Processing an INN Outpatient Hospital Claim in Facets

Today I am giving an example of INN Outpatient Hospital claim. These are the steps that you are supposed to perform to process an INN  Outpatient 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 Outpatient Hospital claim using following data: INN Provider 000011117777 (Hospital);Type of Bill: Type-class 013, Frequency 01; Statement Covers Period:01/01/2017 To 01/01/2017; Admission date and Discharged date; Revenue code 0360, CPT code 36561, diagnosis code ICD10  C50912,  Subscriber ID-100200300, Charges (Hospital Fee) $500, 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 01/01/2017; 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), Revenue code, CPT code, Charges(suppose $500), Unit(suppose 1), Total charges(Suppose $500).

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 000011118888

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.

Note: Revenue code is a unique 4 digit Numbers code which tells an insurance company whether the procedure was performed in the emergency room, operating room or another department.