We recently sent a survey regarding the new ProviderOne remittance
advice (RA) to a sample of 2,000 providers.  The following is a summary
of what we have learned - followed by a list of the new "requirements"
identified.  We are in the process of asking our contractor to provide
estimates of both time and money for making these types of changes.  

Once this is complete, the Department can determine what we have the
funding and capacity to do, and our contractor can create a prototype
for DSHS approval.  The Department has a strong interest in improving
the new RA.  The scope of any improvements will be based on the
financial estimates we get back from our contractor.  

We realize that time is of the essence and the Department is moving as
quickly on possible on this issue. We do, however, want to ensure we
take the appropriate steps up front to get it right.  Building in time
to gather provider input has been time well spent.  Provider feedback
revealed some important data elements needed and critical formatting
changes that have the potential for making reconciliation easier.

Summary of what was learned from providers:

The ProviderOne RA does not contain data elements that were provided on
the legacy (MMIS) RA.  As a result, providers report difficulty:

-          Reconciling large documents to determine what they were paid
for, 

-          Determining the payment methodology DSHS used, 

-          Applying payments to the correct patient accounts,  and

-          Preparing a bad debt cost report to get reimbursed for
Medicare coinsurance days.    

The most critical missing data elements include:

-          Class code

-          Sales tax and total

-          Client date of birth 

-          Identification of ADATSA/GAU clients (contained an * on the
legacy RA)

-          Pricing action (i.e. DRG)

-          Pharmacy RX# on 835 (separate Change Request in progress to
address this)

Format and Sorting

In addition, the format of the new RA does not appear to maximize the
number of claim lines per page.  Overall, the size of the RA is a big
concern to providers due to costs of printing, time to download and
inability to reconcile to such large documents.  Providers report that
this has become an administrative burden.  

There are other formatting and sorting issues that are contributing to
the difficulty in reconciliation.

-          The original credit and debit transaction control numbers
(TCNs) are not grouped together, making it difficult for providers to
reconcile when the elements are often 20-30 pages apart.  

-          Providers are having difficulty differentiating audit
overpayments for IRS liens.

-          Claim status and subtotals are sorted by invoice type
(professional, institutional and dental), not claim type.

-          Managed care and TPL information is being returned for all
clients, even when a claim is paid, which is causing confusion for
providers.  

The following additional formatting issues are being addressed through
other efforts:

-          Claims are not sorting alphabetically beyond last name.

-          Crossover claims are mixed in with other claim types. 

-          Entering first name during direct data entry (DDE) is not
available, resulting in lack of first name on RA.

Summary of Changes under consideration (new system requirements):

A group of 2,000 providers were surveyed to validate that we have
identified the most important requirements and changes.  Over 400
providers representing nearly every provider type participated in the
survey.  There were no audiology/speech or oxygen providers that
responded to the survey.  

A.	Maximize the number of claim lines per page with a goal of 25-35
claim lines per page on the RA (considering the following changes)

1.            Maximize page margins

2.            Remove provider name and mailing address from the top of
each page

3.            Remove prepared date from the top of each page

4.            Display column headings only once at the top of each page
(not for each client)

B.	 Add sales tax 

C.	Add total of sales tax on summary page

D.	Add class code  

E.	Add original TCN number for adjusted claims

F.	Add client date of birth

G.	Add pricing action code/pricing rule (i.e.  DRG)

H.	Add client's Benefit Service Package (7 characters) 

I.	Add rendering/servicing physician's name

J.	Add client's middle initial

K.	Add tooth number 

L.	Add modifier used on the claims

M.	Add authorization number

N.	More clearly differentiate audit overpayment from IRS lien
(adjustment amount on payment status - second page)

O.	View claim status and subtotals by claim type - not invoice type
(professional, institutional, dental)

P.	Within the adjustment category, create separate sections for
paid, denied and in process

Q.	Claims to be sorted in the following hierarchy:

	a.	Claims status; client name (client id); claim type

R.	Display MC plan name and TPL ONLY when claim denies for one of
these reasons

S.	Only report client summary if there are multiple claims for the
client

T.	Group new TCNs and paid or denied TCNs together on adjusted
claims (credits, debits and original), keeping whole claim together

U.	Repeat client name if claim is separated by a page break

We hope you find the update of value.  

Thank you.

 

KD/JHS