Today I
am giving an example of INN Inpatient Hospital claim. These are the steps that
you are supposed to perform to process an INN Inpatient Hospital claim in Facets under medical
plan.
Step 1: Open
Test Lab Module of ALM, you will see the following test case in test lab module
of ALM/QC.
Test Case description:
Process a claim for INN Inpatient Hospital claim using following data: INN Provider 000011113333
(Hospital);Type of Bill: Type-class 011, Frequency 01; Statement Covers Period:
01/01/2017 To 01/03/2017; Admission date 01/01/2017 and Discharged date 01/03/2017;
Revenue codes 0110, 0250, 0272, 0636,
diagnosis code ICD10 K5732, Subscriber
ID-100500700, Charges (Hospital Fee) $2500, Unit 1(One Time Visit).
Expected
Result: Claim should process at 80% of the allowable.
Step 2: Open
Facets Claims Processing application group and scroll down to Hospital Claims
processing application.
Step 3: In the
Indicative page of Medical Claims processing application, enter the following
data: Subscriber ID and select a member from the drop down menu, Claim Received
Date(suppose Jan 25, 2017), Provider ID and Diagnosis code, Type of Bill:
Type-class 013, Frequency 01; Statement Covers Period:01/01/2017 To 01/03/2017;
Admission date and Discharged date (01/01/2017)
Step 4: Now
double click on Line Item page and when you are in Line Item page, enter the
following data: Date of service (01/01/2017 to 01/03/2017), Revenue codes,
Charges(suppose $2500), Unit(suppose 1 per revenue code), Total charges(Suppose
$2500).
Step 5: Press
F3 on your keyboard to process the claim. Now check the claim pricing.
Step 6:
Claim should process at 80% of the allowable. if the expected result matches
with the actual result, save the claim by pressing F4 on your keyboard. Facets
will generate a claim ID automatically. Suppose the claim ID is 000011115555
Step7: Open
Lab module of ALM, take required screenshots and type as follows in actual
result edit box:
Claim
processed as expected and write the claim ID and pass the test case.
Thanks Blogger for your Nice explanation on inpatient claim on Factes.It's very helpful and very practical example. please keep continue writing like this.we all will be very helpful.
ReplyDeleteThanks
Thank you very MD Harun Rashid for great comment.
ReplyDeleteHI Blogger ! you wrote in your heading "INN Inpatient Hospital Claim". But the first line you wrote "INN Outpatient Hospital claim."
ReplyDeletePlease make it clear.
Thanks
This comment has been removed by the author.
DeletePlease check Healthcare Terminology section, here INN provider, OON provider, Inpatient and Outpatient have been explained.
ReplyDeletePlease also visit the post named "Outpatient Care and Facets". Hope everything will be clear to you.
ReplyDeleteHi Blogger. can you please explain "Claim should process at 80% of the allowable". i have a two question.
ReplyDelete1) Why claim should be process 80% allowable process ?
2) what do you mean by allowable process ? please explain.
Allowable means negotiated cost that the insurance companies will give the providers. For each specific type of treatment, there is a negotiated price. For example, if the allowable charge is $100 for routine office visit and the provider submits a claim of $120 for the same service, the insurance company will consider up to $100.
ReplyDeleteNow, let us explain your first question. Suppose coinsurance rate is 80%/20%, that is, if the claim amount is $100 and the subscriber has already paid his deductible amount, here 80% of the allowable means the insurance company will pay $80 and the subscriber(patient) will pay $20.
Thanks for your kind explanation.
ReplyDelete