Agencies who are or will be submitting Medicare PPS claims for Pre-claim review will need to update the Main Office Software to Version 6022 dated 09/12/16.

Upon receipt of the provisional approval and Unique Tracking Number (UTN), agencies will need to enter the UTN in the ‘Edit PPS Billing screen for each PPS Billable Assessment.  The UTN should be entered into the 2nd Auth/UTN field found in the section for ‘Final Bills Only’ PRIOR to creating and submitting the final claim.  The software will place the UTN appropriately in the electronic final claim.  The UTN will print immediately after the Treatment Authorization Code on the UB04.  The UTN may overlap the boundaries of the field on the UB04 print form.  As Palmetto GBA is the intermediary for states submitting pre-claim review and Palmetto GBA only accepts electronic claims, the overlap will only occur on printed UB04s kept for agency records.

As a reminder:

Agencies located in Illinois are to submit claims with a UTN for Start of Care dates August 3, 2016 or later.

Agencies located in Florida will start the pre-claim review process no earlier than October 1, 2016.

Agencies located in Texas will start the pre-claim review no earlier than December 1, 2016.

Agencies in Michigan and Massachusetts will start pre-claim review no earlier than January 1, 2017.

Agencies will need Main Office Software Version 6010 dated 08/15/16 and Clinical Point of Care Software Version 2478 dated 08/15/16.  The Authorization Request document now has an additional tab for Insurance specific Authorization request/ justification items related to homebound status and skilled need.  Upon accessing the Insurance tab with in the document, select the Navinet button in the upper right corner of the screen.  Navinet/Highmark specific items will be available for selection.  Upon completion of all applicable items justifying the request, select the post button.  Items will now appear on the Insurance tab screen and will be included in the print form for direct data entry into the Navinet system.  Be aware, if items are forgotten in the intial posting, the selection screen does not save the previously marked items.  All responses will need to be selected again.  Posting beyond the initial time will clear previously posted items.

Updated instructions through Navinet indicate that the OASIS file to be submitted with an authorization request must not be in a zipped folder.  Navinet will accept only the xml file.  Agencies with Main Office Software Version 6002 dated 08/01/2016 will note the check box in the ‘Create XML’ screen will no longer be automatically marked.  The software will only create the XML file of the OASIS.  Agencies not yet utilizing software version 6002 or later will need to un-mark the ‘zip’ check box manually prior to creating the xml file.

Beginning August 1, 2016 agencies requesting new and/or additional authorizations for services for Highmark commercial and Medicare Advantage members will need to upload the Patient (member) OASIS in XML format and a PDF of the patient’s Plan of Care.  To accommodate the need to generate an XML file of the required OASIS a new button to perform the task has been made available with Main Office Software Version 5998 dated 7/26/2016.  The button, “Create XML” will appear at the bottom of the patient activity screen when the OASIS Assessment is highlighted in the grid.  The new button can also be found at the top of the Assessments tab in the Control Board in PT Activities section.  Again when the desired OASIS Assessment is highlighted selecting the button will offer the Export File screen to allow users to indicate the location on their local computer where the file is to be saved.  The software will auto-populate the file name.  The software will create the XML file and place it in a zipped folder.  Agencies will need to submit the entire zipped folder when requesting the authorization or reporting Discharges and Transfers to Inpatient Facilities through Navinet.  Authorization XML files created in the Assessment tab of the Control Board will have an Auth XML Date auto populated for tracking purposes.

PDF files of a patient’s Plan of Care can be created through the print feature available historically within the software.

As of January 31, 2014, Managed Hosting Clinical Software users will have a new screen available for tracking Authorized Visits.  The button to open the Authorization Board is available when the patient’s medical information screens are accessed.  Each authorization will display with a listing of corresponding authorized visits.  Authorization totals and remaining balances are displayed.  Visits without an authorization will also be listed.

We have added the responsible employee to the sort order for the Authorization Status Report and the Possible Billing Errors Report.

On the authorizations screen under patient maintenance we added a “Authorizations vs Visit Only” column to the balance displays.  The existing balance column includes scheduled and unverified visits.  The new column includes only verified visits when calculating the balance.  This was a request from one of our agencies.

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