The Electronic Media Claims (EMC) software allows hospital
and physician claim detail to be collected from an existing patient information
system and loaded into an extensive database. From this database, the claim
information can be edited, modified, and formatted for direct submission to
multiple payers. Claims are not routed through a third party; therefore, no
per claim fees are associated with processing. The EMC software functions
entirely on an IBM AS/400. Our company has installed the system and written
interfaces for several AS/400 resident patient information systems including
McKesson Series 2000, Keane First Coast Systems, and Siemens MedSeries4®.
There are several benefits of claim processing on the AS/400:
1. The EMC software resides on the same AS/400 platform used for the patient information system, therefore a seamless interface may be provided without additional hardware being necessary.
2. Any workstations with access to the AS/400 may reference the claim information contained in the EMC system while using existing security.
3. Due to the extensive storage capabilities of the AS/400, large amounts of history may be stored in the EMC database.
4. All claim information and format generators are provided with the EMC system. This detail may be submitted directly to the payer, therefore no per claim charges are applied.
5. The EMC claim information data files and the associated history which resides on the AS/400 are accessible for reporting and/or download to other computer platforms or systems.
How does claim information enter the EMC software?
Each patient information system interface is customized depending on the payers being defined. Claim detail enters the EMC system by any of the following four methods:
1. Modifications are provided by our company, under the direction of your personnel, to key billing programs allowing claim information to populate a series of interface files.
2. Print files are generated on the AS/400 by your patient information system. Our company would then provide programming to translate this information into a series of interface files.
3. ANSI X12 837 claim files are generated by your patient information system. Our company would then provide programming to translate this information into a series of interface files.
4. Your information systems personnel provide programming to populate a series of interface files.
All information contained in the interface files is analyzed, and claims are generated in the hospital and/or physician database. As claims enter the system, they are identified as outstanding and given a unique date-and-time stamp.
Are the claims edited before submission?
Claims contained in the EMC database may be edited either in a batch or individually. Any claims which are edited in a batch, may be automatically corrected when no errors are found. Edits are driven by files which are defined by payer and type of bill. Each edit record contains a reference number and an error description which may be either printed or displayed. Separate records are used for editing hospital and physician claims. Even though standardized code sets are loaded into the edit files, a maintenance module is provided which allows edits to be modified, copied, or deleted.
Maintenance modules are provided with the EMC software for claims requiring modification. Either number or name may be used to access these records. The editing module is called for each claim accessed and displays any error detail. A UB92 or 1500 may also be printed from within the maintenance function. In addition, a hot key is provided which allows access to the patient information system.
None of my electronic payers are the same, how are my claims formatted?
Claims contained in the EMC database are formatted using
ANSI X12 837, NSF, and proprietary EDI standards. Each electronic payer utilizes
a separately maintained format generator. Formats may be generated separately
or in groups. As claims are formatted, they are updated with a history flag
and given a unique date-and-time stamp. In addition, an interface is provided
to post notes on the patient information system identifying submission has
Acknowledgement and/or claim status detail received from payers is also translated and loaded into a database residing within the EMC system. Detail contained in these files may be displayed, and an interface is provided to post these notes on the patient information system.
Is reporting provided?
A reporting module for the hospital and the physician claims is also provided with the EMC system. Each list allows outstanding, corrected, and history claims to be printed in different orders and with multiple selection criteria. The following reports are provided:
1. Summary listing of the present status (outstanding, corrected, history) of any group of claims.
2. Hardcopy print of UB92s and/or 1500s for any group of claims.
3. Summary or detail listing of any group ofclaims previously submitted to payers.
4. Error detail for any group of outstanding claims.
5. Summary of payments which have been received by payers (EMR software required) for a group of claims.
6. Detail of modifications performed to the content of any group of claims.
7. Summary of secondary payers associated with any group of claims.