Claims Handbook

If the CCPI claim has an Office Service note marked on the Claim, process the claim using the CI code “hi.”
Additionally, if there is a line with the cc CI code as well as an Office Service note, override the subsequent
hospitalist lines pending ii with CI code “hi.” Do NOT OVERRIDE THE “cc” CI code.
Deny the claim “hp” if a Crescent City Physicians’ claim does not have cc CI code nor does it have an Office
Service note, but does have a participating facility listed on the PHN Water Cooler Hospitalists Grid.

Note xxxxF: Claims with procedure codes ending in the letter F (xxxxF), should pay $0 (zero) for hospitalists.
Additionally, these service lines should have “hi” in the CI field as well as automatically pay “FA,” which means
procedure code not eligible for payment.

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Note Kenner Hosp Based Clinic: If the facility on the claim (field name - Facility 1) is from Kenner Hosp Based

Clinic at 200 West Esplanade, the facility is a clinic. (The hospital facility is 180 W Esplanade, which should be
denied with hp.) Claims from the 200 West Esplanade address should be processed using the CI code “hi.”

Note Kindred Hospital: Kindred Hospital is a LTAC (long-term acute care) facility, which does not participate in
the hospitalist program; therefore, process the claim using the CI code “hi.”

LA Extended Care Hospital: LA Extended Care Hospital is a LTAC (long-term acute care) facility, which does not
participate in the hospitalist program; therefore, process the claim using the CI code “hi.”

Touro/Ochsner-Kenner (As of 8/15/2014): Updated 1/9/2015
 If the servicing provider is listed in the table below, deny the claim with EX “hp,” which means hospitalist

coverage applies.
 If the servicing provider is not listed in the table, process the claim using the CI code “hi,” which means

IPA PCPs allowed services outside of hospitalist contract.

TOURO as of 8/15/14 OCHSNER-KENNER
John Amoss Najy Masri
Paul Thien Kristi Boudreaux
Shane Sanne Sanjay Kamboj
Shane Guillory Ross McCarron
Jorge Martinez
Lee Engel
Sanjay Kamboj
Ross McCarron
Najy Masri
Seema Walvekar
Danny Englert
Matt Jordan

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Claims Pend Processing Profile

Pend: UR Queue Profile
Servicing Provider Has Been Terminated
Pend Description One
Pend Category July 6, 2006
Date Implemented December 9, 2011
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

UR Queue claims generate when the servicing provider has been terminated.

 Open two Amisys Advance screens.

First
 Open Amisys and login.
 Click “Claims Processing” on Main Menu.
 Click “Medical Readjudication” under the “Readjudication” heading.

Second
 Open Amisys and login.
 Click “Provider” on Main Menu.
 Click “Provider Affiliation” under “Provider” heading.

 Determine if claim is Electronic or Manual and populate it.
Electronic
 Use EDI Viewer to view the claim when the claim contains the letter “E.” (e.g. 11265E030758)
 Open EDI Viewer and login.
 Enter claim number in blank field.
 Press Enter and claim image should populate.
Manual
 Use Macess when the claim contains the letter “M.” (e.g. 11263M001302 and
112970000010)
 Open Macess and login.
 Select “Open” from the toolbar.
 Select “Document” from the drop down menu.
 Put cursor in “Document ID” field.
 Enter claim number.
 Press Enter and claim image should populate.
 If no claim populates, wait two days for Scanning Department to upload the image; however, if
 there is no image after those two days, inform management.

 Review the information on the Amisys readjudication screen and verify it matches the
information on the claim image.

 Add any missing information if necessary.
 Certain modifiers are the difference between a claim being paid and rejected.

 Correct the readjudication screen information if necessary and click ReAdjudicate or REset/Adj
to save changes.

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 Verify that the Referring NPI # on claim is the same provider is Amisys.
Open an ecare screen
 Open Internet Explorer.
 Type www.ecare.com in the URL field and hit Enter.
 Click “NPI.”
 Place cursor in NPI field and type in NPI number.
 Click “Process” or hit Enter.
 Provider’s information will generate.
 Compare provider name and address.

 Verify that the Servicing Provider NPI # on claim is the same provider in Amisys through ecare.
 Click “NPI” on the left pane of ecare.
 Place cursor in NPI field and type in NPI number.
 Click “Process” or hit Enter.
 Provider’s information will generate.
 Compare provider name.
 Click blue NPI hyperlink to view more precise information referring to name and/or
address.
 If there is no Servicing NPI, deny claim.
 Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
 Click on drop down menu under “Claim Status.”
 Select ”51-Denied.”
 Place cursor in “Ex code” field.
 Type “np.”
 Click ReAdjudicate to save all changes made.
 Verify the claim status and Ex codes on the service lines.

 Space out physicians’ four digit affiliation(s) and click ReAdjudicate. The system will generate
affiliation(s).
 Pick the affiliation that matches the member/region.
 Match the Referring Provider affiliation with the member’s PCP if they are the same.
 Match Referring Provider affiliation with the member’s Provider if they are the same.
 Remove the Referring Provider if the affiliation is not generated after spacing it out.
 Enter the member’s PCP number and affiliation in the Referring Provider fields.
 Click ReAdjudicate to save all changes made.

 Verify the correct Provider has been selected.
 Highlight and copy the “Prov #” field from readjudication screen.
 Paste number into “Provider” field on Provider Affiliation screen.
 Type or copy the four digit affiliation from the readjudication screen to affiliation screen.
 Hit Enter and Provider information populates.
 Verify that the Effective Dates, Carrier, Region, Area (AA), and IRS# (TID) are correct.
 If the information does not match, pend the claim with one of the Provider Relations
pend codes below.
 Locality (AA) does not have to match with Referring Provider.
 Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.
 Click on the Claim Status drop down menu and select “41- Pended.”
 Place cursor in Ex field and enter the Ex code from the list below that associates with
the reason the claim is being pended. (E.g. Par Address Doesn’t Match EX code = 73)

Participating Providers (Status PP, CP, RP, LP, or OP)

Par Medicare Number Needed (31D) - Amisys #0003 - EX code = 84
Par Member Region Doesn’t Match (31E) - Amisys #0005 - EX code = 85
Par Additional Tax ID# Needed (31C) - Amisys #0002 - EX code = 83
Par Address Doesn’t Match (31B) - Amisys #0001 - EX code = 73

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Locality Does Not Match – EX Code = BU

Non- Participating Providers (Status OA or NP)

Non-Par Medicare Number Needed (322) - Amisys #0010 - EX code = p1
Non-Par Medicare Not in System (324) - Amisys #0009 - EX code = p3
Non-Par Member Region Doesn’t Match (323) - Amisys #0008 - EX code = p2
Non-Par Additional Tax ID# Needed (321) - Amisys #0007 - EX code = p0
Non-Par Address Doesn’t Match (320) - Amisys #0006 - EX code = 98

Review Area Field - EX code = BU (manual pend)

 Verify that “Pay Class” does not read “DUMMY”.
 If it reads “DUMMY” but the Carrier and Region match the member’s Carrier and
Region, then it is OK.
 If it reads “DUMMY” and Carrier and Region do not match, space out affiliation and
readjudicate.
 Verify the correct affiliation has been generated.
 If that does not work, enter the member’s PCP number and affiliation in the Referring
Provider fields.

 Verify address by clicking “Aff Address” in the left-hand pane.
 If the servicing provider’s address and Amisys do not match, review the Provider’s
Remarks in Amisys.
 Copy the Provider # from adjudication screen.
 Click on “Remarks” and a new screen will pop up.
 Click on the binoculars/find icon on the top tool bar.
 Click on the “ID# Type” drop down menu.
 Select “PV.”
 Place cursor in “Provider#:” field and paste Provider #.
 Hit Enter and the remarks will display.
 Hit the “Next” button in the top tool bar to scroll through.
 If the remarks state to pay to a different address than what is stated on
the readjudication screen and it is also on the affiliation screen, it is OK
to pay.
 If the remarks do not match the information on the provider claim, pend
the claim with the Provider Relations pend code for “address doesn’t
match” from the list above.

 Confirm claim address and Amisys address are correct.
 Exit out of address pop-up window.
 Click binoculars/find icon on the top tool bar to clear fields.

 Select “Diagnosis, Procedures & Service Detail” tab on the readjudication screen.

 Check that the Status “St” has ALL 10s, 11s, 12s, 50s, 51s, or a combination of 10s, 11s, 12s,
50s, and 51s.
 If the status contains ANY other codes, DO NOT demand draw. The claim will fall into an
appropriate queue to be fixed.
 Do not Demand Draw 31 or 41 status.
 If there are other EX Codes remaining and you are able to process them, continue to process
them.
 It is OK if there are other Ex codes besides AP or CP if you do not know how to process them.

 Demand Draw the claim from the queue.
 Maximize Macess.
 Select “My Work” from tool bar.
 Select “Workflow Examination” on the drop down menu.

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 Click the “Draw Mode - Demand” icon.
 Click the “Select Work Item” icon.
 Place cursor in Document ID field and type in claim number.
 Check New, Pended, and Rerouted options in Work Item Status section.
 Hit Enter.
 Select “Work Flow Examination.”
 Select “Complete.”
 Select “Save” and X out the screen.

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Claims Pend Processing Profile

Pend: v5 Queue Profile
Possible Duplicate by Provider (iCES pend code)
Pend Description Two
Pend Category October 10, 2010
Date Implemented April 23, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

The purpose of this pend is to determine what other claim(s) the claim is duping against and verify that the
current claim is not a duplicate or corrected claim.

 Review the information on the Amisys readjudication screen and verify it matches all of the
information on the claim image.

 If there are two identical service lines submitted by the provider, verify if there are any modifiers
to support that they are different.

 If they are different, process both lines.
 If they are identical and have no differences, deny the second line Status 51 – EX Code DU.

 Definition of a corrected claim: Corrected claim is stamped or written on claim, bill type ends in
seven, or something has changed on the claim. (e.g. modifier, billed charges, etc.)

 Demand Draw the claim from the queue.

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Claims Pend Processing Profile

Process: VF Queue Profile
Price Manually According to Provider Contract/Auth
Pend Description Three
Pend Category August 6, 2014
Date Implemented
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

Cypress Pointe Surgical Hospital (Provider #100067845)

Cypress Pointe Surgical Hospital claims (provider #100067845) are manually reviewed to determine if CI code
CY is required for pricing according to contract.

Effective July 1, 2014, the following pricing guidelines apply:
- 100% of the Medicare allowable for claims submitted with implant revenue code 278.
- 85% of the Medicare allowable for claims submitted without implant revenue code 278.

 Review the claim image to determine if revenue code 278 is present.

 If revenue code 278 is present:
 Enter CY in the CI field on the “Service Detail” screen.
 Click Readjudicate.
 Process the claim according to normal processing guidelines.
 The claim will process at 100% of the Medicare allowable.

 If revenue code 278 is not present:
 Click EX Overrides.
 Type “VF” in the Old EX field and type “AP” in the New EX field. Press Enter.
 Type “Y” in the “Are the above overrides correct” field.
 Press Enter and exit the screen.
 Click Readjudicate.
 Process the claim according to normal processing guidelines.
 The claim will process at 85% of the Medicare allowable.

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Claims Pend Processing Profile

Pend: vp Queue Profile
Pend For Vascular Access Duplicate Codes/Assign Reimbursement
Pend Description Management
Pend Category September 21, 2011
Date Implemented December 10, 2013
Date Updated/Revised Management
Person(s) Responsible As defined below:
Processing Instructions

The billing provider on the claims is Vac of New Orleans or Vac of North Shore Louisiana. The payment should
be made to the individual provider (Philip Gardner, Matthew Sanger or James McGuckin.)

 The allowed amount cannot exceed the contracted rate amount or the bill charges submitted on the
claim.

 Review the claim information, if the servicing provider information is not correct update the information
in Amisys to the correct provider.

 Review the procedure codes on the claim and match them to the procedure codes on the contract.
 Pay the highest billed procedure code, if it is more than the billed charges pay the bill charges.
 To pay the line, you have to go into the amount override screen.
 Override the vp on the line you priced.
 There can be multiple lines pending vp; once you pay the primary code all others should pay 0.
 To pay zero on the other lines, if the line pending is a code from the Primary Codes use the CI code of

V8 to pay 0. If from the multi procedures use the CI of V0 to pay 0.
 All inclusive codes should pay 0 with an EX code of 5J (covered under the global per diem/per visit

rate).
 All codes from vascular access require an authorization.
 If there is no authorization on file, the claim should be denied JL.
 If the count is greater than 1, the claim will pend vv. We should only pay one unit.

Effective 12/01/2013, Vascular Access have new CI codes to be used to process their claim.
 Review the note field on the claim and then apply the CI code according to the codes (see
attached rate sheet).
 If no note, put in the CI code of V8 to each line. The pricing line will pay out zero.
 All codes for Vascular Access require an authorization, if no authorization deny the claim QQ.
 If the note field does not contain the code, deny the claim DJ.

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Claims Pend Processing Profile

Pend: XG Queue Profile
Hospitalist Claim in Facility Location with Specialty or OUTOFIPA Affiliation
Pend Description Two
Pend Category December 1, 2006
Date Implemented April 23, 2013
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

Review affiliations if location that’s being billed is a hospital location (21,22,23,31,61) the hospital payclass
should be picked, these claims will not pay a dollar amount the provider is capped – should return an EX code of

RI (Services paid under hospitalist program. If the location is 11 the other affiliation should be picked these
should pay a dollar amount.

If payclass option is not available, pend to provider relations to review. The remarks should read “Please update
payclass to include hospitalist”.

Claims Pend Processing Profile

Process: zz Queue Profile
Mental Health Network Pends
Pend Description Three
Pend Category January 1, 2014
Date Implemented February 25, 2016
Date Updated/Revised Claims Examiners
Person(s) Responsible As defined below:
Processing Instructions

The purpose of the zz pend code is to ensure that inpatient and outpatient psychiatric facility claims with a
primary diagnosis code that ranges from 290-319 (ICD-9) pend for manual review.

For a list of ICD-10 codes that pend for manual review, review the MHNet ICD-10 Diagnosis Codes
spreadsheet located at: \\phn-win-30\Shared\Departments\Claims Department\Training Material\Claim Pends\zz
MHNet ICD-10 Diagnosis Codes 02.2016.xlsx.

 Determine and confirm the specialty of the attending provider.

Open Provider Affiliation screen in Amisys
 Enter the attending provider number and affiliation.
 Press Enter and the provider information will populate.
 The provider specialty is located in box “Spec (SP).”
 Determine the specialty of the attending provider.

Open an eCare screen
 Open Internet Explorer.
 Type www.ecare.com in the URL field and hit Enter.
 Click “NPI.”
 Place cursor in NPI field and type in the attending providers NPI number from EDI Viewer.
 Click “Process” or hit Enter.
 Click the NPI number highlighted in blue.
 Scroll down to the provider’s taxonomy code.
 Hover over the taxonomy code, this will display the provider’s specialty.
 Confirm the provider’s specialty in Amisys and eCare match.

 If the provider’s specialty in Amisys and eCare do not match, inform your

supervisor/manager. Your supervisor/manager will request from Provider Affiliations
confirmation or possible update of the provider’s specialty in Amisys.

 If the provider’s specialty is listed below, deny the claim with EX code FM, “Claim forwarded to
contracted mental health/behavioral health provider,” regardless of whether or not the claim is

hitting an authorization.
 (MH) Mental Health
 (NY) Neuropsychology
 (PC) Psychology - Child
 (PS) Psychiatry
 (PY) Psychology-phd/psyd

 If the provider’s specialty does not fit the above criteria, override the zz pend code with EX
code AP and process the claim following normal processing guidelines.

 Override the zz with EX code after confirming the attending provider’s specialty.

Single EX code
 Select “Diagnosis, Procedures & Service Detail” tab.

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 Click “Service Detail.”
 Click “REset/Adj.”
 Put cursor in “EX code” field.
 Type in “AP” for approval, or the denial code “FM.”
 Click disk/save icon and close/X out that screen.
 Close/X out the next screen as well.
Multiple EX codes (used most often)
 Select “Diagnosis, Procedures & Service Detail” tab.
 Click “EX Overrides.”
 Place cursor in the “OLD EX” code field and type “zz.”
 Press Tab.
 Type “AP” in the “NEW EX” code field, or the denial code “FM.”
 Press Enter.
 Enter “Y” when the system asks “Are the above overrides correct? Y / N.”
 Press Enter and close screen.
 Click ReAdjudicate and select “Diagnosis, Procedures & Service Detail” tab. The

zz code should be replaced with the new EX code.
 Go into Service Detail for each service line and enter “AP” or ”FM” (as appropriate) for the

EX Code if zz does not change.
 Click REset/Adj to save changes.
 Close/X out screen and click ReAdjudicate.

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