions or coverage for the other insurance. For example, if the other insurance does not cover prescriptions, this information is located here.

• Comments contains any other freeform comments.

CCI,123456,S123456789,DONALD,EE,0001234567



The following table lists the Other Insurance section field descriptions.

Field This Field . . . First line: INS CO ADDR CITY ST ZIP ATTN PHONE EFF DATE COVERED

Contains the name of the specified enrollee’s other insurance company. Contains the street address of the specified enrollee’s other carrier. Contains the city of the specified enrollee’s other carrier. Contains the two-letter state code for the specified enrollee’s other carrier. Contains the five- or nine-digit zip code of the specified enrollee’s other carrier. Identifies the contact person at the specified enrollee’s other carrier. Contains the telephone number of the specified enrollee’s other carrier. Indicates the effective date of insurance coverage with the other carrier. Indicates who is covered by other insurance; may be a combination of the following values: • SP (Spouse) • ALL DP (All dependents) • OTHER (All dependents including

stepchildren/grandchildren) • Blank or N (Spouse/dependents not

covered by carrier) • Y (Spouse/dependents covered by other

carrier)


Field This Field . . . Second line: EMPLOYER ADDR CITY ST ZIP ATTN PHONE POLICY

Contains the name of employer through which other coverage is carried. Contains the street address of the employer. Contains the employer’s city. Contains the employer’s two-character state code. Contains the employer’s five-digit zip code. Contains the name of the employer’s contact person. Contains the employer’s telephone number. Contains the policy number of the other insurance carrier.

This table contains the field descriptions for the Benefits section.

Field This Field . . . DATE Indicates the date of benefit comments entry.


BENEFITS Contains freeform comments regarding special instructions or coverage for the other insurance.


The following table contains field descriptions for the Comments section.

Field This Field . . . DATE Indicates the date of benefit comments entry.


COMMENTS Contains freeform comments related to COB benefits.


FCI Screen (Freeform Comments)

Overview

The FCI screen documents information regarding an enrollee’s record. Examples of information that might be documented are:

• Accident information • Special instructions for processing a claim • Student eligibility

This screen contains the following:

• Comments entry dates • Comments • Enrollee’s name and address


Before you begin working with the FCI screen, be aware that:

• The information on the first line of the FCI screen appears on the MHI, MPI, MDI, MRI, and MNI screens. This information appears on the first line below the control line on each of these screens.

• Information vital to claim processing or an alert to view the FCI screen should be entered on this line. For example, a “C/FCI” on the first line of the FCI screen indicates that the claims processor should view the FCI screen before processing a claim.


Procedures

Use the procedures that follow to view or document enrollee comments. The field descriptions follow the procedures and example.

Accessing the FCI Screen

To access the FCI screen, complete the steps below.



FCI,(Policy #),S(SSN) or (Alternate Scheme)


2 Press the Enter key. The system displays any documented comments for the specified enrollee.

Documenting Comments

To document comments, complete the steps below.


1 Access the FCI screen. Use the procedure to access the FCI screen described above. The system displays any comments that already exist for this enrollee.

2 In the top line of the screen, change FCI to FCU.

3 Type any applicable information.

The system displays the text as you type it.

4 Press the Enter key. The system saves the comments you just entered.


Example

This example illustrates the FCI screen.

FCI Screen Field Descriptions

The following table lists the FCI screen field descriptions.


DATE Contains the date a comment was entered.

COMMENTS Contains the comment text.

unlabeled bottom line

Contains the employee’s last name and mailing address.

FCI,123456,S123456789,DONALD,EE,0001234567



PII Screen (Preexisting Investigator)

Overview

The PII screen is specifically intended to document preexisting information regarding an enrollee. Examples of preexisting information are:

• Any steps that are taken during an investigation of a

possible preexisting condition (e.g., letters or phone calls) • Results of an investigation and processing instructions

(e.g., which diagnoses to deny)

This screen contains:

• Comment entry dates • Comments • Enrollee name and address


Before you begin working the PII screen, be aware that:

• The comments are in freeform text and enrollee specific. • If a diagnosis is being questioned regarding possible

preexisting limitations or has been determined to be a preexisting condition, the top line of the FCI screen flags you to view the PII screen before answering calls regarding coverage for that diagnosis for the enrollee.

Procedures

Use the procedures that follow to view or document an enrollee’s preexisting information comments. The screen field descriptions follow the procedures and example.


Accessing the PII Screen

Follow the steps below to access the PII screen.



PII,(Policy #),S(SSN),(First Name),(Rel)


2 Press the Enter key. The system displays any documented preexisting information for the specified enrollee.

Documenting Preexisting Information Comments

To document preexisting information, complete the steps below.


1 Access the PII screen. Use the procedure described above. The system displays any comments that already exist for this enrollee.

2 In the top line of the screen, change PII to PIU.

3 Type any applicable information.

The system displays the text as you type it.

4 Press the Enter key. The system saves the comments you just entered.


Example

This example illustrates the PII screen.

PII Screen Field Descriptions

The following table lists the PII screen field descriptions.


DATE Contains the date a preexisting information was entered.

COMMENTS

Contains the preexisting information text.

unlabeled bottom line

Contains the employee’s last name and mailing address.

PII,123456,S123456789,ANDREA,EE,


August 2005 TOPS Contract and Claim Reference Manual Training & Development Provider Screens 243

Provider Screens

Overview

This chapter includes descriptions of, procedures to use, and examples of the screens that contain provider information, such as provider demographics, tax identification numbers, IPA information, and contract information. The provider screens are PHI, PMI, PAI, PRI, IPI, and NAI. Chapter Topics


• Provider information • IPA information • PCP information

TOPS Contract and Claim Reference Manual August 2005 244 Provider Screens Training & Development

PHI Screen (Primary Care Physician History)

Overview

The PHI screen lists a history of past and current PCPs for a specific enrollee. Before You Work with This Screen

Before you work with the PHI screen, be aware that:

• You may access the PHI screen from the CEI screen by entering a “P” in the Select field.

• You should know the Social Security number of the enrollee whose record you want to access.

Procedures

Use the procedure that follows to locate enrollee information. The screen field descriptions follow the procedure and example.

Accessing the PHI Screen

To access the PHI screen, complete the steps below.



PHI,(Policy #),S(SSN),(First Name),(Rel)


2 Press the Enter key. The system displays the PCPs for the enrollee specified.


Example

This example illustrates a PHI screen.

PHI,123456,S123456789,DONALD,EE


PHI Screen Field Descriptions

The following table lists the PHI fields and contains descriptions of each field.


AV Contains a one-character identifier that indicates how the provider was chosen. The valid values for this field are:

A - PCP was assigned to the enrollee.

V - Enrollee has chosen the PCP voluntarily.

TIN Displays the PCP’s ten-digit prefix and Social Security or Tax Identification number.

SUF Displays the three-digit suffix number of the PCP. The suffix is the specific identifier for the provider under this particular TIN.

PROVIDER NAME

Displays the text of the provider’s name.

ENROLLEE MARKET

Displays the seven-digit state and geographic area in which the provider and IPA is located.

MBR IPA Displays the five-digit PCP’s and associated enrollee’s IPA number.

EFF DT Displays the date the PCP became effective for the enrollee. The format of this field is mmddyy.



CAN DT Displays the date that the PCP was no longer effective for the enrollee. The format of this field is mmddyy. Six nines indicates the PCP is still active for the enrollee.

LAST UPD DT

Displays the date the information in this record was last updated. The format of this field is mmddyy.


PMI Screen (Provider Maintenance)

Overview

The PMI screen displays detailed information about a specific health care professional or facility. This information can influence claims processing and benefit payments. This screen contains the following provider information:

• Demographics • PPO status • Specialty


Before you begin working with the PMI screen, be aware that:

• Two rows of freeform comments can appear above the message line. They may relate to any special paying instructions, savings agreements, or security information.

• The search is quicker if you know the provider’s tax identifier.

Procedures

Use the procedure that follows whenever you need to access detailed information about a specific provider. The PMI field descriptions follow the procedure and example.


Accessing the PMI Screen

To access information in the PMI screen, complete the steps in the following table.



PMI,(Prefix and TIN or Alternate Scheme)

Remember to include the one-digit prefix before the provider’s TIN. For TIN, the prefix is 2.


The PMI screen will be displayed.

Example

This example illustrates the PMI screen.


PMI Screen Field Descriptions

There are four sections on the PMI screen: • Header/site information • Specific provider information • Suffix list • Comments

This table lists the field descriptions within the Header/Site section.


TIN# Displays the nine-digit TIN of the provider preceded by a one-digit prefix to indicate the type of TIN.

The most commonly used prefix values assigned by EPD are:

• 0 - Pseudo TIN • 1 - Social Security number • 2 - Employer ID or Tax Identification

Number (EIN or TIN) • 3 - Special payee

• 8 - Identification for suffixes 1001-1999

SUF Displays the three-digit suffix of the specific provider used to distinguish that provider from multiple providers using the same TIN and/or a provider with multiple addresses. The valid values assigned by EPD are from 001 to 999.



FLAG Displays a code if the provider is being “flagged” for reasons from payment instructions to security investigations on the provider. The valid values for this field are: • 1-9 - Provider flags • A-O - Fraud and abuse flags

See Appendix G for a comprehensive list of flag codes, descriptions, and instructions for claims processors.

LAST UPD Indicates the last date that the provider’s

record was updated. The format of this field is mm dd yyyy.

ADDR IND Identifies the one-character source of an address change. The valid values for this field are: • M - Manually updated for correction

notification, other than Post Office • P - Manually updated for correction

notification from the Post Office • T - Tape or diskette update from provider

files



PRD Identifies the three-character products that the provider or IPA offers. The valid values for this field are: • HMO

• EPO

• PPO

• POS

• ALL

• USB

• IND



TY Contains the two-digit market type used to identify the level of control in a network. The valid values for this field are:

00 - Default, Wide Access or Blank

01 - Medicaid

02 - Medicare

03 - Worker’s Compensation (not used)

04 - Small Access

20 - Parallel Wide Access, Gatekeeper, Commercial

50 - Open Access, Commercial

51 - Medicaid Open Access

52 - Medicare Open Access

54 - Small Access

70 - Parallel, Commercial See Appendix M to see how market types are associated with the product lines.

MARKET Identifies the seven-digit state and geographic area in which the provider or IPA is located.

IPA Identifies the Independent Practice Association (IPA) entity or affiliation of the provider.


This table lists the field descriptions within the Specific Provider Information section.


NAME Contains the text of the provider’s name.

ADDR2 Contains the “Care Of” information from EPD.

ADDR Contains the text of the billing or combination billing/place of service address of the provider.

CITY Contains the text of the provider’s city.

ST Contains the two-character provider’s state code.

ZIP Contains the five- or nine-digit zip code of the provider.

TELE# Contains the ten-digit telephone number of the provider.

REMIT ADD This field is not used.

EOB NAME Contains the first initial and last name of the provider.

BANK ID This field is not currently used.

ACCT# This field is not currently used.



BLK PAY Contains the bulk pay indicator which indicates if a prompt payment discount (PPD) was negotiated and/or state mandated and if it applies to inpatient and/or outpatient services. The valid values for this field are:

B - Inpatient Hospital negotiated PPD.

C - Outpatient Hospital negotiated PPD.

D - State mandated inpatient hospital PPD.

E - State mandated outpatient hospital PPD.

F - State mandated but solicited and negotiated inpatient discount.

G - State mandated but solicited and negotiated outpatient discount.

H - Negotiated on a policy by policy basis inpatient.

I - Negotiated on a policy by policy basis outpatient.

J - Inpatient & Outpatient negotiated PPD.

K - State mandated inpatient and outpatient discount.

MX Medicare exclusion indicator (if Medicare payments are excluded from prompt payment discounts). This field is not currently used.

M CDE This field is not currently used.



TYPE Contains the two-digit provider code to indicate the type of provider. See Appendix C for a list of valid provider type codes and descriptions.

STAT Indicates the provider’s status code, which is often used in conjunction with the flag field to prevent or restrict payments. The valid values for this field are:

Blank - Active provider

A - Surcharge provider located in New York

B - Surcharge provider located outside New York

D - Deceased

F - Indicates Massachusetts surcharge in effect on this facility

I - Inactive

K - Limited certification (Catch all status code)

L - Outstanding tax issue or legal problem

M - Moved

N - Nonprovider

R - Retired

S - Special payee (not a provider of services)

T - Termination of business



EFF DATE Contains the date that the status became effective or last updated. The format of this field is mm dd yyyy.

PCP Indicates if the provider is a PCP The valid values for this field are:

Y - Provider is a PCP.

N - Provider is not a PCP.

FAC ID (Medicare No.)

This field will contain 99999 for hospitals.

COAL ID This field is not used.

SPEC CD Contains the provider’s primary specialty code. See the codes in Appendix J.

HOSP CD Indicates if a facility is qualified for payment. The valid values for this field are:

YYYYY (qualifies for payment)

NNNNN (does not qualify for payment

FAC CD This field is not currently used.



PPO NO Indicates if provider is or was a contracted provider. The valid values for this field are:

Y - Provider is or was a contracted provider

Blank or N - Provider is not currently and has never been a network contracted provider

EMC Contains the code found on NEIC (National Electronic Information Corporation ) bills to indicate the provider is/was participating in NEIC. This field is not currently used.

EMC EFF DATE

Contains the date that the provider began participating in NEIC. The format of this field is mm dd yyyy. This field is not currently used.

EMC CANC DATE

Contains the date that the provider stopped participating in NEIC. The format of this field is mm dd yyyy. This field is not currently used.

VER DATE Contains the last date that the file was updated. The format of this field is mm dd yyyy.



DOC Contains the operator ID number of the person that last updated the file.

HMO/SSO CD

This field is not currently used.

BATCH This field is not currently used.

SP CD This field is not currently used.

This table lists the field descriptions within the Suffix list.


NAME Contains the text of the provider’s name.

SU Displays the three-digit suffix of the specific provider used to distinguish that provider from multiple providers using the same TIN and/or a provider with multiple addresses. The valid values are from 001 to 999.

Note: The comments at the bottom of the screen are the first two lines of the General comments entered in EPD.


PAI Screen (Provider Alpha Search)

Overview

The PAI screen displays providers and suffixes under a specific TIN or displays providers that match an alternate scheme. Before You Work with This Screen

Before you begin working with the PAI screen, be aware that:

• You are not allowed to pick a specific provider when accessing this screen directly. If you are a claims processor, you may get routed to the PAI screen where you can select a specific provider.

• Suffix information on the PAI screen is easier to find than the suffix information displayed at the bottom of the PMI screen.

• To learn about alternate schemes for providers, see page 22.

• To find a particular provider, you must either have a TIN or an alternate scheme.

Procedures

Use the procedure that follows whenever you need to locate a specific provider. The PAI field descriptions follow the procedure and example.


Accessing the PAI Screen

Complete the steps below to accessthe PAI screen.



PAI,(Prefix and TIN or Alternate Scheme)

Remember to include the one-digit prefix before the provider’s TIN.

2 Press the Enter key. The PAI screen appears.

3 If the message “MORE PROVIDERS” appears at the lower left corner, enter the next suffix in the SUF 1 field to scroll to the next screen and press the Enter key.

The next page of the PAI screen appears.

Example

This example illustrates the PAI screen.


PAI Screen Field Descriptions

The following table lists the PAI field descriptions of each field.


SUF 1 Allows you to scroll to the next page by entering the next three-digit suffix following the one at the end of the page.

SUF 2 Used by claims processors if there was a second provider TIN in the control line..

A Used by claims processors to select providers.

# Indicates if the suffix displayed is attached to the first or second TIN in the control line if multiple TINS are entered in the control line. The valid values are either a 1 or a 2.

TIN # Displays the provider TIN which the suffix is attached to.

SUF Displays the suffix of the provider’s TIN.

NAME Displays the provider’s name. Asterisks will follow the provider’s name if the provider is inactive.

ADDRESS Displays the provider’s billing address.

CITY Displays the provider’s city connected with the billing address.

ST Displays the provider’s state connected with the billing address.




P Indicates the proivder’s network/PCP status. The valid values are: • YY - The provider is or has been in the

network and is or has been a PCP. • YN - The provider is or has been in the

network but has never been a PCP. • NN - The provider has never been in the

Network; therefore, the provider cannot be a PCP.

• -N - The provider’s network status has never been investigated; therefore, the provider cannot be a PCP.

TY Displays the two-character provider code to

indicate the type of provider. See Appendix C for a list of valid provider type codes and descriptions.


PRI Screen (Provider Association File)

Overview

The PRI Screen is primarily used to display contract information for a specific Prefix/TIN/Suffix, and to determine pertinent claim information based on information displayed in the Facility Contract field. Information displayed on this screen includes: • Product • Market type • Market Number • IPA • Group Table Number • Contract Arrangement • Contract effective and expiration dates • Code indicating whether the product is active or canceled • Facility contract code indicating whether the claim details

are sent to the EPD rate tables (Exclusion, I-Rate and DRG or new EPD Service Category, O-Rate Table) or to the TOPS rate tables (PPI, PXI, DPI, DRI, CRI, NXI and EPD Service Category, O-Rate Table).


Before you begin working with PRI screen, be aware that:

• You must know the prefix, tax identifier (Social Security or Tax Identification number), and suffix of the provider whose products you are accessing.


Procedures

Use the procedure that follows to locate provider product information. The screen field descriptions follow the procedure and example.

Accessing the PRI Screen

To access the PRI screen, complete the steps below.



PRI,(Prefix,TIN,Suffix)


2 Press the Enter key. The system displays current and historical contracted product information for the specified provider.

Example

This example illustrates a PRI screen with information shown.


PRI Screen Field Descriptions

The following table lists the PRI fields and contains descriptions of each field.

Field Description PRD Product code for which the provider is contracted

for a particular UHC Health Plan, CSP or other contracting entity of UHG. Valid values are: • EPO • POS • HMO • PPO • IND - Indemnity • ALL – used for CSP/GSP, National Ancillary,

NDM Master PPI records

TYPE Code, if any, indicating the Market Type the provider is part of. Common values seen are: 00 – Personal Physician, Commerical Business (standard), Select/Select Plus. Also used for Options PPO and identification of National Ancillaries, SSP and CSPs. 50 – Choice/Choice Plus. Other less common values are: 04 – Restricted Access, Select, Select Plus 20 – Parallel Network, Select, Select Plus or PPO 55 – Rhapsody 70 – Parallel Network, Choice or Choice Plus. See Appendix M to see how market types are associated with the product lines.

For a complete listing of Market Types, go to to Network Data Management web site on Frontier.


Field Description

MARKET Market Number (seven digits) representing a service area for a given Health Plan. It “owns” a unique set of zip codes.

The market number will be displayed if the provider is contracted for this specific TIN/Suffix

All products and the effective/ cancellation information can be viewed on the PRI record.

Note: The market number differs between TOPS and EPD. EPD utilizes the state code and the three-digit market code when identifying the market number. TOPS utilizes the three-digit market code only. For example, For North Carolina, the market number in EPD is 32540; 32 is the state code; and 540 is the actual market code which would be used in TOPS.

Customer Specific Provider Networks are frequently loaded to TOPS as 4 digits, where the first digit is a 9. To see the latest market chart, click on the link below.

Market Chart

IPA Provider’s IPA number (if applicable). This is usually not used for Facilities or Ancillaries.

IPA represents a “grouping” of providers; either a contracted legal entity; where the contracted providers have a legal relationship with each other, or it may represent a way that market staff have grouped individually contracted providers together because of similar reimbursement, county or location. IPA is an EPD/UNET system structure used primarily for Choice, Choice Plus, Select or Select Plus, though an IPA may be used for ancillaries and hospitals as well.

http://uniprisefp.uhc.com/technologies/provider/Products/Reports/page_report_market_chart.htm


Field Description

GROUP TAB # Contains a group table number if the provider or group has two sets of rates (if applicable).

Note: Normally, this field is blank. If a policyholder is part of a provider’s special package rates, the policyholder’s Group Table # (in their policymaster) corresponds to this Group Tab #.

This is not currently used in TOPS.


Field Description

CA Code indicating contract arrangement.

Valid values are:

• Blank or 0 – provider is participating for any UHC member nationally

• 1 - Customer Sponsored Provider network (CSP)

• 2 - Market type specific, Customers must match provider's market type and products.

• 3 – National reciprocity, Members must match provider of service's market, market type, and products.

• 4 – Non–national reciprocity, Members must match provider of service's market, market type, and products.

• 5 – National, Customers of rival vendors cannot access network providers.

The contract arrangement can be used for HMO (H), EPO (E) and POS (P) delivery systems but not for PPO (O), National Ancillary (A) and Indemnity (I) delivery systems. Note: Contract Arrangement is used in certain situations where there is a need to limit the availability of the provider's rates to certain membership or customers only. While EPD allows 5 different values in this field, only one value, "4" is ever used or found on TOPS.

EFF DATE Effective date of the new timelined data, displayed in month, day, year (MMDDYYYY) format.


Field Description

CANCEL DATE Date the product has been canceled, displayed in month, day, year (MMDDYYYY) format. Note: If no cancel date applies, 99999999 will be displayed in this field.

ACT/CAN Code indicating contract status. A = Active; C = Canceled.

FACILITY CONTR

Code (one character) indicating what types of contracting methods are applicable to the PPI. • I - Irate only

• O - Orate only with old Input without PXI

• Z - Orate only with old Input with PXI

• B – Both Irate and Orate

• Y – Old revenue code processing applies

• Blank – Old revenue code processing does not apply

If the FACILITY CONTR field equals B or I, then the contract has been loaded on the new Irate and new revenue code translations are required to determine rates and process the claim.

If the FACILITY CONTR field equals O, Z or B, then the contract has been loaded on the new Orate and new revenue code translations are required to determine rates and process the claim. If the FACILITY CONTR field equals Y or Blank, then old revenue code translation and processing applies.


IPI Screen (IPA General Display)

Overview

The IPI screen displays demographic and payment information for an IPA. Information maintenance occurs through EPD. This screen contains the following information:

• Provider name and address • Products offered • Referral • Claims • Capitation

Before You Work With This Screen

Before you begin working with the IPI screen, be aware that:

• You should know the product, market type, market, and IPA in order to access information.


Procedures

Use the procedure that follows to locate IPA information. The screen field descriptions follow the procedure and example.

Accessing the IPI Screen

To access the IPI screen, complete the steps below.



IPI,(Product),(Market Type) (Market),(IPA)


2 Press the Enter key. The system displays the information about the specific IPA accessed.

Example

This example illustrates an IPI screen.


IPI Screen Field Descriptions

The IPI screen contains four sections:

• IPA demographic information • Referral information • Claims information • Capitation information

This table lists the IPI field descriptions for the IPA demographic section.


NAME Displays the name of the IPA.

ADD1/ADD2 Displays one or two address lines of the IPA.

CITY Displays the IPA’s city.

ST Displays the IPA’s two-character state code.

ZIP Displays the IPA’s five- or nine-digit zip code.

ADMIN PHONE

Displays the ten-digit administration phone number of the IPA.

CLAIM PHONE

Displays the ten-digit phone number of the claims office.

PRODUCTS Indicates valid products for IPA capitation arrangements.



The valid values are:

H - HMO

M - HMO plus

P - POS

E - EPO

• O - PPO

I - Indemnity

IPA TYPE Displays the IPA type. The valid values are:

A - Legal IPA

G - Grouping of physicians

H - PHO or hospital based physicians

L - Locations driven (county, city, zip) TOPS does not use this field.


This table lists the field descriptions for the referral section.


MBR NETWORK KEY

Indicates, in conjunction with the Y-coded table, how to pay claims. The valid values for these fields are:

• C - Indicates contiguous markets so Y-coded procedures can be processed in network without an notification if the enrollee and provider PRODUCT, CONTIGUOUS MARKETS, and MARKET TYPE match.

• M - Use the Y-coded table (no prior notification needed) if the enrollee and provider PRODUCT and MARKET TYPE match.

• T - Use the Y-coded table (no prior notification needed) if the enrollee and provider PRODUCT, MARKET TYPE, and MARKET NUMBER match.

• I - Use the Y-coded table (no prior notification needed) if the enrollee and provider PRODUCT, MARKET TYPE, MARKET NUMBER, and IPA match.

• I - Use the Y-coded table (no prior notification needed) if the enrollee and provider PRODUCT, MARKET TYPE, and MARKET NUMBER match and if the provider type is ancillary or facility.

• P - Use the Y-coded table (no prior notification needed) if the enrollee and provider PRODUCT, MARKET TYPE, MARKET NUMBER, and IPA match. This is used for California networks and PHOs.



LOCK COV PCR/AUTH SEARCH PERIOD

Not supported after 1/1/96.

IPA SELF REF

Indicates if specialists in the same IPA as the enrollee’s PCP can render care without an notification. The valid value when applicable is S.

This table lists the field descriptions in the claims section.


FILING LIMIT

Displays the number of days contract providers within the IPA must file claims for reimbursement.

Note: TOPS does not use this field.

PCP GRACE PERIOD


OON CONTRACT



This table lists field descriptions in the capitation section.


CAP MODEL Indicates the capitation pay method. The valid values for this field are:

I - IPA capitation

H - PHO capitation

P - Direct PCP capitation

S - Specialty capitation

T - Direct PCP with phase-in capitation

K - Specialty & IPA capitation

L - Specialty & PHO capitation

M - Specialty & direct PCP capitation

N - Speciality capitation and direct PCP capitation with phase-in

Note: TOPS does not currently use this field.

CAP PAY METHOD

Indicates the capitation payment method for the IPA. The valid values for this field are:

D - Delegated claim/notification

T - TPA claim/notification

E - Encounter

P - Risk pool

B - Both delegated & TPA claim/notification

M - TAP capitation

CAP CON Indicates valid products for the capitation arrangement.



The valid values for this field are:

H - HMO

M - HMO plus

P - POS

E - EPO/NPP

O - PPO

I - Indemnity

A - All contracts

OON POOL Indicates, for the HMO+ product, whether the risk pool contains out of network benefits. The valid values for this field are:

Y - Yes

N - No

OON CAP PROCESS

Indicates, for the HMO+ product, whether the capitation process includes out of network benefits. The valid values for this field are:

Y - Do not capitate out of network claims

N - Capitate out of network claims

C - Standard capitation applies



PROV TPA Indicates if United HealthCare is the TPA for the IPA. The valid values for this field are:

Y - Yes

N - No

IPA GRP Contains banking information.


IPA BLK Contains banking information.



NAI Screen (Table of Notifications/Capitations/Withholds)

Overview

The NAI screen lists services covered in a PCP’s monthly capitation reimbursement. It also lists network PCP and specialist precovered services, which do not require that the system check service notification, as well as Y-coded services, which do not require a referral notification.

The screen contains the following:

• Notification exceptions • Capitation information • NEI table information • Dollar tolerances


Before you begin working with the NAI screen, be aware that:

• TOPS reads this screen to determine the correct notification, capitation, and withhold tables to access, if applicable.

• You should know the provider’s TIN and suffix, product, market type, market, or IPA in order to access information on this screen.

Procedures

Use the procedure that follows whenever you need to access capitation notifications or withholds information. The NAI field descriptions follow the procedure and example.


Accessing the NAI Screen

Complete the steps below to access the NAI screen.



NAI,(Prefix,TIN,Suffix), (Product),(Market Type), (Market #),(IPA)



The NAI screen appears.

Example

This example illustrates the NAI screen.


NAI Screen Field Descriptions

The NAI screen consists of three sections:

• Dollar Tolerance • Notification Exceptions • Capitation Information


The table that follows contains the field descriptions within the Dollar Tolerance section.


LST UPDATE Indicates date the record was last updated. The format of this field is mmddyyyy.

DOLLAR TOLERANCE

Specifies the dollar limit for which no referral is required for Y-coded services when a network MD or DO renders those services.

The table that follows contains the field descriptions within the Notification Exceptions section. This section contains information on the precovered (Y-coded) services.


EFF Contains the effective date of the table specified on each line. The format of this field is mmddyyyy.

CANC Contains the cancellation date of the table specified on each line. The format of this field is mmddyyyy.

TABLE Displays the five-digit NEI table number for the requested provider.

PAR Indicates whether a CCS (PARS) referral is required. The valid values for this field are:

Y - Yes, a referral is required.

N - No, a referral is not required.


The table that follows contains the field descriptions within the Capitation Information section, which contains information from the tables that specify the services paid at a flat rate.


EFF Contains the effective date of the table specified on each line. The format of this field is mmddyyyy.

CANC Contains the cancellation date of the table specified on each line. The format of this field is mmddyyyy.

PHASE IN Contains no values at this time.

CAP EXC Contains no values at this time.

August 2005 TOPS Contract and Claim Reference Manual Training & Development Negotiated Rates 285

Negotiated Rates Screens

Overview

This chapter includes descriptions of, procedures to use, and examples of the screens that contain participating provider rates, surgery rates, factors, case rates, DRG rates, and exception tables. These screens are PPI, ETI, FSI, RCI, FXI, PXI, DPI, DRI, NXI, SGI, CRI, OCI and IRI. Learning Objectives

This chapter teaches you to:

• Identify rate information and rate pointers for specific providers.

• Access schedule and table information. • Access EPD hard $ schedule information.

TOPS Contract and Claim Reference Manual August 2005 286 Negotiated Rates Screens Training & Development

PPI Screen (PPO Provider)

Overview

The PPI screen identifies, by provider, rate information and rate pointers to various other files, such as:

• Schedule file • Factor file • Surgical case rate file, • Stop loss/threshold exception file • EPD Inpatient Rate (I-Rate) file • EPD Exclusion file • EPD DRG file • Room and board revenue code file

Rate information and pointers can vary by service type categories, and the overall record can vary by:

• Product • Market type • Market • IPA

Use this screen to determine how a claim should be paid. Before You Work with This Screen


• You should use the IPA if associated with the provider. • Hospitals negotiate rates yearly so multiple pages of the PPI

with different contract effective and cancellation dates can exist.

• It is necessary to verify the effective and cancellation date of the record being viewed.

• All of the information needed to build the PPI control line is accessible on the PMI screen.


Procedures

Use the procedure that follows to locate negotiated rate information for a provider. The screen field descriptions follow the procedure and example.


Accessing the PPI Screen

Complete the steps below to access the PPI screen.



PPI,(Prefix/TIN/Suffix), (Product),(Market Type),(Market #),(IPA) or If there is no market type, enter

PPI,(Prefix/TIN/Suffix), (Product),,(Market #),(IPA) or If there is no market number or IPA number, enter

PPI,(Prefix/TIN/Suffix), (Product),,(Market #)


2 Press the Enter key. The system displays the specified physician or facility contract information.

Note: You can add DOS to the end of the Control Line once the PPI Screen is displayed. This will ensure that you have the correct date of service information.


Examples:

This example shows a PPI screen for a physician.

This example illustrates a PPI screen for a facility.


PPI Screen Field Descriptions

Field Description LST UPD Date that information was last updated on this

screen, displayed by the system in month, day, year (MM DD YYYY) format.

OPER ID Number (six characters) that identifies the operator who last updated this screen.

CONT ARRNG One-digit code indicating how the contract can be used between the members and the providers. The Contract Arrangement defines the scope & terms of access our customers have to this provider. The Contract Arrangement is used in certain situations where there is a need to limit the availability of the provider's rates to certain membership or customers only. While EPD allows five different values in this field, only one value, 4 is ever used or found on TOPS. Listed below are the valid contract arrangement codes and descriptions.

0 – Standard value, rates are available to any member for this product. 1 - Group specific and customer sponsored site providers. Rates are not available to anyone except members for that customer. 2 – Restricts use of the contract to members that match the provider’s market type. This is typically used on restricted access (Market Type = 04 or 54), Medicaid (Market Types 01, 51, 06), Medicare (Market Type 02). Note: This is used for EPD contract lines that have market type 02, 52, 01, 51, 06, 04 and 54.


Field Description

WITHHOLD % Withhold percentage. This field is not currently used.

TABLE Table number (five digits). This field is used in conjunction with the FAC CONTR field to point outpatient and/or inpatient services to an EPD I-Rate and/or O-Rate Table where a callable module will be used to determine how the rates should be calculated. If the FAC CONTR field has a value of I, O or B, the rate table will be displayed in this field. The rate table number is the same number for inpatient and outpatient services.

A/C/D/M Code indicating action that can be taken. A – User can add record. C – User can cancel a record. D – User can deactivate or edit a record. M – User can model a record

MODEL T/S Prefix, Tax Identification Number (TIN) and Suffix information for the provider, used only when modeling a PPI.

(MODEL) PRD Provider’s product information, used only when modeling a PPI.

(MODEL) MRKT

Provider’s market number, used only when modeling a PPI.

(MODEL) TY Provider’s market type, used only when modeling a PPI.

(MODEL) IPA Provider’s Independent Practice Association (IPA) number, used only when modeling a PPI.

(MODEL) # Provider’s group table number, used only when modeling a PPI.

EFF DT Contract effective date, displayed in month, day, year (MM DD YYYY) format.


Field Description

CANC DT Date the contract became inactive, displayed in month, day, year (MM DD YYYY) format. If no cancel date applies to the PPI record, 99 99 9999 will be shown in this field.

OUTLIER AMT Outlier amount or the flat dollar amount that will be used in the calculation of the Outlier Type B calculation. Outlier Type B uses lesser of actual charges or the negotiated amount. If the negotiated amount is less, use the greater of the actual charges multiplied by the outlier percent OR the actual charges minus the outlier amount OR the negotiated rate.

Note: This is used only when the reimbursement type on the DRI is N or Z.

SPI IND Code indicating that this PPI record has Special Processing Instructions (SPI) that cannot be automated. The SPI indicator results in text edits to approvers or instructions to access Preference. Valid Values are: 1335 = Inpatient 1336 = Out-patient 1337 = Inpatient & Out-patient 1344 = SPI Chgs> $30,000 1345 = SPI Chgs> $40,000 Note: This is only a sample of some of the valid values. To retrieve a complete listing of the Valid Values, this can be done in two ways. • See the Preference AIDS Volume 1 index

term W1335) to view all valid SPI indicators

• Hot key on the field into the help function.


Field Description

UP Untimely Payment Period. This field will replace the logic that was associated with the second byte of the RT field for the untimely payment information. This field can only be populated when the FAC CONTR field is O, B, or I.

This is commonly referred to as “Prompt Pay Discount” period. If the network claim was paid within the days indicated, normal in-network processing would apply. If the network claim was paid after these days, the system will allow 100% of the billed allowable charge. Valid Values are: B - 2 Days C - 3 Days E - 4 Days F - 5 Days G - 10 Days T - 15 Days H - 20 Days I - 25 Days U - 30 days V - 60 Days

If…the FAC CONTR field is Y or blank, or PPI contains professional fee schedule reimbursement, or PPI is loaded with a outpatient service categories pointing to a O, B, C, or a number,

Then…the UP field will be blank. The prompt pay/ untimely payment information would be loaded into the second byte of the RT field.


Field Description STOP LOSS AMOUNT

Stop loss amount (six digits) Dollar amounts are indicated in whole dollars. Cents cannot be handled in this field. Amount examples in whole dollars: 125000 = $125,000.00 065000 = $ 65,000.00 For $30,000.50, no data would be entered. The SPI indicator of 1344 (based on $ amount of example) would apply.

This field indicates the outlier/stop loss dollar threshold trigger that is based on global inpatient services. This is when the Health Plan has included in the Hospital agreement a financial risk mitigation method that will be triggered when services reach the trigger. The Billed Allowable Charges on a claim will look at the threshold indicated to verify if the negotiated rates listed on the rate tables would be applied or if the maximum limit had been met. Then TOPS would apply the provider's threshold discount indicated in the STOP LOSS % field. Note: The ETI Screen will store the DRG specific outliers, which are based on either a day or dollar trigger.

Indicate the dollar amount in whole dollars. Cents cannot be handled in this field. Amount in whole dollars: $125,000.00 = 125000 $ 65,000.00 = 065000

$ 30,000.50 = No data would be entered, the SPI indicator of 1344 (based on $ amount of example) with SPI.


Field Description STOP LOSS %

Displays the numerical percentage (three digits) used to calculate the allowable dollar amount once the stop loss amount has been reached.

If the Stop Loss Amount trigger is reached, the claim will calculate the billed allowable services on the claim related to the single confinement at the threshold discount percentage listed in this field. Examples of Percentages: 80% = 080 65% = 065 10.5 % = 105 Note: The STP IND field may also apply to stop loss processing.

FAC CONTR (This field replaces the REV field)

Code (one character) indicating what types of contracting methods are applicable to the PPI. • I - Irate only

• O - Orate only with old Input without PXI

• Z - Orate only with old Input with PXI

• B – Both Irate and Orate

• Y – Old revenue code processing applies

• Blank – Old revenue code processing does not apply

If the FAC CONTR field equals B or I, then the contract has been loaded on the new Irate and new revenue code translations are required to determine rates and process the claim.

If the FAC CONTR field equals O, Z or B, then the contract has been loaded on Orate and new revenue code translations are required to determine rates and process the claim. If the FAC CONTR field equals Y or Blank, then old revenue code translation and processing applies.


Field Description

STP IND Stop Loss Indicator (one-character) used to indicate that additional Stop Loss logic applies. Valid Values are:

• Y – Additional Stop Loss logic exists and can be found on the ETI.

• Blank – No additional Stop Loss logic exists and no ETI exists.

PI HCFA Processing Indicator. Values are blank or Y

SERV TYPE Abbreviation of service type category. The service type category includes a group of service codes. The service type represents a grouping of service codes that are reimbursed to a network provider.

The service types that are indicated on a specific PPI will be based upon the FAC CONTR field and the contracting methods that are applicable to the PPI. For PPIs that have a SERV TYPE indicated when a revenue code or CPT-4 code is received, the front end or sometimes the claim processor will convert the code into a “Service Code”. The service code will then point to a service type on the PPI table for reimbursement instructions. For PPIs that do not have a SERV TYPE indicated the system will send the claim details to the I-Rate or O-Rate table indicated in the TABLE field.

Shown on the following page are valid service types and descriptions. Note: The listings shown may be different for physicians and facilities.


Service

Type Description of Medical Service

ANES Anesthesia Services

ASTSUR Assistant Surgeon Services

CHEMO Chemotherapy Services

DIAL Dialysis Services

EMERG Emergency Room Services

HEAR Hearing Exams and Hearing Aids

HOME Home Health Care Services

IH Inpatient Hospital Services. Includes charges for private room, semi-private room, isolation, intensive care, ward room and other miscellaneous services

IHB Nursery Services

IHM Inpatient Hospital Miscellaneous Medical Services. Includes x-ray, dialysis laboratory, radiation therapy, prescription drugs, intensive care, electrconvulsive therapy, miscellaneous hospital fees and late charges

IHMP Inpatient Hospital Miscellaneous Psychiatric Fees. Includes miscellaneous, x-ray, radiation, drugs, laboratory, dialysis and late charges

IHP Inpatient Hospital Psychiatric Services. Includes private room, semi-private room, isolation, intensive care, ward room and other miscellaneous services.

LAB Laboratory and special diagnostic services


Service


MED Medical Services. Includes convalescent facility visits, home visits, hospital visits, injections, intensive care medical, medical consultation, office visits, outpatient hospital visits, physical medicine and surgical consultation

MEDA Includes emergency medical visits, immunizations, initial visits, pediatrics, regular visits and special visits.

MEDRX Prescription Drugs

MS Medical Supplies

OH Outpatient Miscellaneous Services

OPS Outpatient Miscellaneous Surgical Fees

PAT Pre-admission testing

PREV Immunizations and Preventive Care

PSYVI Inpatient Psychological Services. Includes psychological testing, psychotherapy, family psychotherapy and special therapy.

PSYVO Outpatient Psychological Services. Includes psychological testing, psychotherapy, family psychotherapy and special therapy.

PT Physical Therapy Services

RADIAT Radiation Therapy Services

RN Nursing Services

RX Prescription Drugs

SMS Special Medical Services

SPCH Speech Therapy

SSO Second Surgical Opinion


Service


SURG Surgery

TRANS Transportation and Ambulance Services

XRL X-ray and Nuclear Medicine Services

Note: The following are the service type categories along with the corresponding service code ranges:

• IH - PR, SP, WD, IS, IC, NB, OA

• IHM - MISC, DIA, RAD, XR, LAB, RX, ECT, ICEX (POS: IH, OL, and CL only)

• IHB - NB

• IHP - CAUSE 1 ONLY - PR, SP, WD, IS, IC, NB, OA

• IHMP - CAUSE 1 ONLY - MISC, DIA, RA, XR, LAB, RX (POS: IH, CF, BC and CL only)

• PAT - PAT

• OPS - OPS

• OH - MISC, ECT (POS: OH, OL and AS only)

• EMERG - EMERG

• SURG - 10000(0)

• ASTSUR - 10000(2)

• ANES - 10000(4)

• SSO - 10000(6)

• MED - 90000,90100,90200,90300,90500, 90600 (0 & 1), 97000,90780 and 99160

• MEDA - PEDE, IV, IM, RV, SPV, and EMV

• MEDRX - RX (POS: OF only)

• PREV - 90700, 90750

• SPCH - 92507

• XRL - 70000 & 78000


• LAB - 80000 & 91000

• RADIAT - 77000 & 79000

• DIAL - 90941

• CHEMO - 96500 (formerly 90790)

• RN - RN

• TRANS - TRANS, AMB

• PSYVI - PSYV, FT, SPTH, PSTE, & 90800 (POS: IH, CF, BC, HS, and CL)

• PSYVO - PSYV, FT, SPTH, PSTE, & 90800 (POS: OF, OH, AS, FS, HM & OL)

• HOME - HHC, HHCA

• MS - MS

• PT - PT

• VISION - VI

• DENTAL - DENT

• HEAR - HAD, HEX

• MATERN - AIM

• SMS – 29130

RT The reimbursement type field consists of two characters and will only be populated for the specific service types indicated. The first byte indicates what reimbursement table / type applies to the service type. The second byte indicates if a contract contains an untimely payment provision. This is commonly referred to as “Prompt Pay Discount”. If the network claim were paid within the days indicated, normal in-network processing would apply. If the network claim is paid after these days, the system will allow 100% of the billed allowable charge. Note: It is important to understand that this field will not be used for outpatient nonsurgical and inpatient service types if the FAC CONTR field is populated with I, O or B.


Field Description

RT (continued)

Valid Values for the first byte (can be numeric or an alpha character) are: • O – Orate Processing • S – Fee Schedule Processing • B – Both Orate processing and Fee

Schedule processing apply • P – Percent of Charge • C – Outpatient Surgical Case Rates (CRI

Table) • A – Adjuster Determined. Note: An SPI is

always required when anything is adjuster determined except on a hospital PPI table, no SPI is required for the service types of IHM, IHMP, SURG, ASTSURG and ANES

• R – Lesser of percent of charge or a specific dollar amount (100 % language)

• F – Flat Rate (No 100 % Language) • L – Lesser of percent of charge or fee

schedule amount (professional). • 0 – 9 indicates that DRI Processing applies.

This is to be used only for inpatient service types of IH, IHB and IHP and points the inpatient room and board services to the appropriate DRG version for DRG Grouping. Once the claim has slotted to a DRG number, it will then look for the negotiated rates on the DRI Table. . 1 – 2004 version 0 – 2003 version 9 – 2002 version 8 – 2001 version 7 – 2000 version 6 - 1999 version


RT (Continued)

Valid Values for the second byte are: B - 2 Days C - 3 Days E - 4 Days F - 5 Days G - 10 Days T - 15 Days H - 20 Days I - 25 Days U - 30 days V - 60 Days

When a contract has both ORate and Fee Schedule Processing, a B goes on the service type lines that are to be pointed to the ORate and the S goes on the service type line(s) that are to be pointed to the fee schedule.

When a Hospital provider type has a PPI table loaded with service types of IHM, IHMP, SURG, ASTSURG and ANES, the ‘RT’ will always be an A except when it is a percent of charge contract. No SPI is required for these service types. When a percent of charge contract, the ‘RT’ field will indicate “P” and the actual percent will be indicated in the ‘%’ field.


Field Description

FACTOR % OR $

This field is used in conjunction with the corresponding reimbursement type. Valid values are numeric. The chart below shows the relationship between the RT field and the FACTOR % OR $ field.

If RT contains…

Then…FACTOR % $

L Indicates a fee schedule number that is compared to a percent of charge indicated in the % field. The lesser amount is reimbursed on the claim.

R Indicates a specific dollar amount in this field compared to a percent of charge indicated in the % field. The lesser amount is reimbursed on the claim.

F Indicates a flat rate payment loaded in this field.

O or B Indicates the EPD Orate Table Number.

S Indicates the EPD/UNet Fee Schedule number or Factor number.

C Indicates the CRI Table Number.

The following examples will illustrate how the Factor % or $ field will be completed for the various data depending upon the RT value. O-Rate Table number (RT of O or B)

Ex: #108 00108 00 Fee Schedule (RT of S or L)

Ex: #1332 01332 00 Flat rate (RT of F or R)

Ex: $1500.00 01500 00 CRI table (RT of C) Ex: #30015 30015 00


Field Description SCH NUM The Sch Num field is used in conjunction with

the reimbursement types indicated below. The value in this field will depend on the reimbursement type RT field.

If the RT is numeric, then the number will represent the DRI table number.

If the RT is S, then the number will represent a schedule number to be used to access the scheduled units or values. If 09999 is indicated, the services will call to EPD for reimbursement instructions. The following examples will illustrate how the Sch Num field will be completed for the various data depending upon the RT value. For DRI table number (RT of Numeric

Number) For example, 09718 = 09718 For Fee Schedules that utilize a callable

module, (RT of S) the appropriate input would be 09999. A callable module is when the system will call back to EPD for reimbursement instructions.

% Percentage (three digits) is used in conjunction with the following reimbursement types. P – Percent of billed allowable charges. L – Compares the percent of billed allowable charges to the fee schedule number indicated in the Factor % or $ field and pays the lesser of. R – Compares the percent of billed allowable charges to the specific dollar amount indicated in the Factor % or $ field and pays the lesser of. Examples of Percentages:

80% = 080 65% = 065 10.5 % = 105 85.5 % = 855


Field Description

EXCPT TABLE

Five-digit NXI Table Number. The exception table is indicated on specific service types that have exceptions (carve-outs) to their reimbursement. This occurs when services are to be excluded and processed in addition to other services. For hospital and ancillary provider types when the service types are indicated on the PPI vs using the FAC CONTR field to point to EPD processing, an NXI will usually only apply to Inpatient and Outpatient Surgical Service Types. An outpatient non-surgical carve out exceptions are handled by EPD Service Category and ORate Table logic. When the service types are pointed to EPD rate tables using the FAC CONTR field, the NXI will be only used for the OPS service type for Out-patient Surgical Services exceptions. For physician and other allied health care providers that utilize a fee schedule for reimbursement, the NXI table could apply to any or all PPI service types.


ETI Screen (Outlier/Exclusion Inquiry)

Overview

The ETI Outlier/Exclusion Inquiry screen is used to indicate outlier or exclusions that are not partially or totally identified on the PPI table. The PPI table is only able to automate an outlier when it hits a certain dollar amount to pay a percent of charge. The ETI table is used to indicate inpatient outliers that fall outside the PPI Table. The ETI will also be utilized when there are DRG exceptions and/or exclusions for the outlier processing.

The ETI Screen was designed to automate three processes that were previously handled through Special Processing Instructions on the SPI Screen. These are listed blow. • Allow the exclusion of specific Diagnostic Related Groups

(DRGs) from the Stop Loss process and allow DRGs to have specific Stop Loss amounts assigned.

• Allow Stop Loss Per Diem based on the amount of dollars or days of the confinement.

• Allow Stop Loss to pay based on the lesser of Percent of Charges or Per Diem.

Global Stop Loss is listed on the PPI screen. Services listed on the ETI screen will be excluded from global Stop Loss processing and will be processed per the criteria loaded on this screen.


Accessing the ETI Screen

Complete the steps below to access the ETI screen.

Step Action

1 In the control line, enter ETI,Prefix/TIN/Suffix,Product,Market Type,Market Number,IPA(if applicable)

Note: The product must be entered in three-character format. For example, EPO instead of ‘E. Also, the market number must be entered in TOPS format, without the state code. For example, market 38564 would be entered as 564.

2 Press the Enter key. The ETI in the control line will change to ETN after pressing the ENTER key.

Example

This example illustrates the ETI screen.


ETI Screen Field Descriptions

This table lists the ETI screen fields and their descriptions.

Field Description LAST UPDT Date the ETI screenwas last updated, displayed

in month, day, year (MM/DD/YYYY) format.

OPER ID Identification of the operator who last made changes to this screen.

A Code indicating the action to be performed on the specific line of information. A – Add C – change D – Delete

DRG The applicable three-digit DRG number to which the Stop Loss applies, or, the DRG number that is to be excluded from the general Stop Loss. The absence of a DRG indicates that all DRGs are subject to that line entry.

EFFDT Effective date for the specific Stop Loss entered on that specific line, displayed in month, day, year (MM/DD/YYYY) format. Note: There may be more than one Stop Loss in effect simultaneously. Therefore, you must determine the best match for the claim when it is necessary to do so.

CANCDT Cancellation date for the specific Stop Loss entered on that specific line, displayed in month, day, year (MM/DD/YYYY) format. Note: There may be more than one Stop Loss in effect simultaneously. Therefore, you must determine the best match for the claim when it is necessary to do so.


Field Description

STP IND Code identifying the type of Stop Loss applicable for that particular line. Valid values for this field are:

E – DRG is excluded form Stop Loss processing

D – A dollar threshold applies with a percentage Stop Loss

P – A dollar threshold applies with a per diem Stop Loss

R – A day threshold applies with a per diem Stop Loss

S – There is a day limit with a percentage Stop Loss

B – A dollar limit applies with per diem or percentage Stop Loss, whichever is less

C – A day limit applies with per diem or percentage Stop Loss, whichever is less

T - A dollar limit applies with per diem max or percentage Stop Loss, whichever is less

A – Adjuster determined

DOLLAR THRESH

Dollar amount that is allowed to be billed for a particular confinement before applying a Stop Loss.

Example: $60000 (060000) Note: This field can only be used when the Stop Loss indicator is B, D or P.


Field Description

DAY THRESH Number of days of a particular confinement before a Stop Loss is applied.

Example: 1 (01) Note: This field can only be used when the Stop Loss indicator is C, R or S.

PER DIEM AMT/MAX

Daily rate to be paid if the Stop Loss applies to the threshold limit or DRG on that particular line.

Example: $2100 (002100) Note: When the STP IND field = T, the value in this field will be used as the maximum amount.

STOP % Percentage that is to be applied if the Stop Loss applies to the threshold limit or DRG on that particular line.

Example: 89% (089) Note: This field can only be used when the Stop Loss indicator is B, C, D or S.

Use the table below to determine which fields are necessary for a particular Stop Loss indicator. * = Not DRG specific ** = DRG specific STP IND DRG DOLLAR

THRESH DAY THRESH

PER DIEM AMT

STOP %

A* - X A* - X A** X X A** X X E X D X X X P* X X P** X X X R* X X R** X X X S* X X S** X X X B* X X X B** X X X X C* X X X C** X X X X T* X X X T** X X X X


FSI Screen (EPD Hard $ Schedule)

Overview

With the FSI screen, you can select various criteria and view fee schedule dollar amounts. The information in this screen includes:

• Market number • Fee schedule number • Procedure code plus modifier • Time/units (optional) • Date (optional)


Before you begin working with the FSI screen, be aware that:

• You must know the market number, fee schedule number (PPI or NXI screen), procedure code number and modifier (if appropriate), anesthesia time or units (if appropriate), and the date of service you want to inquire on.

Procedures

Use the procedure that follows to access fee schedule dollar amounts for a procedure code. The screen field descriptions follow the procedure and example. Accessing the FSI Screen

Complete the steps on the following page to access the FSI screen.




FSI,,

2 Press the Enter key. The system displays the FSI screen and allows you enter up to 18 lines of procedure codes.

3 In the MARKET NUMBER field, enter

(Market # for the contract)

The system displays the data as you enter it.

Note: You must enter zeros before the market number to fill the field.

4 In the FEE SCHEDULE field, enter

(Fee Schedule # from FACTOR field on the PPI or NXI screen)


Note: You must enter zeros before the fee schedule to fill the field.

5 In the PROC CD/MOD field, enter

(Numeric Procedure Code into the first five positions and a valid TOPS modifier (if appropriate) into the sixth position)




6 In the TIME/UNITS field, enter

(Anesthesia Time Units for anesthesia procedures)


7 In the DATE field, enter

(Service Date for the information you need)

The system displays the data as you enter it. The format of this field is mmddyyyy.

8 Press the Enter key. The system displays the default percent, fee schedule dollar amount, anesthesia information (if appropriate), and description of procedure code for each line you enter.


Example

This example illustrates the FSI screen.

FSI Screen Field Descriptions

This table lists the FSI screen fields and their descriptions.


MARKET NUMBER

Contains the seven-digit market number.

FEE SCHEDULE

Contains the five-digit fee schedule number.

Obtain the fee schedule number from the FACTOR field on the PPI or NXI screen.

PCT Displays the default percentage for the market and schedule.



PROC CD/MOD

Contains the procedure code and modifier, if appropriate. See Appendix I for a list of surgical modifers and descriptions.

TIME/UNITS Contains the anesthesia time units that you enter for anesthesia procedures.

DATE Contains the date of service. The format of this field is mmddyyyy.

AMOUNT Displays the scheduled amount which is fully calculated for anesthesia and 20 percent for an assistant surgeon.



ERR MESS Displays an error message when appropriate. You may see one of the following error message codes:

• IP - Invalid procedure code

• PC - Procedure not covered, pay code 2

• BR - Refer procedure, pay code 3 or 4

• DM - Procedure deactivated, pay code 5

• CO - Cosmetic, medical class of c

• ND - No schedule value, no default

• SC - No state code found for market

• AD - Code built as adjuster determined on EPD

• MY - Schedule changed from hard to soft dollars and EPD should not be accessed

• CP - Code built on EPD as percent of charge; percent appears in amount as PXXX

• DC - No value on schedule, default is percent of charge, use PCT field

• DR - No value on schedule, default is percent of R&C

• IS - EPD cannot find the schedule requested

ANES BASE Displays the ASA base units for anesthesia.

ANES CONV Displays the conversion factor for anesthesia from the EPD soft dollar screen.

DESCRIPTION Displays the description from the EPD procedure file.


RCI Screen (Reasonable and Customary)

Overview

The RCI screen allows you to retrieve amounts in the Schedule/ Reasonable and Customary file for a specific CPT code. It also allows you to retrieve unit values for specified schedules and dollar conversion factors for anesthesia. Access the Schedule/Reasonable and Customary file for the procedure code indicated and the geographic area table for the zip code indicated.


Before you begin working with the RCI screen, be aware that:

• You need to access the RCI screen before you can access the dollar amount for a specific CPT procedure code.

• You must know whether the CPT procedure code is a medical or dental code, the code number, and the first three digits of the provider’s zip code.

Procedures

Use the procedure that follows to access dollar amounts for a specific CPT procedure code. The screen field descriptions follow the procedure and example. Accessing the RCI Screen

Complete the steps below to access the RCI screen.




RCI,,

2 Press the Enter key. The system displays the RCI screen and allows you enter up to 19 lines of procedure codes.

3 In the M/D field, enter

M for a medical code or

D for a dental code.


4 In the PROC CODE field, enter a numeric procedure code into the first five positions and a valid modifier (if appropriate) into the sixth position.


Note: See the RCI screen field descriptions for additional details on what should be entered.

5 In the ZIP CODE field, enter at least the first three digits of the provider’s zip code.




6 In the PCT field, enter a three-digit percentile rate (e.g., 090) determined by the policy contract to get the current amount from the R & C file.

ter a three-digit unit value (e.g., 062) as identified by the policy contract.


Notes: See the RCI screen field descriptions for additional details on the unit values. To access the R&C allowance for the previous six months, enter a “1” as the first digit of the three-digit value entered in the PCT field. For RCI access to HCPCS schedule 350, use 050 for the current schedule and 150 for the prior one.

7 Press the Enter key. The system displays the dollar amount and zip code range for each line you enter.


RCI Screen Example

This example illustrates the RCI screen.


RCI Screen Field Descriptions

This table lists the RCI screen field descriptions.


M/D Contains the letter “M” for a medical procedure code or “D” for a dental procedure code.

PROC CODE

Contains six characters related to a procedure code. The first five digits represent the procedure code. The sixth position contains a valid modifier if the procedure code is for a surgeon, assistant surgeon, anesthesiologist, second surgical opinion, or consultation. See Appendix I for a list of valid TOPS modifier codes.

ZIP CODE Contains at least the first three digits of the provider’s zip code.



PCT Contains a three-digit percentile rate (e.g., 090) or unit value as determined by the policy contract. The valid unit values are:

• 061 - Market 22502 (Selectcare) Network Allowable

• 062 - Mod. MRBRVS (various conversion factors apply)

• 066 - McGraw Hill units

• 067 - Site 41570 Network Allowable

• 078 - Anesthesia Base units/64 TARVAS (Met Anesth units)

• 079 - Anesthesia Base units/75 TARVS

• 081 - Network units/69 TARVS (XMet managed care units)

• 082 - XTIC Network Units

• 195 - 70th percentile




• 300 - Blue Cross/Blue Shield

• 350 - HCPC Claim Pay Methodology Table

• 399 - 80th percentile (current XTIC R&C)


AMOUNT Displays the dollar amount or units derived from the data entered.

ZIP CODE RANGE

Displays the zip code range applicable to the entered zip code.

Note: The system does not display a zip code for a Canadian provider.

Note: When you enter a 080, 090, 180, or 190 and a CPT code with the “4” TOPS modifier for anesthesia, the system provides the dollar conversion factor for the zip code area.


FXI Screen (Conversion Factor File)

Overview

The FXI screen shows the conversion factors established for certain ranges of procedures. The following items serve as the basis for the monetary factor:

• Zip code • Hospital affiliation • Provider specialty

TOPS reads the factor file after finding a reimbursement type S (Schedule) and factor file number on the PPI.


Before you work with the FXI screen, be aware that:

• You must obtain the three- or four-digit factor file number from the PPI screen.

• You can save time in locating conversion factors if you enter the procedure code.

Procedures

Use the procedure that follows to access conversion factors for ranges of procedures. The screen field descriptions follow the procedure and example.


Accessing the FXI Screen

Complete the steps below to access the FXI screen.


1 Obtain the factor file number on the provider’s PPI screen.

Use the procedure described earlier to access the PPI screen.


FXI,(Factor File #),(Procedure Code--optional)

If you do not specify the procedure code in the control line, the system displays all procedure code ranges and their corresponding conversion factor for the factor file number specified.

3 Press the Enter key. The system displays the conversion factor for the procedure specified.


Example

This example illustrates an exception table.

FXI Screen Field Descriptions

This table lists the descriptions of each field on the FXI screen.


FUNC Allows you to enter a one-character code used to update the FXI screen.

PROC FROM

Displays the five-digit lower limit of the procedure code for this factor.

PROC TO Displays the five-digit upper limit of the procedure code for this factor.

FACTOR Indicates the conversion factor used to calculate the negotiated charge for the procedure code range. The format of this field is nnn nn.


PXI Screen (Room and Board Exception Table)

Overview

The PXI screen, also known as a Room and Board Exception Table, contains a facility’s exceptions to a standard network contract. Not all network facilities have a PXI. If a facility has this table, FAC CONTR field will be “Y”, “Z” or “blank”. Before You Work with This Screen

Before you work with the PXI screen, be aware that:

• Not all network facilities have a PXI screen. • The modifiers associated with the control line are the IPA

indicator and Date (mmyy). • You must know the provider’s tax number, product,

market type, market number, and IPA.

Accessing the PXI Screen

Follow the steps below to access the PXI screen and view a facility’s Room and Board Exception table. The PXI screen field descriptions follow the procedure and example.



PXI,(Prefix,TIN or SSN,Suffix),(Product), (Market Type),(Market #), (IPA)


2 Press the Enter key. The system displays a room and board exception table for the facility listed.


Example

This example illustrates a room and board exception table.

PXI Screen Field Descriptions

This table lists the fields and provides descriptions of each field in a PXI screen.


LST UPDT Displays the last date this screen was updated. The format of this field is mm dd yyyy.



OPER ID Displays the nine-digit operator identification number of the individual who last updated this screen.

unlabeled; followed by: A/ADD, C/CANC, U/UPDATE, M/MODEL

Allows you to specify which action you want to take for the file. The valid values for this field are:

• A - Add

• C - Cancel

• I - Update

• M - Model (copy)

EFF Displays the file’s effective date. The format of this field is mm dd yyyy.

CANC Displays the file’s cancellation date. The format of this field is mm dd yyyy or 99 99 9999 if the record is active (does not have a cancellation date).

MODEL TIN/SUF

TIN/Suffix (12 digits) into which you want to copy the displayed PXI record.



PRD Allows you to enter the three-digit network product identifier to which this file should be copied. The valid values for this field are:

• HMO

• EPO

• PPO

• POS

• ALL

• UBS

• IND



TY

Allows you to enter the two-digit market type used to identify the level of control in a network. The valid values for this field are:

• 00 - Default, or Wide Access

• 01 - Medicaid

• 02 - Medicare

• 03 - Worker’s Compensation (not used)

• 04 - Small Access

• 20 - Parallel Wide Access, Gatekeeper, Commercial

• 50 - Open Access, Commercial

• 51 - Medicaid Open Access

• 52 - Medicare Open Access

• 54 - Small Access

• 70 - Parallel, Commercial See Appendix M to see how market types are associated with the product lines.

MRKT

Allows you to enter the seven-digit market number (state and geographic area) of which the provider is a part of.

IPA

Allows you to enter the provider’s IPA group number.

OUTLIER AMT

Contains the dollar amount at which the contracted rate stops and the outlier percentage applies to the entire confinement.



% Contains the percentage used when the outlier amount has been reached.

EXC DRG Contains a three-digit DRG exception to this file.

REV CDE Displays the three-digit revenue codes on this exception table.

AMOUNT Displays the per diem dollar rate for the revenue code listed.

TYP Indicates the type of reimbursement. The valid values for this field are:

• B - Per Diem (Pays the lesser of the per diem or actual charge.)

• C - Per Diem with Outlier Type A (Outlier A uses the lesser of the actual charge or the negotiated amount. If the negotiated amount is less, it uses the greater of the actual charges multiplied by the outlier percent or the negotiated amount.)

• E - Per Diem with Outlier Type B (Outlier B uses the lesser of the actual charge or the negotiated amount. If the negotiated amount is less, it uses the greater of the actual charges multiplied by the outlier percent or the actual charges minus the outlier amount or the negotiated rate.)

LOS Displays the length of stay limitations.


DPI Screen (DRG Carve-Outs)

Overview

The DRI screen is used to display the DRG “carve-outs” for inpatient hospital contracted rates. TOPS reads this screen once it identifies a number in the DRG field on the PPI screen. This applies to an inpatient service (rate types 0, 9, 8, 7, 6 or 5).

Note: The DRG “carve-outs” will override any room and board exception procedures codes shown on the PXI screen.


Before you work with the DPI screen, be aware that:

• You must know the DRG number to access information in this screen. Find the DRG number in the “DRG” field on the PPI screen.


Procedures

Follow the procedures below to view DRG “carve-outs” on the DPI screen. The DPI screen field descriptions follow the procedure and example.

Accessing the DPI Screen

Follow the steps below to access the DPI screen and view DRG “carve-outs”.



DPI,(DRG Number)


2 Press the Enter key. The system displays all SRG ranges that have been “carved-out” from the contracted DRG schedule.

Example

This example shows a DPI screen with DRG “carve-out” ranges.


DPI Screen Field Descriptions

Descriptions of each field on the DPI screen are shown below.


TABLE NUMBER ASSIGNED

DRG table number.

DRG RANGES

This area will show the range of DRG codes that have been “carved-out”.


DRI Screen (DRG Schedule)

Overview

The DRI screen is used to display the scheduled amounts for each DRG code negotiated with a network DRG or DRG per diem hospital. TOPS reads this screen once it identifies a schedule number on the PPI screen for a DRG reimbursement type. The information on this screen is used when manual calculation of the negotiated rate is necessary. Before You Work with This Screen

Before you work with the DRI screen, be aware that:

• You must know the DRI schedule number to access information in this screen. Find the DRI schedule in the SCH NUM field on the PPI screen.


Accessing the DRI Screen Follow the steps below to display DRI screen and view a DRG schedule. The DRI screen field descriptions follow the procedure and example.



DRI,(DRI Schedule #),(DRG Code—optional)


2 Press the Enter key. The system displays a DRG schedule beginning with the first DRG on the schedule or at the DRG code specified in the control line.


Example

This example illustrates a DRI screen with a DRG schedule.


DRI Screen Field Descriptions

This table lists the descriptions of each field in a DRI screen.


UPDATE CODE

Allows you to enter an update code. The valid values for this field are:

• A – Add

• C – Change

• M – Model

MODEL SCHED #

Allows you to copy the screen contents to a specified schedule number.

DRG Displays the DRG codes listed on the schedule.

AMOUNT Displays the schedule amount negotiated for that DRG code.



TYPE Displays the type of reimbursement. Each schedule can contain a mixture of reimbursement types. The valid values for this field are:

• A – Adjuster determined

• D – Per diem

• N – DRG with outlier Type B

• F – Flat rate with no outlier

• P – Percent of charge

• S – DRG with outlier Type A

• X – Per diem with outlier Type B

• Z – Per diem with outlier Type B

Notes: Outlier Type A uses lesser of actual charges

or the negotiated amount. If the negotiated amount is less, the system uses the greater of the actual charges multiplied by the outlier percent in the Factor % field or the negotiated amount.

Outlier Type B uses lesser of actual charges or the negotiated amount. If the negotiated amount is less, the system uses the greater of the actual charges multiplied by the outlier percent OR the actual charges minus the outlier amount OR the negotiated rate.


NXI Screen (Network Exception Inquiry)

Overview

The NXI screen is used to display the procedures or services that require an “exception”, or a different contracted rate or reimbursement type than is shown on the PPI Screen. The exceptions are carved-out procedure codes from inpatient service types, outpatient surgical service types or fee schedule processing. The NXI Screen will also be used when a provider has services that are split between O-Rate Table processing and Fee Schedule processing. The codes on the NXI screen will point ot the appropriate reimbursement methodology. A provider can have multiple NXI tables when a provider has different reimbursement methodology for inpatient and outpatient surgery exceptions vs. services on a fee schedule where services on the fee schedule need to be pointed to a different reimbursement. Before You Work with This Screen

Before you work with the NXI screen, be aware that:

• You must obtain the exception table number from the PPI screen before you can access the information in this screen.


Accessing an NXI Screen

Follow the steps below to display a network provider’s exception table. The NXI screen field descriptions follow the procedure and example.


1 Obtain the exception table number on the provider’s PPI screen.

The exception table is shown in the EXCPT TABLE field.


NXI,(Table #),(Procedure Code—optional)


3 Press the Enter key. The system displays the exception table for the network provider listed.


Example

This example illustrates an exception table.


NXI Screen Field Descriptions

This table lists the descriptions of each field in an NXI screen.

Field Description LAST UPDT Date the NXI Table was created or last updated,

displayed in month, day, year (MMDDYY) format.

OPER ID Operator number (six digits) identifying the individual who last updated this screen.

(First Field) _

Code indicating the action to be taken on the line indicated. Valid values are A – Add codes and D – Delete codes.

FROM Displays the characters of the first service code in a range of service codes to be excluded from the reimbursement of the Service types indicated on the PPI Screen. The service that is to be carved out will be pointed to a specific reimbursement methodology as indicated in the RB TP field.

Note: There are some special UNet specific alpha codes that are used to point to certain services for a special reimbursement methodology. The most common alpha code is OA (Other Accommodations). This is to be included anytime a contract indicates contractual agreements for Skilled Nursing / Convalescent Facility, Inpatient Rehabilitation and/or Hospice


Field Description

TO Displays the characters of the last service code in a range of service codes to be excluded from the reimbursement of the Service types indicated on the PPI Screen. The service that is to be carved out will be pointed to a specific reimbursement methodology as indicated in the RB TP field.

Note: There are some special UNet specific alpha codes that are used to point to certain services for a special reimbursement methodology. The most common alpha codes are listed below: OA (Other Accommodations). This is to be included anytime a contract indicates contractual agreements for Skilled Nursing / Convalescent Facility, Inpatient Rehabilitation and/or Hospice IC – Facility Inpatient ICU DRI Table

PLACE OF SERVICE (S)

Code indicating the place of service associated with the procedure(s) shown in the FROM and TO fields. A list of place of service codes is shown below. IH – Inpatient Hospital OH – Outpatient Hospital CF – Convalescent Facility OF – Office IL – Independent Lab BC – Birthing Clinic AS – Ambulatory Surgical Facility AT – Alcoholic Treatment Center HM – Home FS – Free Standing Treatment Center RX – Pharmacy or Medical Supplies HS – Hospice SA – Substance Abuse Center OL – Other Locations CL – Clinic

Field Description


PLACE OF SERVICE (S) (continued)

Note: Inpatient Services – The following places of service are associated with services excluded from Inpatient Services: IH, CF, BC, AT, HS, SA, OL, CL. Note: Outpatient Services – The following places of service are associated with services excluded from Outpatient Services: OH, IL, BC, AS, HM, FS, RX, HS, OL, CL

Note: Outpatient Surgery Services – The following places of service are associated with services excluded from Outpatient Surgery Services: OH, AS, OL, CL, FS.

CAUSE Cause codes applicable for the service code range displayed in the FROM and TO fields.

Valid cause codes and descriptions are listed below. A – Accident. This is used to identify an accident claim. The accident must qualify under the policy definition and will prompt the system to generate a special benefit on some policies 0 – General sickness. This is the most commonly used CC and identifies chronic or routine illness. It is used when the type of claim cannot be classified under any other CC. 1 – Psychiatric This CC is used to identify Mental and Nervous claims on all policies assigned to:

-Psychiatric /Family Therapy by psychiatric provider or Psychiatric diagnosis. -Psychiatric Testing Electronic convulsive Therapy Outpatient psychiatric professional services: revenue codes


Field Description

CAUSE (continued)

2 – Normal Maternity. Identifies pregnancy claims. (If complications develop, the CC can be changed.) 3 – Emergency illness. If a plan provides benefits for sudden and serious illness, this CC is used to prompt the system to pay special benefits. 4 – Routine care. If a plan provides special benefits for routine care, this CC will prompt the system to pay special benefits 5 – Complications of pregnancy. Identifies a maternity diagnosis that developed complications 6 – Alcoholism/ Drug abuse. Identifies Psychiatric Therapy for chemical dependency diagnosis that includes the following: • Inpatient visits for chemical dependency

diagnosis • Inpatient hospital charges for chemical

dependency diagnosis where psychiatric services are performed

• Inpatient Alcoholic/ Substance Abuse Treatment Center for chemical dependency diagnosis where psychiatric services are performed.

Additional information can be found in: Preference AIDS volume (F1) At the index prompt type => Cause Codes (for complete list) or At the index prompt type => Cause Codes assigned by EMC (for the cause code and assigned diagnosis list).

U Usage code that indicates if an exception to the procedure code is excluded from the reimbursement rate. Valid Values are: C – Reimbursement rate does not apply to the listed causes. When C is used during the adding of a procedure code it will disappear during inquiry. X – Reimbursement rate excluded from this service. Blank – The reimbursement rate applies to all causes listed.


Field Description

RB TP

The reimbursement type field consists of two characters.

The first byte indicates what reimbursement table / type applies to the service type.

The second byte indicates whether a contract contains prompt payment penalties. An example of this is when a contract has a prompt pay penalty of 30 days, the value will be a 30. If the claim is paid after 30 days of receipt, the system will allow 100% of billed allowable services vs. the negotiated rate. All Valid Values can be found in Preference. Valid Values for the first byte are: O – Orate Processing S – Fee Schedule Processing B – Both Orate processing and Fee Schedule processing apply P – Percent of Charge C – Outpatient Surgical Case Rates (CRI Table) A – Adjuster Determined. An SPI is always required when anything is adjuster determined. The exception to this is on a hospital PPI table, no SPI is required for the service types of IHM, IHMP, SURG, ASTSURG and ANES. R – Lesser of percent of charge or a specific dollar amount (100 % language) F – Flat Rate (No 100 % Language) L – Lesser of percent of charge or fee schedule amount (professional).

Additional values can found in Preference.


Field Description

FACTOR % or $

The Factor % or $ field is used in conjunction with the reimbursement types indicated below. The value in this field will depend on the reimbursement type indicated.

If the RT field is…

Then…

L A fee schedule number in this field is compared to a percent of charge indicated in the % field. The lesser amount is reimbursed on the claim

R A specific dollar amount in this field compared to a percent of charge indicated in the % field. The lesser amount is reimbursed on the claim.

F Flat payment rate is shown in this field.

O or B EPD Orate Table S EPD/UNet Fee Schedule number

or Factor number. C CRI table numbers.

Note: The following xxamples will illustrate how the Factor field will be input for the various data. O-Rate Table number Ex: #108 00108 00 Fee Schedule Ex: #1332 01332 00 Flat Rate (F or R) Ex: $1500.00 01500 00 CRI table Ex: #30015 30015 00 *Required field if RB TP is ‘F’, ‘R’, ‘O’ or ‘S’


Field Description

SCH NUM The SCH NBR field is used in conjunction with the reimbursement types indicated below. The value in this field will depend on the reimbursement type ‘RT’ field.

If the RT field is…

Then…

Numeric Number will represent the DRI number.

S Number will represent a schedule number to be used to access the scheduled units/values.

Note: If 09999 is indicated, the services will call to EPD for reimbursement instructions. If a different schedule number is indicated, see the Knowledge Library for information on how the system will use this information to calculate the older fee schedules in UNet. The following examples will illustrate how the SCH NBR field will be read. • For DRI table number

Ex: # 09718 = 09718 • For Fee Schedules that utilize a callable

module, the appropriate input would be 09999. A callable module is when the system will callback to EPD for reimbursement instructions.

% The Percent field is used in conjunction with the

following reimbursement types indicated.

P – Percent of billed allowable charges.

L – Compares the percent of billed allowable charges to the fee schedule number indicated in the Factor % or $ field and pays the lesser of.

R – Compares the percent of billed allowable charges to the specific dollar amount indicated in the Factor % or $ field and pays the lesser of.


SGI Screen (Surgical Grouper Inquiry)

Overview

The SGI table is used to view the surgical CPT – 4 Procedures Codes and the ASC Grouper the procedure code falls into.

The SGI table does not read the exceptions on the NXI table, it only displays the ASC Grouper number associated with a surgical CPT – 4 Procedure code. This table allows updating on an as needed basis and eliminate the need for storage on Preference.

Accessing the SGI Screen

Follow the steps below to display the SGI screen. The SGI screen field descriptions follow the procedure and example.



SGI,(SGI Table #) The system displays this information as you enter it.

2 Press the Enter key. The system displays a SGI table.


Example

SGI Screen Field Descriptions

Field Description

ALT ID Number identifying the person who created or last updated the SGI table.

A Code indicating the action to be taken on the specific line. A = Add Codes D = Delete Codes

PROC CODE This field indicates the surgical procedure code.

GROUP This field indicates the ASC grouper based on the surgical procedure code displayed.


Field Description

ALL GRP Grouper reimbursement based on groupers 0 – 10 or 1 – 9. The valid values are:

Y – Contracted rates are based on groupers 0 – 10 Blank – Contracted rates are based on groupers 1 – 9

FROM Begin effective date for the procedure code associated with the specific ASC grouper.

TO Cancel date for the procedure code associated with the specific ASC grouper.

LAST UPDATE

Date information was last updated on the SGI screen, displayed in month, day, year (MMDDYYYY) format.


CRI Screen (Case Rate Inquiry)

Overview

The CRI table is used to view the contracted rate for surgical procedure codes that are reimbursed based on an ASC grouper. The CRI table shows the ASC grouper rate and any surgical procedure code exceptions being reimbursed on an individual basis.


Before you work with the CRI screen, be aware that:

• If a case rate calculation applies for a facility, the RT field on the facility’s PPI will contain a C and a CRI table number will be identified in the FACTOR, %, OR $ field.

• There is only one page per CRI table. If the exceptions do not fit on one CRI page, an SPI (Special Processing Instruction) is required.

• Case rate grouping levels are loaded into the SPI Volume of Preference.

Accessing the CRI Screen

Follow the steps below to display the CRI screen. The CRI screen field descriptions follow the procedure and example.



CRI,(CRI Table #)


2 Press the Enter key. The system displays a CRI table.


Example

This example illustrates a CRI screen.


CRI Screen Field Descriptions

This table lists the descriptions of each field in a CRI screen.

Field Description

DEFAULT R Contains the reimbursement type for services that do not fall under a category or exception. The valid values are P = Percent of Charge R = Contracted amount or billed charges, whichever is less F = Flat Dollar Amount

$LIMIT Contains a dollar amount limit if the DEFAULT R field contains an R or F. The examples below show how to read dollar amounts in this field. Example: 01500 = $1500.00 Example: 0400 = $400.00

% Contains a percent of charge if the the DEFAULT R field contains an R or F. The examples below show how to read percentages in this field. Example: 089 = 89% Example: 100 = 100%

MP% (1st surgical procedure)

Multiple procedure percent of charge reimbursement for the first surgical procedure.

MP% (2nd surgical procedure)

Multiple procedure percent of charge reimbursement for the second surgical procedure.


Field Description

MP% (3rd surgical procedure)

Multiple procedure percent of charge reimbursement for the third surgical procedure.

MP CONT Code indicating whether multiple procedure processing continues. Valid values are: Y – Continue processing multiple procedure logic Blank – Do not continue processing multiple procedure logic

UNLSTD Code indicating whether unlisted procedures are included in the multiple procedure processing. Valid values are: Y – Unlisted procedures processing is based on multiple procedure logic. Blank – Does not apply unlisted procedures processing based on multiple procedure logic.

GRP ASC Grouping. The UHC groupers are based on groupers 0 – 10 or 1 – 9.

R Code indicating reimbursement type for the ASC groupings. Valid values are: P – Percent of charge R – Contracted amount or billed charges whichever is less F – Flat dollar amount

$LMT Contains a dollar amount limit for each ASC grouping if the R field is an R or F.

% Contains a percent of charge for each ASC grouping if the R field is an P.

ALL GRP Designates the ASC grouping. UHC groupers are based on groupers 0 – 10 or 1 – 9.


Field Description

OPER ID Operator identification of the person who created or last updated the CRI table.

LST UPDT Date the CRI table was created or last updated, displayed in month, day, year (MMDDYYYY) format.

CPT Contains the exception CPT code.

R Contains the reimbursement type for the CPT code exception. Valid values are: P – Percent of charge R – Contracted amount or billed charges, whichever is less F – Flat dollar amount

$LIMIT Contains a dollar amount limit for the CPT code if the R field is an R or F.

% Contains a percent of charge for the CPT code if the R field is a P.


OCI Screen (Outpatient Rate)

Overview

The TOPS OCI screen allows the user to obtain the allowable charge for services that are contracted as ‘case rate’ or ‘per visit’, outside of the normal claim processing methods.

Professional Case Rates, also called per visit fees or flat rates, are negotiated rates for services such as anesthesia, physical therapy or chiropractic. Reimbursement is based on a per visit basis regardless of the number of procedures performed or the CPT-4 codes billed. The OCI screen displays the allowable amount for case rate services. Before You Work with This Screen

Before you work with the OCI screen, be aware that:

• If an outpatient case rate calculation applies for a facility, the RT field on the facility’s PPI will contain an O and an OCI table number will be identified in the FACTOR, %, OR $ field.

• To inquire on an allowable amount, you must know the market number of the provider, O-Rate table number (PPI or NXI screen), total charge on the claim, primary diagnosis code, patient’s date of birth, cause code, place of service code, procedure code, dates of service, number of units per procedure and the charge per procedure.


Accessing the OCI Screen

Follow the steps below to display the OCI screen. The OCI screen field descriptions follow the procedure and example.



OCI,(OCI Table # ) The system displays this information as you enter it.

2 Press the Enter key. The system displays an OCI screen.

3 In the MKT # field, enter

(Market # of the provider)



4 In the ORATE TABLE # field, enter

(Orate Table # from FACTOR, %, OR $ field on the PPI or NXI screen)


Note: You must enter zeros before the orate table number to fill the field.

5 In the FC field, enter the Facility Contract indicator.

Valid Values are: I, O, B, Y, Z or blank

6 In the TOT CHG field, enter

(Total Charge listed on the claim)


Note: You must enter zeros before the amount to fill the field.

7 In the DX1 field, enter

(Primary diagnosis code listed on the claim)


Note: You must enter zeros before the code to fill the field.



8 In the DX2 field, enter

(Secondary diagnosis code listed on the claim)



9 In the I field, enter

(ICD-9 diagnosis code listed on the claim)



10 In the DOB field, enter

(Patient’s date of birth listed on the claim)


11 In the CAUSE field, enter

(Cause code listed on the claim)


12 In the POS field, enter

(Place of service code listed on the claim)


13 In the PROC field, enter

(Procedure code listed on the claim)


14 In the FROM DT field, enter

(First date of service listed on the claim)




15 In the TO DT field, enter

(Last date of service listed on the claim)


16 In the UNITS field, enter

(Number of units listed on the claim)


Note: You must enter zeros before the number to fill the field.

17 In the CHARGE field, enter

(Charge for the service listed on the claim)


Note: You must enter zeros before the amount to fill the field.

18 Press the Enter key. The system displays the not covered amount, the allowable amount, compatibility indicator, payment processing rule, pay method and total allowable amount.


Example

This example illustrates an OCI screen without information.


OCI Screen Field Descriptions

This table lists the descriptions of each field in an OCI screen.


MKT # Market Number for which the provider is contracted. This field is required.

The Market Number represents a service area for a given Health Plan. It “owns” a unique set of zip codes.

The market # number differs between TOPS and EPD. EPD utilizes the state code and the three-digit market code when identifying the market number. TOPS will utilizes the three-digit market code only. Example: For North Carolina, the market number in EPD is 32540, 32 is the state code and 540 is the actual market code which would be used in TOPS.

Note: Customer Specific Provider Networks are frequently loaded to TOPS as 4 digits, where the first digit is a '9'.

ORATE TABLE #

This field is used to point outpatient services to an EPD O-Rate Table (five digits) where a callable module will be used to determine how the rates should be calculated.

This field is required.

FC Facility Contract code indicating how the contract was set up.

I = I-Rate O = O-Rate B = Both I-Rate and O-Rate Y, Z or blank = Old Processing Applies



TOT CHG Total charge. This dollar amount must equal the total of all the amounts entered in the CHARGE fields in the body of the screen. This field is required.

DX1 Primary diagnosis code. Enter all five digits and no decimal point.

This field is required. DX2 Secondary diagnosis code (if billed). Enter all

five digits and no decimal point.

I ICD-9 procedure code (if billed).

DOB Patient’s date of birth, entered in month, day year (MMDDYYYY) format.

This field is required.



CAUSE Cause code (one character). Valid codes are listed below A - Accidents – identifies an accident claim.

0 - General Sickness - identifies chronic or routine illnesses. For example: bronchitis, back disorders, heart disease, etc. Use Cause Code 0 when the type of claim cannot be classified under any other Cause Code.

1 - Psychiatric – identifies mental and nervous claims on all policies.

2 - Normal Maternity

3 - Emergency Illness

4 – Routine - If a plan provides a special benefit for routine care. For example: pap smear, newborn In-hospital charges, etc.

5 - Complications of Pregnancy 6 - Alcoholism and Drug Addiction

D/W/V/H Code indicating visits type indicator. This code will be displayed by the system. Valid values are listed below. D - Days W - Weeks V - Visits H - Hours

ASC Ambulatory Surgical Center Grouper number Valid value between 1 and 9 when service is a surgery charge. This value is displayed by the system.

DX3 to DX9 Additional Diagnosis code or codes (if billed).

Enter the digits in 99999 format. Do not enter the decimal point.



I (five fields) Additional ICD-9 procedure code or codes (if billed).

Enter the digits in 9999 format. Do not enter the decimal point.

POS Two-character code indicating place of service. Valid values are listed below. BC – Birthing Center HS – Hospice OH – Outpatient Hospital CL – Clinic AS – Ambulatory Surgery CF – Convalescent Facility OF - Office

REV Revenue code (four digits).

PROC Procedure code. Alpha/numeric – CPT, ASA or Revenue Code in CXXYYY format.

FROM DT First date of service, displayed in month, day, year (MMDDYYYY) format.

TO DT Last date of service, displayed in month, day, year (MMDDYYYY) format.

UNITS Number of units.

CHARGE Amount charged for the procedure.

NOT COV Amount not covered for the procedure. This amount is not entered. It will be displayed by the system.

ALLOWABLE Allowed amount. This amount is not entered. It will be displayed by the system.



CI Code indicating compatibility indicator. This code will be displayed by the system. Codes and descriptions are shown below. C1 - All includes case rate C2 - Medicare ASC C3 - Proc Specific Case Rate, all inclusive C4 - POC all inclusive case rate (not proc specific) C5 - Case Rate POC to a Max (not procedure specific) CN - Case Rate non-compatible CI – Carve-in, included in other all-inclusive case rate/per visit processing D – Discount/ POC N - Non-compatible L - Lump P - Per Diem B - Both Lump and Per Diem CP- if trigger amount reached pay POC up to optional cap/maximum limit FS – Fee Schedule processing FN – Fee Schedule Non-Compatible



RULE Code indicating payment processing rule. This code will be generated by the system.

C - Case Rate V - Per Visit (excluding misc.) T - Per Visit (including misc.) U - Per Unit R - Carve Out S - Step Rate (excluding misc.) P - Step Rate (including misc.) T1 - Per Visit, rolls into case rates (includes Misc), stand alone per visit T2 – Per Visit pays in addition to case rates (includes Misc, stand alone per visit) R1 – Carve Out (threshold/cap) SC – Stack Case Rate, allow in addition to other case rates F – Fee Schedule

PM Code indicating payment method. This code will be displayed by the system. A - Pay the contracted rate always, on a detail line basis. B - Pay the lessor of the contracted rate or a percent of charge, on a detail line basis. Blank - Pay the lessor of the contracted rate or 100% of charge, on a detail line basis.

# Row number (three digits) on the O-Rate

Table. This number will be displayed by the system.



MD (4) A two-character field that displays the procedure code modifier. AA - Anesthesia services performed personally by an anesthesiologist • AD - Medical supervision by a physician:

more than four concurrent anesthesia procedures

• QY - Medical direction of one Certified Registered Nurse Anesthetist (CRNA) by an anesthesiologist

• QK - Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals

• GC - This service has been performed in part by a resident under the direction of a teaching physician.

• G8 - Monitored anesthesia care (MAC) for deep, complex, complicated, or markedly invasive surgical procedure

• G9 – M onitored anesthesia care for a patient who has a history of severe cardio-pulmonary condition

• QS - Monitored anesthesia care services • QX - CRNA service: with medical direction by

a physician • QZ - CRNA service: without medical direction

by a physician • SG – Surgical Procedure Facility Fee

M / S The medical / surgical indicator is use to identify whether medical services are to be reimbursed in addition to surgical case rates.

Valid Values: • ‘S’ – Surgical only • ‘B’ – Both Medical and Surgical • ‘R’ – Pay Rule of ‘C’ (Case Rate) in addition to

Rule of ‘OC’ (Out-Patient Surgical Grouper) • ‘Blank’ – Medical Only

GRP The Out-Patient Surgical Grouper number. Valid Values: 00 –10



TOTAL ALLOWABLE

Contains the total allowable amount for all procedures entered. This amount will be displayed by the system


IRI Screen (Inpatient Rate)

Overview

The TOPS Inpatient Rate Inquiry (IRI) Screen allows you to input inpatient claim detail information on a screen to obtain the inpatient facility rate reimbursement amounts from EPD. The use of this table is similar to the Outpatient Case Inquiry (OCI) Screen. Before You Work with This Screen

Before you work with the IRI screen, be aware that:

• If an inpatient calculation applies for a facility, I or B will be displayed in the FAC CONTR field on the facility’s PPI and the TABLE field will contain an I-Rate table number.

• To inquire on an allowable amount, you must know the market number of the provider, I-Rate table number (PPI screen), total charge on the claim, primary diagnosis code, patient’s date of birth, cause code, place of service code, procedure code, dates of service, number of units per procedure and the charge per procedure.


Accessing the IRI Screen

Follow the steps below to display the IRI screen. The IRI screen field descriptions follow the procedure and example.



IRI,(IRI Table # )


2 Press the Enter key. The system displays an IRI screen.

Adding a TOPS IRI

1 Enter the Market Number in the MKT # field.



2 Enter the EPD I-Rate Table Number in the TABLE # field.

(Note: This is the I-Rate Table # from TABLE field on the PPI screen)


Note: You must enter zeros before the I-Rate table number to fill the field.

3 In the DX fields, enter all of the diagnosis codes listed on the claim.

4 In the I fields, enter all of the ICD 9 procedure codes listed on the claim.

5 Enter the date of service range in the FROM DT and TO DT fields.

Enter the dates in month, day, year (MMDDYYYY) format.



6 In the POS field, enter the code indicating where where the services were rendered.

7 Enter the row number in the # field.

8 In the REV/PROC field, enter the revenue code or procedure code (whichever the services are for).

9 Enter the month and day the services are for in the DOS field. For example, enter 0110 for January 10.

10 Enter the number of units in the UNIT field.

11 Enter the charge for each service line in the CHARGE field.

12 Press the Enter key. IRI will change to IRC. The system displays the not covered amount, the allowable amount, compatibility indicator, payment processing rule, pay method and total allowable amount.


Example

This example illustrates an IRI screen without information.


IRI Screen Field Descriptions

This table lists the descriptions of each field in an IRII screen.

Field Description

MKT # Market number is defined by unique zip codes. This means that a zip code can be identified to one and only one market for a given time period. Market Number is part of the key to the record. This field is required.

TABLE # Displays the I-Rate table number (five positions).

This field is required. DOB Date of birth, entered or displayed in month,

day, year (MM/DD/YYYY) format.

GENDER Code indicating sex of patient-specific contract agreement. M = Male; F = Female

DRG Diagnostic Related Group (DRG) code. DRG is a system of classification for inpatient hospital services based on the principal diagnosis, secondary diagnosis, surgical procedures, age, sex, and presence of complications

DC Discharge code, if any.

TOT CHG Total charge. This dollar amount must equal the total of all the amounts entered in the CHARGE fields in the body of the screen. This field is required.

DX (nine fields)

Diagnosis code. You can enter up to nine diagnosis codes on this screen. A minimum of one is required.

I (six fields)

ICD-9 procedure code. You can enter up to six different procedure codes. A minimum of one is required.


Field Description

FROM DT Claim start date, displayed in month, day, year (MMDDYYYY) format.

TO DT Claim ending date, displayed in month, day, year (MMDDYYYY) format.

POS Two-character code indicating place of service. Valid values are listed below. BC – Birthing Center HS – Hospice IH – Inpatient Hospital CL – Clinic SA – Substance Abuse AT – Alcohol Treatment CF – Convalescent Facility Blank – All other places of service.

TOT ALLOW Total allowed amount.

PG Page number.

# Row number.

REV/PROC Revenue code (four digits) or procedure code for services being rendered.

DOS Date health care services were provided, displayed in month, day (MMDD) format.

UNITS Number of units.

CHARGE Amount charged for the procedure.

NOT COV Amount not covered for the procedure. This amount is not entered. It will be displayed by the system.

ALLOW Total allowable for each service line entered. This amount is not entered. It will be displayed by the system.


Field Description COMP Compatibility Indicator code that identifies the

processing that will be governed by the I-Rate line. Valid Values are:

N - Non-compatible D – Discount P - Per Diem L - Lump / case LB - Both Lump / case and Per Diem LP – Both Lump / case and Percent of

Charge PM Pay Method code that indicates when the

agreement is to pay contracted rates regardless of the billed charges. Valid Values:

A - Pay the contracted rate always, on a detail line basis.

Blank - Pay the lessor of the contracted rate or 100% of charge, on a detail line basis.

CRV OUT Carve Out indicator. A decision to purchase separately an additional service that typically is a component of that benefit plan. Example: an HMO may "carve out" the behavioral health benefit and select a specialized vendor to supply these services on a stand-alone basis.

EXC OL Exclude Outlier indicator Valid Value:

Y= Yes, excluded from Outlier Blank= not excluded from Outlier

FND INFO Foundation Information field indicates where the information on the IRI is being pulled from (For example, I is for I-Rate table, E – is for Exclusion table.) Valid Values are:

I = I-Rate table E = Exclusion table D = DRG table

TOPS Contract and Claim Reference Manual August 2005 378 Miscellaneous Screens Training & Development

Miscellaneous Screens

Overview

This chapter has descriptions of how to use and an example of the electronic claims screen, MEI, EDS 1, EDS 6.5 and the three accounting screens: IDI, SCI/SDI, and SFI. Learning Objectives


• Electronic claims. • Individual and family deductible information. • Maximums and out-of-pocket information. • Summary check information.

August 2005 TOPS Contract and Claim Reference Manual Training & Development Miscellaneous Screens 379

MEI Screen (Electronic Media Claim)

Overview

The MEI screen provides access to electronic claims received by the claim office. This screen lists a summary of the claims received electronically and their current status.

The provider of the services, software vendors, clearinghouses, and billing services submit claims into an electronic media system. They then go through the Practice Review System (PRS) and autoadjudication. Claims that do not autoadjudicate are held in a queue for manual processing. Claims are then brought up from the queue into TOPS where they are processed.

Claims should be released for further processing or completion within three to four days after they have been received. If claims are not processed during this timeframe, the claim office should be notified.

The MEI screen contains the following information:

• Policy • Name • Document Control Number assigned to the claim • Service dates • Dollar amount claimed • Claim status



Before you work with the MEI screen be aware that:

• Claims from this screen should be processed or complete within three to four days. If not, contact the claims office.

• If a claim processes under a different inventory control number (ICN) than the one under which it was pre-keyed, there was a clerical error in the original keying. The ICN number should not change unless there was a correction.

• The search is quicker if you know the employee’s social security number.

• To return to the TOPS system from the MEI screen keep pressing the F1 key and choose TOPS or press the key representing the Clear Screen function.

Procedures

Use the procedure that follows to determine if a claim has reached the claims office, even if it is not yet entered in the system. The screen field descriptions follow the procedure and example.


Accessing the MEI Screen

Complete the steps below to access the MEI screen.



MEI,S(SSN)


2 Press the Enter key. The system displays policy, patient name and relationship, and claim information.

Example

This example illustrates an MEI screen.

S123456789


MEI Screen Field Descriptions

The following table lists the MEI field descriptions.


unlabeled Julian date

Displays the current year and Julian date.

unlabeled calendar date

Displays the current calendar date.

OFFICE Displays the office number of the operator logged into the system.

EMPLOYEE ID NUMBER

Displays the SSN of the employee.

O Allows the entry of option codes that are used by claims processors.

POLICY Displays the employee’s policy number.

NAME Displays the first name of the patient.

REL Displays the code that describes the relationship of the patient to the employee.

DCN Displays the document control number assigned to the claim when entered into TOPS.

SUF Displays the document control number suffix.



TAX ID 1 Displays the tax identification or social security number of the servicing provider.

TOTAL CHG Displays the total billed charge on the claim.

OFF Displays the claims office number.

SVC DATES Displays the range of dates that services were performed.



STAT Displays the status of the claim. The valid values are:

• (Blank) - Not processed

• APAY - Autoadjudicated

• APND - Auto pended

• CLSD - Auto closed

• DLTD - Deleted

• HMO - HMO queue

• MPAY - Manually paid

• MPND - Manually pended

• PROC - Processing queue

• RJCT - Rejected

• RSLV - Resolved

• SEND - Send back queue

• SMRT - Smarts queue

• TRAN - Transferred

• UNID - Unidentified queue

• UBSH - USBH queue

• PRS - PRS


IDI Screen (Individual Deductible)

Overview

The IDI screen displays an individual's deductible and out-of-pocket expense for a specific year as well as any carryover amounts from the previous year. The screen also displays the following information for the family:

• Number of individual family members that have any deductible or out-of-pocket expense applied to their file for the specified year

• Total dollar amount of family deductible the family has met for the specified year

• Number of individual family members that have any carryover applied to their file from the previous year

• Total dollar amount of carryover that the family Before You Work with This Screen

Before you work with the IDI screen, be aware that:

• The IDI screen may not be accurate if there have been accounting adjustments. If there are not adjustments, it should be accurate.

• Use the IDI screen when there is a discrepancy in the individual or family deductible or out-of-pocket dollar amounts satisfied. This is usually identified by a phone call or a letter from the insured or provider.

• Use the IDI screen only if your health plan has either calendar year or policy year deductibles. Do not use this screen for any other type of deductible frequency.

• If your health plan uses any other type of deductible frequency, the system displays the message, 1030 DED FREQ NOT APPLIC, when you attempt to work with this screen. This message warns you that the screen is not applicable.


• You must know the Social Security number, first name, and relationship code of the enrollee in order to access IDI information.

• An efficient way to access an IDI screen for an enrollee is to access the CEI screen and place an “I” in the Select field.

Procedures

Use the procedure that follows when you need to access current or historical information about an enrollee’s deductible and OOP information. The field descriptions follow the procedure and example.

Accessing an enrollee’s Deductible or OOP Current Year Information

Complete the steps belowrder to access an enrollee’s deductible or OOP information for the current year.



IDI,(Policy #),S(SSN),(First Name),(Rel)


2 Press the Enter key. The system displays the specified enrollee’s deductible and OOP information for the current year.


Accessing an enrollee’s Historical Deductible or OOP Current Information

Complete the steps below to access an enrollee’s deductible or OOP information for an earlier year.



IDI,(Policy #),S(SSN),(First Name),(Rel),(Year)

Enter the last two digits of the year you want to access. The system displays this information as you enter it.

2 Press the Enter key. The system displays the specified enrollee’s deductible and OOP information for the current year.

Example

This example illustrates the IDI screen.

_IDI,123456,S123456789,ALYSSA,CH,


IDI Screen Field Descriptions

The IDI screen contains two sections:

• Individual Information section • Family Information section

This table lists and describes the fields in the Individual Information section.


YEAR Lists the two-digit calendar year to which the individual deductible applies.

DED C/O Displays any applicable deductible dollar amount carried over from the previous year.

DEDUCTIBLE Displays the deductible dollar amount that the enrollee met for the year indicated.

NEW COINS C/O

Displays any applicable coinsurance dollar amount carried over from the previous year.

NEW COINS Displays any coinsurance dollar amount that the enrollee has paid for the year indicated.

DUAL NEW COINS

Displays a second out-of-pocket dollar amount (if included in plan).


This table lists and describes the fields in the Individual Information section.


DED C/O Displays any applicable deductible dollar amount carried over from the previous year.

DEDUCTIBLE

Displays the deductible dollar amount that the enrollee met for the year indicated.

NEW COINS C/O

Displays any applicable coinsurance dollar amount carried over from the previous year.

NEW COINS Displays any coinsurance dollar amount that the enrollee has paid for the year indicated.

DUAL NEW COINS

Displays any second out-of-pocket dollar amount (if included in plan).

NBR IND Contains the number of family members that have any deductible or out-of-pocket applied to their file for the year indicated. If the policy contains an accumulative family deductible, this field is blank.

DED AMOUNT

Displays the total deductible dollar amount that the family has met for the year indicated.

C/O IND Contains the number of family members that have any carryover applied to their file from the previous year. If the policy contains an accumulative family deductible, this field is blank.

C/O AMOUNT

Displays the total dollar amount of carryover that the family has from the previous year. If the policy contains an accumulative family deductible, this field is blank.


SCI/SDI Screen (Summary Check/Draft)

Overview

The SCI and SDI screens display payment information regarding a specific summary check. A summary check is a check that can have multiple patient(s) benefits applied to it. If this screen is filled with data, a summary check has or will be issued. The SCI and SDI screens contain identical information. Use this screen when a caller, particularly a provider, cannot match the check received to a claim submitted and does not have an EOB or has not received a check for a claim submitted.


Before you work with the SCI/SDI screen, be aware that:

• You can access the SCI/SDI screen by accessing a specific claim and then change the transaction code.

• If you know the check number, use the SCI screen to access payment information.

Procedures

Use the procedures that follow when you need to access information about a payment. The field descriptions follow the procedures and example.


Accessing the SCI/SDI Screen Using a Check Number

Complete the steps below to access payment information.



SCI,(Check #)



Accessing the SCI/SDI Screen From the MHI Screen

You can also access this screen from the MHI screen by completing the steps below.


1 On the AHI screen, access a specific enrollee’s claim by entering S in the Select field before the claim you want to view.


2 Press the Enter key. The enrollee’s specific claim is displayed.

2 In the control line in the MHI screen, enter SDI

The system overwrites the MHI on the control line.

2 Press the Enter key. The system displays the summary information for that specific draft number.


Accessing the SCI/SDI Screen Using a Draft Number

You can also access the screen using a draft number by completing the steps below.



SDI,(Policy #),S(SSN),(First Name),(Rel),(Draft #)



Example

This example illustrates an SCI/SDI screen.

SDC,123456,S123456789,ALYSSA,CH,0012345678

S123456789 S123456789


SCI/SDI Screen Field Descriptions

This table lists the SCI/SDI field descriptions.


CHK NO Contains the two-letter prefix and ten-digit check number on the summary check.

CHK AMT Contains the total dollar amount of the summary check.

TR Contains a two-character code that indicates a change in the claim’s disposition.

OV Contains the one-character override code that forces the system to allow manual intervention to process the claim.

RC Contains the two-character remarked code used during processing of the claim.

PROC DT Indicates the date when adjustments were made to the claim or check. The format of this field is mm dd yy.

CHECK ISSUE DT

Indicates the date when the check was issued. The format of this field is mm dd yy.

S Allows you to enter S to go to the MHI screen.

WARN OV Contains the override code that forces the system to allow manual intervention in order to process the line.



POLICY NUMBER

Contains the policy number under which the claim was paid.

EMPLOYEE ID

Contains the employee’s nine-digit Social Security number.

PATIENT NAME

Contains the first name of the patient.

RL Contains the two-character relationship code of the enrollee to the employee.

DRAFT NO Contains the number of the draft.

PAID AMOUNT

Contains the dollar amount paid to a provider for a corresponding claim.

REISSUE Contains information used for accounting purposes.

ALTERED DATA

Allows you to alter data if you need to make an adjustment.

comments lines

(See note.)

Note: The following two messages can appear in the lower left corner of the screen:

• “NOT SUMMARY CHECK,” which indicates that the check and payment should have been sent out within two business days of the processing date.


• “SUMMARY CHECK NOT ISSUED,” which indicates that this check will be sent out as part of a summary check, but the check has not yet been issued. As of 8/14/95, the issue date is based on the following schedule:

Release Day of the Week

First Letter of Provider’s First Name

Monday A, B, C

Tuesday D, E, F, G, H

Wednesday I, J, K, L, M

Thursday N, O, P, Q, R

Friday S, T, U, V, W, X, Y, Z, and all nonalpha


SFI Screen (Set Family)

Overview

The SFI screen displays specific types of benefits and tracks plan limits for lifetime and yearly maximums. It also displays specific types of deductibles or penalties applied. Before You Work with This Screen

Before you work with the SFI screen, be aware that:

• The SFI consists of three screens. To view the second and third screens, press Enter and the next screen will be displayed. This procedure will cycle you through all the screens.

Procedures

Use the procedure that follows when you need to locate enrollee maximums and family deductible information. The field descriptions follow the procedure and example.

Accessing Lifetime and Yearly Maximums and Family Deductible Information

Complete the steps in the table below to access an enrollee’s maximums and a family’s deductible information for the current and previous year.



SFI,(Policy #),S(SSN),(First Name),(Rel)


2 Press the Enter key. The system displays the specified enrollee’s maximums and a family’s deductibles.


Examples

This example illustrates the first page of an SFI screen.

SFN,123456,S123456789,ANDREA,EE,


SFI Screen Field Descriptions

The SFI screen contains two sections:

• Individual maximums section • Family deductible section

This table lists and describes the fields in the individual maximums section. Information is displayed for the current and two previous years. Each year contains two rows of information.


AUDIT Displays the last date that information transferred to this screen.

Row 1: YR/PD

Indicates the year and the total benefit dollars paid for each type of benefit for the current year. The benefit types include Medical, Vision, Early Retirement, Retirement, Psychiatric Confinement, Psychiatric Nonconfinement, Psychiatric Combined, Alcohol and Drug Confinement, Alcohol and Drug Nonconfinement, Alcohol and Drug Combined, and Out-Of-Network Medical.

Row 2: ADJ

Displays the amount that was paid for each type of benefit plus any adjusted amount.

This table lists and describes the fields in the family deductible section. This section only lists the current and previous year deductible information. Each “DED +(letter)”represents a different deductible that was applied with the information listed in the following table.



DED YR/NO IND

Indicates the year and number of family members that the deductible had been applied. The types of deductibles are: DED M - Medical care deductible DED R - Hospital room and board deductible DED P - Prescription deductible DED G - PPO deductible DED 4 - (Unassigned) DED H - CCS (PARS) deductible DED V - Vision deductible DED Y - PPO deductible DED E - Hospital extras or emergency illness deductible DED 5 - (Unassigned) DED S - Surgery deductible DED 6 - (Unassigned) DED O - Outpatient services deductible DED B - Home health care deductible DED C - Midyear change deductible DED F - Second surgical opinion deductible

DED AMOUNT

Displays the amount of deductible that was applied for the family.

CO IND Displays the number of family members that had carryover from the previous year.

CO AMT Displays the amount of carryover for the family.

DED SAT DTE

Displays the date that a deductible has been applied.


EDS 1 Screen

Overview

The majority of claims come via ‘EDI’ (Electronic Data Interchange) or they arrive as a paper claim form that is then scanned or keyed into the Front End Production system. EDI or scanning of paper claims is collectively referred to as ‘electronic’ claims. The data on all of the EDS screens will be available until the claim is processed (paid or denied). Once the claim has been processed, the information will remain available for viewing for 60 days. If the information is needed beyond the 60 days, it will need to be reviewed in TDARS or iDRS. You may retrieve a copy of the Electronic/Paper UB92 or Electronic/Paper HCFA-1500 (you will need to separately read TDARS and iDARS manuals to see how the claims appear in these systems and how to access them). Please note claims that have been keyed directly into the TOPS Payment screen (MPI screen) by a claim processor are not available in EDS. Very few claims are keyed this way, however. If you need to access a claim that was direct keyed to an MPI (it wasn't scanned, it didn't arrive via EDI), the only way is to view the actual information submitted by the provider in iDRS. NDM uses the EDS 1 screen primarily to enable the Contract Coordinator or the DLA to research the services rendered to a patient by a provider. The EDS 1 screen will display information on: The patient information such as name, date of birth, relation

to insured Medical procedure(s) performed CPT-4 Procedure Code,

HCPCS and/or Revenue Codes Diagnosis coding ICD-9 Diagnosis Code, DRG Charge amounts Based on each service rendered and Total

Claim Dates of service System-generated edits PF8 additional procedure lines, PF7

for Previous lines. Don’t confuse this with the edits that the claim processor receives such as SPI warning messages etc., these can be found on the bottom of the MPI Screen.


The provider’s name and address and Tax Identification number

from the information support EDS 3 Screen. (Often times the middle initial of the physician is on this screen, this information will

help to determine which provider should be selected when similar names are on the provider files.)

Whether attachments are present such as operative report, progress report etc.

Accessing the EDS 1 Screen: The EDS 1 Screen Hospital

Sample EDS 1 screen for a UB92 submission.

ICN 0311111217 SSN S1234567890 PAT CxxY RL CH DOB 0xxx19xx NXT SCR _____ POL 1xxxx2 ATT PHY Mxxxx ROxxxxxxx TC 3434.00 AMT PD A FROM 0xxxxx THRU 0xxxxx NR OI ALL OI PD DRG 000 L DRG AMT SPR 611.00 MC:D C --- V3000 V053 ------ ------ ------ ------ ------ ------ ------ ADM V3000 RM REVE RT/DYS DESC DYS/UT HCPC/MD DATE CHARGE SX PS SVC CHARGE 0171 309.00 NURS/NEWBORN 0002 --------- 0000 618.00 01 IH NB171 618.00 0270 MS/GEN CLS 0001 --------- 0608 5.00 01 IH MISC 342.25 0300 LB/GEN CLS 0001 --------- 0608 47.00 01 0391 BLD ST/PRC AD 0001 --------- 0608 82.00 01 0471 DIAG AUDIOLOG 0001 --------- 0608 80.00 01 0636 RX/DETAIL COD 0001 --------- 0608 .25 01 0723 LABOR/DEL CIR 0001 --------- 0608 128.00 01 0001 GENL TOTL CHG 0002 --------- 0000 960.25 01 PROV NAME Kentucky Hospital ACT V0xxxxxx63 1 xxx xxxxxxx xxx xxx xxxxxx, xx xxxxx 2xxx4xxx27 TIN 06xxxxxx4



Field Description

ICN The Inventory Control Number for the claim. SSN The Social Security Number of the member based

on the eligibility selection. RL The RL field displays the Relationship code that

indicates the relationship of the patient to the insured. Valid Values are: EE - employee SP - spouse CH - child SC - stepchild ST - student HC - handicapped CH RR - retired employee SS - Surviving Spouse NB - New Born DP - Domestic Partner

DOB The patient's date of birth from block 2 Paper UB 92 or box 3 on electronic UB 92 submissions

NXT SCR Used to tell the system which screen you want to access next.

POL The member's policy number based on eligibility selection.

ATT PHY Hospital attending physician.

TC Total Charge.

AMT PD Amount paid, if applicable.

FROM This field indicates the date of the hospital admission of the patient to the facility.

THRU This field indicates the discharge date of the patient from the facility.


Field Description

NR Negotiated Rate Indicator: Appears on claims that pass through the Front End with an OI, OIM, or OIMEDI line (other insurance information). Valid Values are: NR=Y When the keyer identifies the prime allowable. NR=D When other lines on the same claim have "Y" in this field. NR=S When the frontend derives the prime allowable. NR =Spaces When no NEG RATE display will be present.

OI ALL Other insurance allowable.

OI PD Other insurance paid amount.

DRG This field indicates the Diagnosis Related Group (DRG) Number from the facility. Please note, this is not the system assigned DRG based on diagnosis, procedure code etc. The system assigned DRG can be found on the MPI screen. This field is especially helpful when investigating a claim where a provider is stating that they billed for DRG 123, but UHC paid for DRG 456. Diagnosis Related Group 1st three bytes - DRG code 4th byte - LIER indicator L = Inlier H = Outlier


Field Description

SPR Semi Private Room rate. This is only indicated on bill that contains inpatient room and board rates.

MC This field shows the amount the patient paid at the time of the visit. (Co-Pay, etc.). The field directly located next to the amount paid identifies whether the payment made was related to the co-insurance or deductible requirements of the policy. The dollar amount if applicable will be entered next to the corresponding field. Medicare information D = Medicare deductible C = Medicare coinsurance Indicators will also appear: P = pricing screen associated with this claim C = other insurance information is on EDS2 A = claim address and MRI address do not match

------ Directly beginning under the DRG field is nine six –byte fields for diagnosis codes associated to the claim.

REVE This field indicates the revenue codes submitted electronically for the services rendered

RT/DYS If an inpatient revenue code of 100-219 is indicated, this field should indicate the rate from the hospital

DESC System generated description of REVE codes.

DYS/UT This field indicates the Days or Unit information that was submitted electronically for the revenue code indicated.


Field Description

HCPC HCPCS codes from the claim. A HCPCS code is a method for coding supplies, materials, injections and services performed by health care professionals. There are three levels of codes within the HCPCS coding system. Level I CPT codes Level II National codes Level III Local codes

MD HCPC code modifiers(s) reported for the service line. A modifier provides the means by which the reporting physician can indicate that a service or procedure has been altered by some specific circumstances but not changed in its definition or code. This field is especially important to verify if the provider of service is rendering Surgeons service vs. Anesthesiologist services or if the service is for professional component vs. the Technical component. Some of the most common modifiers that NDM would see are the following: 80 – Assistant Surgery 26 – Professional component 22- Unusual Procedural Service 50- Bilateral Procedure

Additional information on modifiers can be located: In the CPT Book in Appendix A Knowledge library: Operational Processes:Claim-Customer Service;UNET specific coding.


Field Description

DATE Revenue code date of service. Multiple visits for the same type of service may or may not have taken place. This may be helpful to review when the provider indicated they billed for two visits vs. what they received reimbursement for (for example, received reimbursement for just one visit

CHARGE The charge amount for the revenue code and description as it appears on the claim.

SX When the claim has been split into multiple claims, the ICN suffix indicating on which UNET/TOPS payment screen this service line will be displayed.

PS This field indicates the “after” picture of how UNET/TOPS system had converted the place of service originally submitted by the provider as found on the left-hand side of the EDS 1 Screen. This will play a key role in how the claim will sort to a Service Type on the PPI Rate Table Valid values are; IH =Impatient Hospital OF = Office AT = Alcohol Treatment HS = Hospice BC= Birthing Center OH =Outpatient Hospital IL = Inpatient Lab RX = Pharmacy SA = Substance Abuse Center CL=Clinic CF= Convalescent Facility AS = Ambulatory surgical center HM = Home OL=Outpatient Lab


Field Description

SVC This field indicates the services after the UNET/TOPS system has run the services through PRS. The codes indicated in this column may vary from the information the provider originally billed (as found on the left side of the EDS 1 screen). An example of this would be when the provider billed for two CPT-4 codes for procedures rendered, the system sent the claim through PRS. The PRS logic found one code that more accurately describes the service rendered, the new code would be indicated.

Service code that will carry to MPI screen. Charge Charge amount that will carry to MPI screen for the

PS/SVC Code(s)

PROV NAME This information is from the EDS 3 screen which is the support screen for Provider/Facility demographic information.

ACT Patient account number assigned by the facility Displays up to 20 characters Only 17 pass to UNET

Provider's Address

Address and telephone number of provider. This information is from the EDS 3 screen which is the support screen for Provider/Facility demographic information

TIN Tax Identification number of provider This information is from the EDS 3 screen which is the support screen for Provider / Facility demographic information


EDS 6.5 Screen

Overview The EDS 6.5 is the Revenue Detail Institutional EDS Screen. The purpose of the EDS 6.5 is to review and allow processors to make any necessary adjustments to the updateable fields in order to calculate the correct allowable amount on the new EDS 6.5 screen. The new screen should be used in any situation the service line data being changed by the user does not match the original data from the physician/ provider. Accessing the EDS 6.5 Table: Access to new EDS 6.5 screen is accomplished utilizing ’OPN’ in the ‘A’ (Action) field of the EDS6 screen.

A new value ‘OPN’ will be added to the existing EDS6 (Institutional) ‘A’ (Action) field. When ‘OPN’ is entered in the action field of the existing EDS6 screen the new EDS 6.5 screen will be returned and will display the details associated with the applicable UNET Service line. Shown below is a sample of the EDS 6.5 screen.

(0) ----5---10---15---20---25---30---35---40---45---50---55---60---65---70---75---80 (1) ICN XXXXXXXXXX XX SSN XXXXXXXXXX PAT XXXXXXXXXX RL XX POL XXXXXX NXT SCR _____ (2) DOS FROM ------ DOS TO ------ BYPASS HISTORY - (3) IC1 ---- IC2 ---- IC3 ---- IC4 ---- IC5 ---- IC6 ---- (4) DX1 ----- DX2 ----- DX3 ----- DX4 ----- DX5 ----- DX6 ----- DX7 ----- (5) DX8 ----- DX9 ----- (6) (7) A REV CPT/HCPC DOS NBR CHARGE NOT COV OV RC ALLOWED CI R PM C EXC GRP (8) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (9) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (10) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (11) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (12) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (13) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (14) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (15) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (16) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (17) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (18) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (19) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (20) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (21) --- ---- ------ ---- ---- ------- ------- -- -- ------- -- -- - - - --- (22) (23) PROV TIN/SX ---------- --- PAT ACCT -------------------- (24) MESSAGE LINE


EDS 6.5 Screen Field Descriptions

Field Description ICN This field indicates the 10-digit Inventory

Control Number. This number is unique to each claim. The ICN number was created to give each claim in UNET regardless of what engine it is paid on a unique number. No other claim will have the same number. This number is also utilized to pull up a specific claim for a member. A unique number 10-digit number assigned to each claim as it goes through TOPS Front End processing.

Suffix: When the claim has been split into multiple claims, the ICN suffix indicating on which UNET/TOPS payment screen this service line will be displayed. An example of multiple suffixes is:

ICN=I0145439871 01 ……………………Suffix

SSN Social Security Number of the member based on the eligibility selection The employee social security number from UNET Medical Register (MRI) screen This information is used to access the Insured’s information when researching an EMCCF.

PAT Patient’s first name The first name of the patient from UNET Medical Register (MRI) screen This information is used to identify the specific patient when multiple members appear under the insured. The first name will help you narrow down the selection you need to inquire on.


Field Description

RL The REL field displays the relationship code that indicates the Patient’s relationship to the insured. Valid Values are:

♦EE - employee

♦ SP - spouse

♦ CH - child

♦ SC - stepchild

♦ ST - student

♦ HC - handicapped CH

♦ RR - retired employee


♦ NB - New Born

♦DP - Domestic Partner This information feeds to EMCCF queue. The Contract Coordinator or DLA will infrequently utilize this field.

POL The policy number is used to determine the calculation rate on the Medical Payment Screen (MPI). A policyholder’s number relates to benefits provided from their employer. Policy number appears on: block 8 HCFA paper 1500 box 7B on electronic HCFA 1500 block 5 electronic UB-92 submissions and box 5 paper UB 92. This is a protected field, which will also be displayed on the EPD tracking screen


Field Description

NXT SCR This field will allow the user to enter data to advise the system of the next screen to access. Valid codes are listed below: MPC or “A”= UNET calculated payment screen for this ICN MRI or “F” = UNET Medical Family/Dependent Register for this ICN MNI or “C” = UNET Claim Number Register for this Individual AHI or “H” = UNET Abbreviated History for this individual EPI or “E” = UNET Employee/Policy Screen (SSN look up only) 1 = EDS 1 Screen for either UB92 or HCFA bill 2 = EDS 2 Screen for either UB92 or HCFA bill 3 = EDS 3 Remark Screen for either UB92 or HCFA bill 9 = EDS 9 (ACS) Screen for either UB92 or HCFA bill N = Next Claim in queue Q = Change the queue set up S = MEI selection screen R = Work completed, Releases claim from queue. Johnstown PIM is the only PIM region to use this. U = Update fields that allow processor update. FCI = The UNET Freeform Comments Inquiry Screen will be returned CCI = The UNET Coordination of Benefits Comments Inquiry Screen will be returned BCI = The UNET Benefit Structure Comment Inquiry Screen will be returned


CMI = The UNET Comments Medical Inquiry Screen for the patient will be returned RET = The UNET pended screen will be returned Axx = UNET calculated screen for z specific ICN suffix (xx= ICN suffix to be calculated) This field is utilized to tell the system what screen you want to access next. The most commonly used screens in NDM are: 1 = EDS 1 Screen for either UB92 or HCFA bill 2 = EDS 2 Screen for either UB92 or HCFA bill 3 = EDS 3 Remark Screen for either UB92 or HCFA bill 9 = EDS 9 (ACS) Screen for either UB92 or HCFA bill

DOS FROM The beginning date of the service rendered on the service line. All dates must be entered as month, day & year (mmddyy).

DOS TO The end date of the service rendered for the service line.

BYPASS HISTORY

Bypass history.

IC1 – IC6 Procedure codes (for inpatient hospital bills only).

DX1 Primary diagnosis code used for the claim displayed.

DX2 – DX9 Secondary diagnosis code or codes used for the claim displayed.

A Action

REV Revenue codes submitted electronically for the services rendered.

Field Description

CPT/HCPC Service/Procedure code.


DOS Date of service, displayed in month, day, year (MM/DD/YYYY) format.

NBR The number of services performed for that service code. (i.e., indicates number of days inpatient (facility), may indicate number of units (professional).

CHARGE Charges submitted on the claim.

NOT COV Amount not covered by the policy master for this service line.

OV The override code used to force the system to allow "manual" intervention in the processing of the claim. Some of the more common override codes are: 01-suspect duplicate, 02-Medical Claim Review (MCR) and Reasonable & Customary (R&C) edits. May also be used to clear most ADJ DET (adjuster determined) edits. 07-Investigate COB 13-Eligibility edits plus ALL lower override codes. This edit is to be used with CAUTION and ONLY when absolutely necessary as it impacts downstream reporting A complete list of Override Codes are listed in the Knowledge library http://kl/content/operational%20processes/claim-customer%20service/unet%20claim/override%20codes.doc

RC The remark code number entered during claim processing that displays a corresponding message on the EOB. Some of the more common override codes are; D1-Physician Negotiated Rate D2-Facility Negotiated Rate 29-Charges over Reasonable & Customary (R&C) B9-System generated copay applied Complete instruction on how to review the Remark Codes are listed in the Knowledge library http://kl/content/operational%20processes/claim-customer%20service/unet%20claim/remark%20codes.doc

Field Description ALLOWED The allowed is the amount we will consider after all non-

covered amounts have been subtracted. The allowed then






is the basis for the deductible and coinsurance calculation

CI Compatibility Indicator- displays a one-two character indicator that identifies the processing that will be governed by the I-Rate line. Valid values are: D= discount or factor processing P= per diem processing L= all inclusive lump/case rate processing LB= all inclusive lump/case rate and per diem processing N= incompatible processing LP= all inclusive lump/case rate and POC processing CP = Floor $ amount and POC processing (with or without CAP)

R A rule defines how services will be processed, inclusive of the handling of billed units from the claim. The Valid Values are: C=Case Rate (Includes Miscellaneous) V=Per Visit (Excludes Miscellaneous) T=Per Visit (Includes Miscellaneous) U=Per Unit R=Carve-out S=Step Rate (Excludes Miscellaneous) P=Step Rate (Includes Miscellaneous)

PM Pay Method code that indicates when the agreement is to pay contracted rates regardless of the billed charges. The Valid values are: A = Pay the contracted rate always, on a detail line Basis. B = Pay the lesser of the contracted rate or a percent of charge, on a detail line basis. Blank = The system pays the lesser of the contracted rate or 100% charge, on a detail line basis.

Field Description C A decision to purchase separately an additional service

that typically is a component of that benefit plan. Example: an HMO may "carve out" the behavioral health benefit and select a specialized vendor to supply these services on a


stand-alone basis.

EXC Excluded Outlier Indicator. Y = Excluded from outlier

GRP Group version.

PROV TIN/SX

The TIN and suffix for the provider of service.

PAT ACCT The provider's patient number for the billed expense

TOPS Contract and Claim Reference Manual August 2005 416 Appendices Training & Development

Appendices

Appendix A - CCS (PARS) Remark Codes

This appendix lists the CCS (PARS) remark codes and descriptions.

CCS (PARS) Remark Code

Description

AS Professional services/admission covered network benefits

DA Entire admission/services not covered

DC Entire admission/services not medically necessary

DO Admission/services not approved for network benefits

NI Information to determine medical necessity not available

OS Professional services/admission covered nonnetwork benefits

PD Partial denial

PM Pending for more information/pend to MCR

PS Sanction physician/facility for nonnotification/ nonnotification

August 2005 TOPS Contract and Claim Reference Manual Training & Development Appendices 417

CCS (PARS) Remark Code

Description

SS Professional services/admission requires payment instructions

TO New enrollee transition nonnetwork benefit

XE Employer approved medically necessary (not covered services)

XF Employer approved NOT medically necessary (not covered services)

XL Medical director approved medically necessary (not covered services)

ZZ Professional notification canceled


Appendix B - Relationship Codes

This appendix lists the relationship codes and descriptions.

RelationshipCode

Description

CD Collateral dependent

CH Child

EE

Employee

HC

Handicapped child

OT

Other

RR

Retired employee

SC Stepchild

SD

Sponsored dependent

SP Spouse

SS Surviving spouse (dependent coverage)

ST Student


Appendix C - Provider Types

This appendix lists the provider type codes and descriptions.

Provider Type Code

Description

AA Alcohol & Drug Abuse Counselor

AC Acupuncturist

AD Adult Day Care Center

AM Ambulance

AN Anesthesiologist

AS Ambulatory Surgical Center

AT Alcoholic and/or Drug Treatment Center

AU Audiologist

BC Birthing Center

BI Brain Injury

CA Certified Alcohol Counselor

CD Cardiac Diagnostic

CF Convalescent Facility

CL Clinic

CN Certified RN Anesthesiologist

CO Counselor

CP Licensed Professional Counselor

CS Christian Science Practitioners


Provider Type Code

Description

CW Social Worker, Licensed Clinical

DC Chiropractors

DI Dialysis

DO Osteopath

DP Podiatrist (DPM)

DR Drug Rehab (Not used-see AT)

DS Dental/Oral Surgeon

DT Dental Technician

DW Doctor of Social Work

FA-FZ Freestanding Facility

FS Free Standing Medical Clinic

HO Hospital, Other

H1 General Acute Hospital

H2 Psychiatric Hosptial

H3 Rehab. Hospital (Physical)

H4 Chronic Disease Hospital

H5 Children’s Hospital

H6 Alcoholism and/or Chemical Dependency Hospital

H7 TB or Resp. Disease Hospital

H8 Unassigned (replaced by AD)


Provider Type Code

Description

H9 Unassigned (replaced by JH)

HH Hospital Hotel

HS Hospice

HW Half way House

IL Independent Lab

IV Home IV Therapy Agency

JM Homemaker Services

JH Home Health Care Agency

LN Nurse, Licensed Practical/Vo

LT Lithotripsy

MD Medical

MN Clinical Specialist in Mental Health Nursing

MR MRI

MS Medical Supply Company

MT Massage Therapist

MW Master of Social Work

NM Nurse Midwife

NU Nutritionist

OC Occupational Therapist

OD Optometrist

OP Optician


Provider Type Code

Description

OT Other

PC Pastoral Counselor

PG Psychologist (Licensed)

PH Public Health or Welfare Agency

PN Psych. Nurse Practitioner

PX Portable X-Ray Supplier

PS Psychiatrist

PT Physical Therapist

PW Psychiatric Social Work

RC Respite Center

RH Rehab Center

RN Nurse, Registered

RX Drug Store/Pharmacy

S1 Special Payee-Employee Deceased

S2 Special Payee-Pay other than Provider

SE Speech Therapist

SC School

SP Special Payee

ST Department Store

SW Social Worker

TN Trained Nurse


Provider Type Code

Description

UC Urgent Care Center

VH Voluntary Health or Charitable Agency

WW Not currently in use

XR X-Ray Clinic


Appendix D - Coverage Codes

This appendix lists the coverage codes and descriptions.

Coverage Code

Description

00 No dependent coverage

01 Universal (sponsored and collateral dependents)

02 Spouse only

03 Children only

04 Sponsored dependents only

05 Collateral dependents only

06 Spouse, children, and sponsored dependents

07 Spouse, children, and collateral dependents

08 Spouse, sponsored, and collateral dependents

09 Spouse and children

10 Spouse and sponsored dependents

11 Spouse and collateral dependents

12 Children, sponsored, and collateral

dependents

13 Children and sponsored dependents

14 Children and collateral dependents

15 Sponsored and collateral dependents

16 One dependent

17 HMO


Coverage Code

Description

32 Spouse only (medical)

33 Children only (medical)

39 Spouse and children (medical)

51 Dependent positive enrollment - subscriber

and only listed dependents

71 Positive enrollment, excluding subscriber (medical and vision)


Appendix E - TOPS Screens Reference Sheet

This appendix contains reference information about the TOPS screens.

Screen Description Category Control Line IDI Individual

Deductible Individual and family deductible and out-of-pocket

Accounting IDI,(Policy #),S(SSN),(First Name),(Rel)

SCI Summary Check Check issue date, check number

Accounting SCI,(Check #)

SDI Summary Check Check issue date, check number

Accounting SDI,(Policy #),S(SSN),(First Name),(Rel),(Draft # from MHI)

SFI Set Family Lifetime and yearly maximums for specific types of benefits

Accounting SFI,(Policy #),S(SSN),(First Name),(Rel)

ARI Abbreviated CCS (PARS) Notification

Notification ARI,(Policy #),S(SSN),(First Name),(Rel)

CMI Case Management (OLD)

Notification CMI,(Policy #),S(SSN),(First Name),(Rel)

DLI CCS (PARS) Physician Notification

Notification Access via the POI screen.

PCI CCS (PARS) Comments

Notification Access via the PSI/POI screen.

POI CCS (PARS) Physician Notification

Notification Access via the ARI screen.

PSI CCS (PARS) Global Notifications

Notification Access via the ARI screen.

PTI Payout Control (NEW)

Notification PTI,(Policy #),S(SSN),(First Name),(Rel)

CEI Customer Eligibility Eligibility CEI,,S(SSN or Enrollee Number) or CEI,(Policy #, Group # or Customer #),S(SSN or Enrollee Number)


Screen Description Category Control Line EPI Employee/Policy

Search Match policy/SSN, search on last name

Eligibility EPI,, or EPI,S(SSN)

MDI Medical Dependent Register Dependent eligibility, last name, effective/cancel dates, student date

Eligibility MDI,(Policy #),S(SSN)

MRI Medical Register Employee eligibility, address, effective/cancel dates, COB indicator

Eligibility MRI,(Policy #),S(SSN)

MLI System Form Letters (Medical)

Form Letters MLI,(Policy #),S(SSN),(First Name),(Rel),(Claim #),(ICN),(Form Letter #)

AHI Abbreviated Claim History Date of service range, charge, paid, date processed, ICN, provider name

History AHI,(Policy #),S(SSN),(First Name),(Rel), *(modifiers)

MHI Detailed Claim History Individual CPT codes, charges, negotiated rates, lifetime maximums

History MHI,(Policy #),S(SSN),(First Name),(Rel), *(modifiers)

MNI Claim Number History Claim numbers (by diagnosis) used in claim processing

History MNI,(Policy #),S(SSN),(First Name),(Rel)

BCI Benefit Comments (Manual)

Informational BCI,(Policy #),S(SSN),(First Name),(Rel)

CCI COB Comments Informational CCI,(Policy #),S(SSN) FCI Freeform

Comments Informational FCI,(Policy #),S(SSN)


Screen Description Category Control Line PII Pre-Existing

Comments Informational PII,(Policy #),S(SSN),(First

Name),(Rel) CRI Ambulatory

Surgery Case Rate Negotiated Rates

CRI,(Table #),(PPI - Factor,% or $Field),(DRG Code*)

DRI DRG Based/Inpatient Hospital

Negotiated Rates

DRI,(DRI Schedule #),(DRG Code*)

FSI EPD Hard $ Schedule

Negotiated Rates

FSI,,

FXI Factor File (Conversion Factor)

Negotiated Rates

FXI,(PPI - Factor,% or $ Field),(Procedure Code*)

NXI Exception Table Negotiated Rates

NXI,(Table # from the PPI - EXCPT TABLE Field),(Procedure Code*)

PPI Participating Physician/facility Rates

Negotiated Rates

PPI,(Provider Prefix,TIN or SSN,Suffix),(Product),(Market Type),(Market #),(IPA)

PXI Room & Board Exception Table

Negotiated Rates

PXI,(Provider Prefix,TIN or SSN,Suffix),(Product),(Market Type),( Market #),(IPA)

RCI Schedule Values (RBVS) or R & C

Negotiated Rates

RCI,,

MEI Electronic Media Claim

Paperless Bill Screens

MEI,S(SSN) or MEI,S(SSN),ALL (all claims received electronically or keyed)

CGI Contiguous Market Table

Provider CGI,(Product),(Market Type),(Market #),(IPA)

FTI Funding Table Provider FTI,(Product),(Market Type),(Market #),(IPA)

IPI IPA General Provider IPI,(Product),(Market Type),(Market #),(IPA)

NAI Provider Specific Y-Code Table # Select/move to NEI,A for codes

Provider NAI,(Provider Prefix,TIN or SSN,Suffix),(Product),(Market Type),(Market #),(IPA)

NPI Nonnetwork Covering Physicians

Provider NPI,(Provider Prefix,TIN or SSN,Suffix),(Product),(Market Type),(Market #),(IPA)

PHI Primary Care Physician History PCP name, TIN, effective and cancel dates

Provider PHI,(Policy #),S(SSN),(First Name),(Rel)


Screen Description Category Control Line PMI Provider

Maintenance TIN or SSN, suffix address, comments

Provider PMI,(Provider Prefix,TIN or SSN)

PRI Provider Association File Active/Canceled contract indicator

Provider PRI,(Provider Prefix,TIN or SSN,Suffix)

*Optional Modifiers


Appendix F - Product Names

This appendix lists current product names and descriptions along with the U-Net (TOPS) product codes.

Name Product Descriptions U-Net Product Code

SELECT PCP Gatekeeper/HMO license

HM1 (EBDS) HM2 (Prime)

PCP Gatekeeper/insurance license

EPO

PCP Gatekeeper/self-funded

EPO

SELECT PLUS

PCP Gatekeeper with out-of-network benefits/HMO license w/insurance wrap

HM3 (EBDS) HM4 (Prime) HM5 (Syracuse)

PCP Gatekeeper with out-of-network benefits/ insurance license

POS

PCP Gatekeeper with out-of-network benefits/self- funded

POS

CHOICE Open access**/HMO license


Open access**/insurance license

EP1

Open access**/self-funded

EP1



CHOICE PLUS

Open access** with out-of-network benefits/HMO license w/insurance wrap


Open access** with out-of-network benefits/insurance license or self-funded

PS1

Open access**with out-of network benefits/insurance license or self-funded. Written as single contract.

HMA

INDEMNITY Any physician/facility can provide services.

IND

MANAGED INDEMNITY

Any physician/facility can provide services. Additional coverage and benefits are provided for specified services if the services have been covered in advance.

MIN

OPTIONS The options product gives members the freedom to receive care for covered services from any physician/facility. In order to receive the highest level of benefits, the members must use participating physician/facilitys. Members may choose to obtain medical care from nonparticipating physician/facilitys.

PPO



OPTIONS Same as the previous options product except with no benefit differential.

PP1

**Open access (Choice/Choice Plus): A locally managed, health plan-based product/program. There is no requirement for members to select a PCP and they may see a specialist without a referral. Note: TOPS product code “NOT” indicates not covered by United HealthCare .


Appendix G - Provider Flag Codes

This appendix lists the provider flag codes that may be displayed on the PMI screen.

Provider Flag Code

Description

O or Blank • No review

1 • Terminated provider • Provider move

2 • Invalid provider record

3 • Pseudo TIN

5 • Pending additional information

• Unable to contact provider

6 • Review PMI (note information in comments line)

• Instructs benefit specialist to see audit exception information

• Prompts benefit specialist to see discount terms on nonhospital suffixes

• Used with status code L for tax levies

7 • Facility does not meet accreditation criteria

8 • Noncompliant with IRS requirements

9 • Special payee


Abuse And Fraud Flags

Abuse and Fraud flags are A through G, and O(alpha).

INDICATOR INSTRUCTIONS Flag A Note: These instructions supersede PMI instructions

• If the bill is for customary services such as an office visit(evaluation and management) and total charges are less than $150, process the claim normally.

• If the bill exceeds $150, deny the claims using UNET Remark Code IP and verify all services with the insured in writing. (send questionnaire) • If the questionnaire is returned, review it for any irregularities, and refer to you MCR nurse if it meets an MCR trigger. Otherwise process the bill using UNET Remark Code HR. • If the questionnaire is returned and fraud is suspected, refer to the Integrity Plus Unit, otherwise process normally.

Flag B Prior to any reductions such as R&C, reduce bill to expenses actually incurred by the insured (i.e., If the pan covers 80% of a fee, and the physician/facility waives the co-pay of 20%, reduce the entire charged amount by 20% and consider the remaining charge as the total bill). Use UNET Remark Code EB to explain the reduction. Example: $200 Original Charge Plan covers 80%. Physician/facility waived co-pay of $40. We will process $160 as the original charge and use UNET Remark Code EB Instructions on PMI screen: Decline 20% of the allowed amount (lesser of fee billed or R&C allowance) with EB until enrollee out-of-pocket met.

Flag C Process normally and mail original paper copies to Integrity Plus. Note: Please do not put any marks or writing on these copies.


INDICATOR INSTRUCTIONS Flag D Deny claims with Remark Code GP and send

system letter 388 Flag F When the Auto-Deny Fraud Unit has flagged a

physician/facility with an “F”, claims submitted by the physician/facility are not eligible for benefit payment. EMC will identify claims for flagged physician/facilitys and auto-deny claims with Remark Code HQ. (We are unable to process this claim as submitted because of billing discrepancies).

Flag G Deny claims with Remark Code GP and send system letter 241

Flag O Claims flagged O should be processed according to instructions on PMI screen. If unclear, refer to your AFL. (More extensive claims instruction may be found on EPD)


Appendix H - Place of Service Codes

This appendix lists place of service codes and their description.

Place of Service Code

Description

All All valid places of service

AS Ambulatory surgical center

AT Alcoholic treatment center

BC Birthing center

CF Convalescent facility

CL Clinic

FS Freestanding treatment center

HM Home

HS Hospice

IH Inpatient hospital

IL Independent lab or x-ray facility

OF Office

OH Outpatient hospital

OL Other locations

RX Pharmacy or medical supplier

SA Substance abuse center


Appendix I - Surgical Modifier Codes

This appendix lists the surgical modifier codes and descriptions that may be used on the RCI screen to access rates in the Schedule/Reasonable and Customary file.

Modifier Description 0 Surgery

1 Consultation

2 Assistant surgeon

3 Anesthesia by surgeon

4 Anesthesia

5 Two surgeons

6 Second surgical opinion


Appendix J - Specialty Codes

This appendix lists the specialty codes that are used to identify providers’ specialties. These are the same codes that exist in the Expanded Provider Database (EPD).

Note: Some old codes may still exist in the TOPS system.

Specialty Alpha Code

Numeric Code

Acupuncture ACU 201 Addition Medicine Specialists AMS 331 Addiction Psychiatry ADP 301 Adolescent Medicine ADL 276 Aerospace Medicine AM 041 Allergy A 252 Allergy And Immunology AI 003 Ambulance Services AMB 046 Ambulatory Surgery Center SCT 302 Anatomic & Clinical Pathology APL 203 Anatomic Pathology ATP 202 Anesthesiology AN 005 Audiology AUD 205 Birthing Center BCT 303 Blood Banking BLB 206 Bronco Esophagology BE 277 Cardiac Diagnostic CAR 513 Cardiac Electrophysiology CDE 304 Cardiac Rehab/Exercise Facil CRE 245 Cardiology C 012 Cardiovascular Disease CD 006 Cardiovascular Surgery CVS 500 Chemical Pathology CMP 207 Chest And Respiratory Therapy CRT 075 Child & Adolescent Psyciatry PSA 257 Child Neurology CHN 208



Numeric Code

Child Psychiatry CHP 209 Child Psychology PPY 268 Chiropractic Medicine CM 035 Clnic Pathology CLP 210 Clinical Biochemical Genetics CBG 305 Clinical Biochemical/Molecular Genetics CBM 306 Clinical Cytogenetics CCG 307 Clinical Genetics CGT 308 Clinical Neurophysiology CNY 310 Clinical Pharmacology PA 211 Clinical Psychology PYG 070 Clinical/Medical Social Worker CSW 063 Colon And Rectal Surgery CRS 015 Cutaneous Micrographic Surg & Onc CSO 311 Cytopathology CPY 312 Dental Medicine DM 050 Dermatology D 007 Dermatology Immunology DMI 217 Dermatopathology DMP 218 Diabetes DIA 278 Deagnostic Lab Immunology DLI 107 Diagnostic Radiology DR 220 Dialysis Center DCT 313 Digestive Diseases DD 509 Dme Medical Supply Company DME 049 Dme Orthotics/Prosthetics Only PED 235 Emergency Medicine EM 042 Endocrinology And Metabolism END 017 Endodontics ENT 051 Endoscopy ENY 294 Family Practice FP 008 Family Practice Specialist FPS 275 Flexible FLX 295 Forensic Pathology FOP 223



Numeric Code

Gastroenterology GE 010 General Hospital GH 000 General Practice GP 001 General Practice Specialist GPS 272 General Preventive Medicine GPM 281 General Vascular Surgery CDS 095 Geriatric Medicine GER 038 Geriatric Psychiatry GEP 314 Gynecologic Oncology GO 221 Gynecology GYN 251 Hand Surgery HS 040 Hematology HEM 093 Hematology/Oncology HO 504 Home Health/Priv Duty Nurse HH 243 Home Health Agency HHA 098 Home Health Aide HHD 067 Home Health/Home Infusion HHI 316 Home Health/Perinatal Care Only HHP 315 Homeopathy HOM 282 Hospice HSP 044 Hypnosis HYP 224 Immunology IG 283 Immunopathology IP 225 Independent Lab LAB 057 Infectious Disease Medicine ID 080 Internal Medicine IM 011 Internal Medicine Specialist IMS 273 Laryngology LAR 284 Legal Medicine LM 285 Licensed Practical Nurse LPN 065 Lithotripsy LIT 512 Marriage And Family Therapy MFT 318 Maternal And Fetal Medicine MFM 226 Medical Director DIR 999



Numeric Code

Medical Microbiology MM 227 Medical Oncology ON 059 Medical Rehab Facility MRE 045 Mental Health Services MHS 506 Mhcd Rehabilitation Facility RFC 317 Movement Disorders MDS 249 Mri/Magnetic Resonance Imaging MRI 511 Neonatology NPM 087 Neoplastic Diseases NPD 502 Nehrology NEP 039 Neurological Surgery NS 014 Neurology N 013 Neurology And Psychiatry NPS 228 Neurometrics NEI 510 Neuromuscular Disease ND 269 Neuropathology NE 229 Nuclear Medicine NM 036 Nuclear Radiology NR 286 Nurse Anesthetist NA 068 Nurse Midwifery NW 069 Nurse Practitioner NP 077 Nutrition Services NTR 089 Obstetrics OBS 250 Obstetrics And Gynecology OBG 230 Occupational Medicine OM 231 Occupational Therapy OTH 061 Ophthalmology OPH 018 Optician OPT 109 Optometry OPY 076 Oral And Maxillofacial Surgery MFS 092 Oral Pathology ORP 232 Oro Facial Plastic Surgery OOF 233 Orthodontics ORD 052 Orthopaedic Surgery ORS 020



Numeric Code

Osteopathic Manipulative Medicine OMM 330 Other OS 287 Other Mental Health Professional MHP 244 Otolaryngology OTO 004 Otology OT 254 Pain Management PMG 319 Pathology PTH 022 Pediatric Adolescent PAD 258 Pediatric Allery Immunology PDA 086 Pediatric Cardiology PDC 085 Pediatric Cardiothoracic Surgery PCS 505 Pediatric Critical Care Medicine PCC 234 Pediatric Developmental PDD 255 Pediatric Emergency Medicine PEM 321 Pediatric Endocrinology PDE 082 Pediatric Gastroenterology PGS 259 Pediatric Genetics PDG 260 Pediatric Hematology Oncology PHO 088 Pediatric Infectious Disease Medicine PID 078 Pediatric Nephrology PNP 031 Pediatric Neurology PDN 262 Pediatric Ophthalmology PDO 263 Pediatric Orthopedic Surgery POS 264 Pediatric Otolaryngology POT 265 Pediatric Pathology PA 322 Pediatric Plastic Surgery PPS 266 Pediatric Pulmonary Medicine PDP 096 Pediatric Radiology PDR 288 Pediatric Rheumatology PRH 261 Pediatric Sports Medicine PSM 323 Pediatric Surgery PDS 114 Pediatric Urology PDU 267 Pediatrics PD 037 Pediatrics Specialist PSP 274



Numeric Code

Pedondontics PDT 053 Peridontics PRT 054 Ph.D. Medical Genetics MGT 309 Pharmacy PHM 047 Physical Medicine And Rehabilitation PM 025 Physical Therapy PT 073 Plastic Surgery PS 024 Podiatrist Board Certified POC 289 Podiatrist Board Eligible POE 290 Podiatry POD 048 Proctology PRC 028 Professional Services Hospital PSD 256 Prosthodontics PST 055 Psych Social Worker PSW 009 Psychiatric Hospital PYH 066 Psychiatric Nurse Specialist PNS 329 Psychiatry P 026 Psychoanalysis PYA 237 Psychosomatic Medicine PYM 291 Public Health PH 238 Public Health & General Preventive Medicine

PPH 236

Pulmonary Medicine PUD 029 Radiation Oncology ROC 032 Radioisotopic Pathology RIP 240 Radioisotopic Radiology RIR 503 Radioloical Physics RPY 324 Radiology R 030 Radiology Center RCT 325 Registered Nurse RN 064 Rehabilitative Medicine RM 253 Reproductive Endocrinology REN 241 Rheumatology RHU 090 Rhinology RHI 292



Numeric Code

Skilled Nursing Facility SNF 072 Speech Pathology SPT 246 Speech Therapy SP 074 Sports Medicine SPM 296 Substance Abuse Services SA 507 Surgery GS 002 Surgery Abdominal ABS 270 Surgery Head And Neck HNS 271 Surgery Traumatic TRS 293 Surgical Critical Care SCC 242 Surgical Oncologists SO 508 Therapeutic Radiology TR 239 Thoracic Cardiovascular Surgery TCS 033 Thoracic Surgery TS 101 Underseas Medicine USM 327 Unknown Nonphysician 099 Unknown Special Physician 097 Urgent Care UCA 328 Urgent Care Center (Hosp Based) ECH 247 Urgent Care Center (Nonhosp) EC 248 Urology U 34


Appendix K - Cause Codes

This appendix lists the cause codes and descriptions.

Cause Code

Description

A Accidents

0 General Sickness

1 Psychiatric

2 Normal maternity

3 Emergency Illness

4 Routine

5 Complications of pregnancy

6 Alcoholism and drug addiction


Appendix I - TOPS Screen Flows

Use the following information to assist you in successfully navigating through the control lines in TOPS. Control lines require information that varies depending on the type of information you wish to access. Eligibility Screens EPI,, .........use to access an enrollee’s social security number CEI,,S(SSN) .........use as primary eligibility screen and starting point

to access other screens. History Screens AHI .........Abbreviated History screen. (First Name & Rel

code in control line) Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI A Takes you to AHI MHI ........Medical History screen. Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI A Takes you to AHI Place in Select field of AHI S Takes you to MHI MNI ........Claim Number register. Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI A Takes you to AHI (First Name &

Rel in control line) Change control line to MNI


Notification Screens ARI ........Notification Records. Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI A Takes you to AHI (First Name &

Rel in control line) Change control line to ARI POI ........CCS (PARS) Outpatient notification and PSI ........CCS (PARS) inpatient notification Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI A

Takes you to AHI (First Name & Rel in control line)

Change control line to ARI Place in Select field of ARI M Routes you appropriately to POI or PSI DLI ........CCS (PARS) outpatient notification TOPS display Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI A Takes you to AHI (First Name &

Rel in control line) Change control line to ARI Place in Select field of ARI M (must be an

oupatient notification)

Takes you to POI Place in 2nd Select field of POI M Takes you to DLI


PCI ........ CCS (PARS) Comments Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI A Takes you to AHI (First Name &

Rel in control line) Change control line to ARI Place in Select field M Routes you appropriately to POI or PSI Place in Select field (2nd Select field of POI) C Takes you to PCI Comments Screens CMI ........Comments Medical Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI A Takes you to AHI (First Name &

Rel in control line) Change control line to CMI BCI ........Benefit Structure Comments Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI A Takes you to AHI (First Name &

Rel in control line) Change control line to BCI CCI ........COB Comments Directions: Start at CEI (May be routed to) EPI (select policy) Change control line to CCI


FCI ........Free Form Comments Directions: Start at CEI (May be routed to) EPI (select policy) Change control line to FCI PII ........ Preexisting Investigator Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI A Takes you to AHI (First Name &

Rel in control line) Change control line to PII PTI .......Personal Tracking Information Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI A Takes you to AHI (First Name &

Rel in control line) Change control line to PTI Miscellaneous Screens IDI ........Individual Deductible Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI I Takes you to IDI SFI ........Set Family Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field A Takes you to AHI (First Name &

Rel in control line) Change control line to SFI


SDI ........Summary Draft Directions: Start at CEI (May be routed to) EPI (select policy) Place in Select field of CEI A Takes you to AHI Place in Select field of AHI S Takes you to MHI Change control line to SDI


Appendix M - Market Type Values

This appendix summarizes the U-Net market types associated with the product lines.

Product Market Type Values

Select, Select Plus

00 Personal physician, commercial business (standard)

04 Personal physician, small access, commercial business

20 Parallel, personal physician, commercial business

Choice, Choice Plus

50 No personal physician, commercial business (standard)

54 No personal physician, small access, commercial business (standard)

70 Parallel, no personal physician, commercial business

Options (PPO) Personal physician

00 Medicaid, personal physician 02 Medicaid risk, personal physician Choice 51 Medicaid, no personal physician 52 Medicare risk, no personal physician

Note: The market type for workers’ compensation (03) is not currently used.

TOPS Contract and Claim Reference Manual August 2005 452 Glossary Training & Development

Glossary

AHI Represents the Abbreviated History screen.

AIDS Represents the Tops Processor Aids.

allied provider A nonphysician or DO professional (e.g., chiropractor, podiatrist, psychologist, social worker, physical and occupational therapist) who provides direct health care services to patients.

ambulatory surgery

The surgery performed in a physician’s office, clinic, or approved ambulatory surgical center.

ancillary provider A non-allied, non-physician, and non-hospital provider (e.g., diagnostic and physiological laboratory, home health agency, and skilled nursing facility) that provides direct health care for patients.

area indicator The indicator that controls whether services are capitated when rendered by a provider within the geographical area of the capitated IPA, as defined by the zip table on the enrollee’s PCP IPA.

ARI Represents the Notification Records screen.

notification A determination that a service is medically necessary.

August 2005 TOPS Contract and Claim Reference Manual Training & Development Glossary 453

Automated Referral System

The system, through a series of call prompts, that guides the PCP to enter the required information for referring an enrollee to a participating specialist physician for an office visit or consultation.

BCI Represents the Benefit Structure Comments screen.

BENDES Acronym for Benefits Description Manual.

care groupings/ covering PCP

The concept that allows members to see a provider who has a relationship with and practices with one of the multiple PCP facilities or clinics without a referral.

CareNet Billing The billing system which produces invoices and manages revenue for nonPRIME (small group) business on U-Net. CareNet Billing draws membership from CES and/or CareNet Qcare, produces invoices based on that membership, and manages the application of cash to the invoices.

CASE1 Acronym for Case Installation Manual.

CCI Represents the COB Comments screen.

CEI Represents the Customer Eligibility screen.


CES (Consolidated Eligibility System)

The membership management system that captures membership enrollment data and provides provider eligibility data to other operations systems.

Choice A locally managed health plan based product where members can “choose” to access any network provider on their own; use of personal physicians is encouraged, but not mandated.

Choice Plus A locally managed health plan based product where members can “choose” to access any network provider on their own; use of personal physicians is encouraged, but not mandated. Members also have the option to choose medical care outside the network, but benefits are paid at a reduced level.

CLMDIS Acronym for Claims Distributions.

CMI Represents the Comments Medical screen.

contiguous market The contiguous markets are those locations where a given market is in close geographic proximity to another market(s).


contract arrangement

Indicates the provider’s type of contract arrangement 1-Group Specific and Customer Sponsored Site Providers; only groups listed on the Site Code Table use this contract line. 2-MKT/IPA Specific Providers; only members in the same MKT/IPA as listed on the contract line, can slot on the contract. 3-Standard Payment and notification reciprocity rules apply for this provider except if the enrollee has the same market and product, but different market type. 4-Nonnational provider can be accessed and used only when the enrollee’s market, market type and delivery systems match the provider of service. 5-Used only on PPO contracts. Indicates a national provider; however, customers of a rival vendor have no access to this provider when parallel networks are in operation. IMCS reads customer entries in this Group Site Code Table as “excluded,” from access to this provider.

coordination of benefits

The determination of whether covered services provided to an enrollee are paid, either in whole or in part, under any other private or government health benefit plan or any other legal or contractual entitlement, including but not limited to a private group indemnity or insurance program.

copayment or copay

A designated amount an enrollee is responsible to pay for covered services under the benefit plan.


coverage documents

The contract, agreement, or policy between United HealthCare and an employer, group, individual, or employee health and welfare benefit plan which sets forth the product(s), level, and type of health care available to members.

CSS Acronym for Customer Service Support.

CSS volume The Preference volume that lists additions and changes to both the system and policies and procedures.

delivery system The system that partially defines the product within the provider’s contract.

diagnosis related group

A system of hospital billing based on prospective rather than retrospective rates. Under a DRG system, the amount a hospital can charge a patient for services rendered is preset by a governmental rate setting commission based on the patient’s diagnosis related group.

DLI Represents the CCS (PARS) Outpatient TOPS Display screen.

Draft A number assigned to a claim which represents a written order directing the payment of money. An actual check is written for the amount due. This check can cover more than one draft.

DRG See diagnosis related group.

EBDS See Employee Benefits Data System.


Employee Benefits Data System

The nonPRIME policy administration component of U-Net. Used by Client Administrators to document in detail and communicate an employer group’s structure, products purchased, premium and fee rates, funding specifications, etc.

EPD See Expanded Provider Database.

EPI Represents the Employee Policy Search screen.

Expanded Provider Database

A United HealthCare national provider database primarily used for U-Net and IMCS systems at this time.

Explanation of Benefits

A printed statement which provides an itemization of services, benefits, and payment information related to those services.

FCI Represents the Freeform Comments screen.

FTI Represents the Funding Table screen.

Group Table# A listing of all group customers using the provider network for group specific, customer sponsored provider network arrangements.

Health Insurance Association of America

The group that maintains a databank of charges obtained from claim payers based on procedure codes.

HIAA See Health Insurance Association of America.


hierarchy indicator A setting of a hierarchy switch in those situations where a provider has multiple IPA affiliations that allows a health plan the flexibility to dictate which should take precedence should a given enrollee possibly match to both.

HIPPA Health Insurance Portability Accountability Act of 1997. See Knowledge Library for a complete HIPPA description.

IDI Represents the Individual Deductible screen.

indemnity product A product under which the enrollee can receive the same level of benefits for covered expenses, regardless of which provider performs the services, including, but not limited to, participating providers.

Independent Practitioner Association

A group of providers; either a contracted legal entity in which the contracted providers have a legal relationship with each other or a representation of market staff that have grouped individually contracted providers together because of similar reimbursement, county, or location. The IPA is a systems structure used for the HMO (and HMO plus), POS, and EPO products for any of the market types.

IPA See Independent Practitioner Association.


IPA Zip Code Table

The table that displays zip code ranges which are considered “in the service area” for the market/IPA. In capitation processing, the provider R&C zip code is compared to this table to determine if the provider is IN or OUT of the market/IPA area.

IPI Represents the IPA General Display screen.

IZI Represents the IPI Zip Code screen.

Managed Indemnity Product

The product that allows members to receive services from any provider, including but not limited to participating providers. It provides additional coverage and benefits for specified services if the services have been covered in advance.

Market Number A service area for a given health plan. It “owns” a unique set of zip codes.

Market Type A standard component for the designation of provider contracts in EPD and TOPS.

MARS See MetraHealth Analysis Repository System.

MCG Acronym for Managed Care Guide.

MCR Acronym for Medical Claims Review.

MCRN Acronym for Medical Claims Review Nurse.


MDI Represents the Medical Dependent Register screen.

Care Coordination The department within United HealthCare that reviews and monitors, under the terms of the health benefit plan, the utilization of covered services provided to members.

medical necessity A medically necessary service, confinement, or supply.

MEI Represents the Electronic Medical Claims Status screen.

enrollee A person who is eligible to receive health care benefits under the terms of a plan.

enrollee network Defines the contracted network of providers, relative to the PCP that the enrollee chose (or relative to open access in the absence of a PCP).

MetCAPS The capitation subsystem of both U-Net and IMCS. It draws membership from CES, aligns membership to providers, and pays the providers prospectively on a per enrollee per month basis (usually) based on that membership.

MetraHealth Analysis Repository System

A DB2 data repository for the analysis and reporting of health care information.

MHI Represents the Medical History screen.


MIS Acronym for Master Informative Schedule.

MMI Represents the Policy Master screen.

MNI Represents the Claim Number Register screen.

modeling A tool that helps each health plan create fee schedules that meet their financial goals by analyzing current fee schedule data in the Health Plans RBRVS rates and R&C data.

MPI Represents the Medical Payment screen.

MRI Represents the Medical Register screen

MXI Represents the Medical Cross-reference screen

NAI Represents the Table of Notifications/Capitation screen.

NEI Represents the Network Pre-covered Service Code screen.

NEIC Acronym for National Electronic Information Corporation.

network indicator A set of contracted provider characteristics, in capitation claim processing, that are used to help determine whether a service is capitated, risk share, or a UHC risk.


Network Provider Plan

See Exclusive Provider Organization/Network Provider Plan.

NPI Represents the Covering Physician screen.

Online Routing System

The system that captures data from service calls and enables service requests to be routed to the appropriate parties for resolution. This system is incorporated into U-Net operations as well as IMCS.

Options The options product gives members the freedom to receive care for covered services from any provider. In order to receive the highest level of benefits, the members must use participating providers. Members may choose to obtain medical care from nonparticipating providers.

ORS See Online Routing System.

outlier Refers to a case or hospital stay that is unusually long or expensive for its type or to a physician practice that uses an abnormally high or low volume of resources.

PARIS See Provider Alternative Reimbursement and Incentive System.

CCS (PARS)

See Patient Notification Review System.


participating provider

A physician or any other licensed or certified health professional, hospital, or health care facility that has contracted with United HealthCare either directly or indirectly through another contracting entity to provide specific covered services to members.

Patient Notification Review System

The utilization management component of U-Net that captures and manages referrals and inpatient and service notifications, provides case management capabilities, access to medical protocols and guidelines, etc.

PCP See primary care physician.

PHI Represents the Primary Care Physician History screen.

PII Represents the Preexisting Investigator screen.

plan A program of health care benefits offered or administered by United HealthCare for groups or individuals.

PMI Represents the Provider Maintenance screen.

POI Represents the CCS (PARS) Outpatient Care Coordination Notification screen.

policy master The database of benefit plan information set up in TOPS for each customer contract providing a foundation for our systems to automate the calculation of benefits.


POLSPI Acronym for policy specific SPIs.

POS See Point of Service Product.

PPI Represents the provider contract screen.

Preference A computer-based reference system that serves as a reimbursement database for the Claims, Care Coordination, Provider Relations, and other supporting departments.

PRI Represents the Provider Association File screen.

primary care physician

A participating physician who is responsible for coordinating all aspects of an enrollee’s medical care. The responsibilities of the PCP include providing medical care to members, as well as referring members to a specialist physician, allied or ancillary provider, or inpatient facility, when appropriate. A PCP is usually a family practitioner, general practitioner, internist, or pediatrician.

PRIME See Proposal, Rating, Installation, Maintenance, and Express Billing System.

Proposal, Rating, Installation, Maintenance, and Express Billing System

An integrated set of systems that handles complete installation and administration of health care products for fully insured small group business.


Provider Alternative Reimbursement and Incentive System

A future system for United HealthCare’s capitation business.

PSI Represents the CCS (PARS) Review screen.

PTI Represents the Personal Tracking screen.

R&C See Reasonable and Customary.

RBRVS See Resource Based Relative Value Scale.

RCI Represents the Reasonable & Customary File screen.

Reasonable & Customary

A method of profiling the prevailing fees in an area and reimbursing providers on the basis of that profile.

Referral The administrative process wherein a PCP requests a Care Coordination benefit notification or certification for an enrollee to be treated by another provider, usually a specialist.

Resource Based Relative Value Scale

The RBRVS assigns relative values to each CPT code on the basis of the resource consumption of the procedure rather than on the basis of historical trends.

RX Acronym for Prescriptions.


SCI Represents the Summary Check screen.

SDI Represents the Summary Check (by draft number) screen.

seamless The ability to move from region to region without having to log in to a different region each time.

Select A locally managed health plan based product where members must “select” a personal physician and the enrollee will be instructed to use the personal physician for referrals to specialists, regardless of whether or not the system tracks those referral notifications.

Select Plus A locally managed health plan network based product where members must “select” a personal physician and the enrollee will be instructed to use the personal physician for referrals to specialists, regardless of whether or not the system tracks those referral notifications. Members also have the option to choose medical care outside the network, but benefits are paid at a reduced level.

service indicator A two-digit code on the provider’s contract indicating if the provider is contracted for specific services only.


service type A procedure assigned to every code on National Procedure File. It represents the grouping of a particular code into a category called service type that represents a standard national definition (i.e., surgery, lab, etc.). The service type is available to many of the provider reimbursement files.

SFI Represents the Set Family screen.

Single Provider Database

The single source for provider entry and related information.

soft dollar The EPD term that refers to any calculated, relative value fee schedule, whether It is based upon RBRVS, McGraw-Hill units, former Traveler’s network units, or former MetLife MCUs.

SPD See Single Provider Database.

specialist physician

A physician who provides specialty care to members. A specialist physician is typically board certified in a particular specialty (e.g., dermatology, neurology, cardiology).

SPI Acronym for Special Processing Instructions.

STMAN Acronym for State Mandates Volume.


subscriber A person who is an enrollee because they are the employee of an employer group contracted with United HealthCare for coverage or because they contract directly with United HealthCare for health care benefits.

SYSPRB Acronym for System Problems Volume.

TACS Acronym for Travelers Automated Certification System.

TCC Acronym for Training Curriculum Group Volume.

TEFRA Acronym for Tax Equity and Fiscal Responsibility October of 1982.

The Online Processing System

The claim subsystem of U-Net.

TMNGM Acronym for Medical Necessity Guidelines Manual.

TOPS See The Online Payment System.

TRAIN Acronym for Training Aids Volume. TRAIN is a Preference volume.

Travelers Automated Certification System

The TACS rules are used to populate the eligibility fields on TOPS with information that is drawn off of CES.

Utilization Management

A process by which United HealthCare reviews proposed or rendered services and makes determinations regarding medical necessity and coverage.

Documents

TOPS Reference Manual