Bills Processing and Adjudication
There are two primary sources for bills:
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Bills submitted to the system from external sources using standard HIPAA transactions.
Possible sources include providers, billing agents, and clearinghouses for Professional, Institutional, and dental services bills. The imaging system transfers paper bills submitted by providers, billing agents, and clearinghouses into 837 HIPAA transactions.
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Bills that originate within the system or bills generated internally by the system within the Bills subsystem.
These include bills keyed in directly through the system’s direct data entry screen.
Regardless of the entry method, the Bills subsystem converts the submitted bill into a common internal format, based on bill type, for processing. The bills loading process falls outside the scope of this document.
During the adjudication process, data validation is performed based on many factors, such as claim type, provider, taxonomy, client eligibility, etc. The following subsystems configure the business rules:
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Client
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Reference
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Provider
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Authorization
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Rate Settings (for example, Pricing)
The Medicare policies for bills are translated into adjudication business rules and edits executed via RuleIT.
During adjudication, edits are posted against a bill based on the disposition assigned to the error code. A disposition is assigned and maintained for each error code in the Bills subsystem. Dispositions are date-sensitive to enable changes to be made by staff, based on business requirements.
All bills are processed at the claim line level with the exception of some “Institutional” bill types. To maintain the integrity of the original submitted bill, a bill is not fully adjudicated until every line of service on the bill is resolved to pay or deny. If any edit is posted on a bill that is suspended but does not have a denial edit posted at the header level, the entire bill is suspended for review.
The error dispositions are as follows:
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Ignore the edit and allow payment of the bill or service.
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Pay and report the bill or service.
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Deny the bill or service.
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Suspend the bill for review by the resolution bills adjudication staff (bills worker).
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Super suspend the bill.
The Bills subsystem maintains a history for inquiry and adjudication processing. Historical Bills are used for some edits, including duplicate checking and service limits.