Direct Data Entry (DDE) Professional Claims in ProviderOne
Table of Contents
- Welcome to the direct data entry webinar training for professional claims submitted through...
- Screen itself to navigate.
- The ID needs to be the insurance carrier code that is listed on the client's eligibility...
- Is not required. If you want to enter it here, use the dropdown to select from the list.
- To do this you would use the dropdown for Attachment Type and select the appropriate...
- The first required question is "is the billing provider also the rendering provider?"...
00:08
Welcome to the direct data entry webinar training
for professional claims submitted through
the ProviderOne Portal.
We are conducting this webinar due to the
policy change at the WA Health Care Authority
where we are no longer accepting paper claims
unless you have an approved waiver.
This was implemented on October 1, 2016 and
we are hoping to reach those providers who
have only submitted paper claims and need
to transition to electronic billing.
This training will focus on billing electronically
through the Direct Data Entry system in ProviderOne
and will not cover HIPAA/EDI claims.
For more information on HIPAA billing, please
visit the following webpage: www.hca.wa.gov/billers-providers
and click on the 3rd link under the blue Claims
and Billing bar titled, HIPAA Electronic Data
01:11
Interchange.
I am Matt Ashton here with my coworker, Marci
Thietje.
We will be reviewing our PowerPoint slideshow
first and break down each field required to
submit the claim and then show a live demonstration
of entering a professional claim through ProviderOne.
Any questions received during this webinar
will be collected and answers to those questions
will be posted after this webinar, along with
a recording of this presentation.
Only questions related to direct data entry
billing will be responded to.
After this training, you will be able to submit
for fee-for-service claims through the ProviderOne
Portal and submit claims for clients who have
commercial insurance.
02:14
Before we get started there are some important
settings on your PC that need to be verified
before you begin.
Make sure your pop-up blockers are turned
off.
The process to turn off pop-ups is different
depending on what browser you are using.
ProviderOne uses pop-ups throughout the claim
form and must be turned off to finalize the
claim.
ProviderOne is a HIPAA-compliant program that
gives you the ability to enter claims directly
into the payment system and all fields that
can be entered on a paper claim can be billed
through direct data entry.
It is easy to use and does not cost anything
to do so.
As long as you have the correct profile and
access to your domain in ProviderOne, you
can bill as many claims as needed using multiple
pc's if necessary.
You can correct and resubmit denied or voided
claims, or adjust or void previously paid
03:17
claims.
Corrections and resubmissions will not be
covered during this session, however see the
contact information on the last slide if you
need to reach out for assistance on these
functions.
Once you have entered your domain, user name
and password, you need to choose a profile.
There are several profiles that allow for
claim submission.
The most frequently used is the EXT Provider
Super User profile.
This profile allows the worker to do all functions
in the system, except for managing user permissions.
If the incorrect profile has been chosen,
ProviderOne gives you 2 ways to change it
by either using the My InBox tab or dropdown,
or by hovering over the user name in the upper
left corner of the portal.
For this session, we will choose the EXT Provider
Super User profile.
04:22
Once you have chosen the correct profile,
you would then choose On-line Claims Entry
from the provider portal.
You would then choose the claim type you would
like to enter.
A professional claim submission would be the
same as a CMS 1500 paper claim form with all
the same fields available for entry.
Here is a snapshot of the first half of the
DDE screen.
The claim itself is broken down into 4 different
sections: Billing Provider, Subscriber or
Client information, the Claim level (or header
information) and the Service Line level.
There are also some basics on navigation that
we should discuss.
Do not click your back arrow on your browser
but use the hyperlinks and buttons on the
05:23
screen itself to navigate.
You also must complete any question or field
with a red asterisk and if you expand an area
by clicking any of the red plus signs, you
must either enter the detail required or close
that area by clicking on the minus sign otherwise
ProviderOne will be looking for entries in
these expanded areas.
Here is the second half of the claim form
showing the required entries.
We will break down each section and show each
field and what is required to submit a claim.
Let's start with Section 1, Provider Information.
The first thing to do is tell ProviderOne
who the billing provider is by entering the
National Provider Identifier or NPI.
06:24
The billing provider is where payment will
be sent to or who is getting paid for the
service.
You will also need to enter a taxonomy code
that is attached to the billing NPI and applicable
to the service you are billing for.
The taxonomy code tells ProviderOne what type
of provider is submitting the claim.
Note the red asterisks, as these are required
entries.
Now you have come to the first question that
must be answered.
Is the Billing NPI or provider also the Rendering
Provider?
This represents the provider actually performing
the service.
If you answer this question Yes you are saying
that you are both the billing provider and
the provider rendering the service, otherwise
you would answer this question No.
Answering the question No opens up the Rendering
or Performing provider area where you would
07:24
enter the NPI and taxonomy for that provider.
This is the second question ProviderOne will
need you to answer.
If the service was not the result of a referral,
you would choose the No radio button.
If the answer is yes you would enter the NPI
of the provider who referred the service.
That completes the first section and we are
now in Section 2, Subscriber or Client Information.
This is where you will tell ProviderOne what
Apple Health client received the service you
are billing for.
This is the ID number noted on the ProviderOne
Services card that each client receives.
You must enter the WA, but it does not need
to be capitalized.
08:26
The next step is to expand the Additional
Subscriber/Client Information by clicking
on the red + sign.
This is where you would tell ProviderOne the
Apple Health client's name, date of birth,
and gender.
You will note that the First Name field is
not required, or marked with the red asterisk.
This information must match what is in the
client's file in ProviderOne.
There are also some fields that are not required
in this section, such as date of death, patient
weight and patient is pregnant so those can
be skipped.
The next required question that must be answered
is related to billing for a baby using the
mom's ID.
If this is the case, you would use the mom's
client ID but enter the baby's name, date
09:27
of birth, and gender.
The next required question is related to client's
with Medicare as their primary coverage.
If Medicare made a payment, whether it is
a co-pay or a deductible for example, these
are considered crossover claims and you would
answer the question Yes.
It will expand the crossover area and you
would enter the total amounts paid for this
claim in these fields.
Every box must have an entry noted, even if
it is zero, as these are required fields.
If Medicare did not make any payment or apply
to deductible, etc., you will answer this
question No and the Medicare explanation of
benefits must be submitted with the claim.
If the client's Medicare coverage is a Part
C or Managed Medicare plan, these are not
entered as commercial insurance claims.
10:29
The same billing rules apply for part c plans
as do regular Medicare claims.
If the Apple Health client has a commercial
payer as their primary insurance, you will
need to complete the Other Insurance Information
fields by clicking the red + sign to open
this section.
Click the very next + sign for Other Payer
Insurance Information.
Skip down to the Other Payer Information box
and enter the commercial payer name.
Once complete, expand the red plus Additional
Other Payer Information section.
Only 2 fields are required here, the ID and
the ID type dropdown.
11:29
The ID needs to be the insurance carrier code
that is listed on the client's eligibility
file which we will show on the next slide.
And the ID Type dropdown should always be
PI for Payer Identification.
This is a snapshot of a Coordination of Benefits
segment from the client eligibility screen
where you will find the Insurance Carrier
Code or the ID number from the previous
slide.
If you need more assistance on finding the
carrier code in ProviderOne, please review
our Fact Sheet titled Successful Eligibility
Checks using ProviderOne at the web address
noted on the slide.
The next entry is to tell ProviderOne how
much the commercial insurance paid by entering
12:31
the amount in the COB Payer Paid Amount field.
This amount can be entered without decimals
if it is a whole dollar amount.
If the insurance denied the service, you would
enter a 0 here.
ProviderOne requires the use of HIPAA compliant
adjustment reason codes.
These codes will be entered by expanding the
Claim Level Adjustments section.
Once expanded, you would enter a Group Code,
reason code, and dollar amount applicable
to the reason code entered.
The HIPAA compliant reason codes can be found
at the WPC's website at the address noted
in the green box.
13:38
Next section to complete is Section 3 Claim
Information.
This is also called the claim header detail
information that covers the entire claim.
The first area for entry is the Prior Authorization
section.
You would click the red plus sign and enter
it here if the services you are billing for
requires a prior authorization or an expedited
authorization number (EPA) provided in the
program billing guides.
If no authorization is needed for the service,
skip this area.
Entering the authorization or EPA number here
would apply to the entire claim.
If you have more than one authorization number
to bill with, this will be covered later in
the slide show.
Recent system changes to ProviderOne have
changed how claim notes are read.
14:42
If a specific program or service requires
you to enter a claim note as instructed in
a program billing guide, they will still be
read by ProviderOne.
If no claim note is needed, skip this option.
Here is the last required question on the
professional claim form.
You will always answer the question "Is
this claim accident related?" as No.
If an Apple Health Medicaid client has a casualty-related
claim, it is handled by a specific unit in
our Coordination of Benefits office.
The next field under Claim Data is for the
Patient Account number.
This is not required but can be used by your
office to identify the client using your own
15:42
identifier.
This number will be carried forward to the
weekly HCA remittance advice to assist in
reconciling accounts.
The next entry is to choose your place of
service.
Most often you are choosing office, so you
can use the number 1 to easily jump down to
place of service 11, or use the dropdown to
select from the list.
Additional Claim Data is needed only if the
Apple Health client has a spenddown liability
they owe that needs to be reported on the
claim.
You would choose the red plus sign and enter
the liability amount in the Patient Paid Amount
field.
Professional claims require at least one ICD10
diagnosis code.
16:47
With HIPAA implementation, you can enter up
to 12 diagnoses codes if needed.
Do not enter decimal points as these are added
automatically by ProviderOne after submission
of the claim.
If a decimal point is entered, you will receive
an error from ProviderOne when you try to
submit the claim.
That completes section 3 and now we will review
Section 4 Basic Service Line Items, again
covering each required entry.
The first required fields are the From and
To Service Dates.
These must be entered in complete digits as
noted on the screen, such as using a 4 digit
year.
ProviderOne allows you to also enter a place
of service at the line level, however this
17:49
is not required.
If you want to enter it here, use the dropdown
to select from the list.
Next up is entering the HCPCS or CPT code
from the most current coding manuals.
If these codes require the use of a modifier,
enter one modifier per box up to 4.
The next field to complete is the Submitted
Charges.
We always recommend that providers bill their
usual and customary amounts here.
However, if the service you are billing for
required a prior authorization, you must bill
the amount that you requested.
Next you need to tell ProviderOne which diagnosis
code goes with the procedure you are entering.
18:52
This is done by using the diagnosis pointer
dropdown.
The numbers in the dropdown boxes correspond
to the diagnosis boxes you entered above.
What you entered in box #1 is considered the
primary diagnosis for that specific line.
Each procedure you entered will requires units.
Enter the number of units billed in this field.
If the Medicare question was answered Yes
at the Claim Level or header area, you must
expand the Medicare Crossover Items at line
level by clicking the red plus sign.
Enter the payment amounts from the Medicare
EOB, specific to the procedure you are entering
for the service line.
Every box must have an entry noted, even if
it is zero, as these are required fields.
19:54
The amounts billed at the line level when
totaled, must match the Medicare amounts listed
at the Claim Level or header.
If the service is for an injectable drug,
the National Drug Code or NDC is required.
The NDC code must be entered in a specific
format which is described in the Physician
Related Billing Guide found on the HCA website.
The Drug Identification area is not required
and can be skipped.
If the authorization number for the procedure
being entered is different than the one listed
at the Claim Level or header area, click the
red plus to expand the Prior Authorization
area and enter that number here.
21:00
Once you have entered all the required information
for the service line, click the Add Service
Line Item button to add the service line to
the claim.
It will remove the information from the service
line area and populate the columns below the
gray bar similar to a CMS 1500 claim form.
If there are additional service lines that
need to be added to the claim, you can quickly
return to the service line area by clicking
on the service hyperlink shown here and follow
the instructions from the previous slides.
If the service line was entered incorrectly
and needs to be updated, you would click on
the service line number.
This will repopulate the service line boxes
for you to make any corrections.
22:03
Once your changes or corrections are completed,
click on the Update Service Line Item button
to add the service line back on the claim.
If you added a service line in error and now
need to remove it, you can simply click the
Delete hyperlink to the right of the service
line and it will delete the service line and
return you to the top of the claim screen.
Once all service lines have been added and
you are ready to submit your claim to ProviderOne,
click the Submit Claim button at the top of
the screen.
If your pop-ups are turned off, you will receive
this dialogue box . If you have backup documentation
that needs to be attached to the claim, click
the Ok button.
23:06
Simply click the Cancel button if there is
no backup being sent.
If you had no backup to attach and you clicked
Cancel on the dialogue box, you will come
to the Submitted Professional Claim Details
page.
This provides you with your claim number and
a summary of the charges being submitted.
When you receive this confirmation screen,
this means ProviderOne has all the required
data needed.
To finalize the claim, you must hit the final
Submit button to send it to ProviderOne.
Once this final step is complete, you will
be returned to a blank claim form.
If you had answered Ok to the question Do
you want to submit backup to the claim,
you have the option of attaching the backup
directly to the claim.
24:06
To do this you would use the dropdown for
Attachment Type and select the appropriate
option from the list.
Then you must choose a Transmission Code from
the next dropdown box as EL for Electronic
Only or Electronic file.
Skip the Line No. box dropdown completely.
You can then click the browse button to search
for the electronic file you want to attach
to your claim.
Once attached, click the Ok button to return
to the Submitted Professional Claim Details
page.
Scanning and attaching your backup electronically,
could result in quicker processing and adjudication
of your claims.
If you are faxing or mailing the backup documentation,
complete only the Attachment Type dropdown
and the Transmission Code dropdown will be
either BM for by mail or FX for fax.
25:09
Click Ok to return to the Submitted Professional
Claim Details page.
If you are choosing to mail or fax your backup
documentation, you must create a cover sheet
so that it can be matched up to your claim
in ProviderOne.
The information noted on this screen is used
to complete the required cover sheet.
Click the Print Cover Page button.
This cover sheet will come up as a separate
screen from ProviderOne as a PDF file.
Complete the first dropdown to choose the
Provider ID NPI and enter that number
in the Provider ID field.
Tab to the TCN field and enter the claim number
you received on your Submitted Professional
Claims Detail screen.
Tab to the Date of Service field and click
the dropdown to bring up the calendar.
26:12
Use the calendar to choose the date of service
you are billing for.
If there is more than one date of service
on your claim, you must use the earliest or
oldest date in this field.
Tab to the ProviderOne Client ID field and
enter the 9-digit ProviderOne Services card
ID number, including the WA.
You will need to tab twice after entering
the client ID to expand the barcode so that
it can be properly read by the ProviderOne
scanner.
Click the Print Cover Sheet button and either
mail or fax in the backup, depending on what
option you chose on the backup screen.
Your DDE claim will be held for 3 to 5 days
waiting for the backup to be received to attached
to the claim.
Now that you have completed the cover sheet
for your backup, you must click the final
27:14
Submit button to send your claim to ProviderOne
for processing.
Once this final step is complete, you will
be returned to a blank claim form.
This slide provides some useful links for
accessing resources on the new HCA website
and for submitting questions on submitted
claims through our contact us form.
We have come to the end of the slide show
portion of entering a Professional Claim using
the direct data entry feature of ProviderOne.
Now I'm going to demonstrate entering a
live professional claim using this same process.
28:57
Hi everyone, this is Marci here.
I will narrate for Matt as he walks us through
the DDE screen.
Once you have accessed ProviderOne, you will
need to select the appropriate profile for
submitting claims.
Matt is going to choose the EXT Provider System
Administrator profile from the dropdown list.
Next he will choose the On-line Claims Entry
option on the Provider Portal.
You will notice he received an error telling
him he does not have sufficient rights to
access this link.
After clicking close on the error page, Matt
is going to demonstrate how you can change
your profile from the Provider Portal screen.
He will click on the user name in the top
left of the screen, and hover over the listed
29:58
profile.
This will bring up a list of all the profiles
assigned to the user.
Matt will now choose one of the correct profiles
for submitting claims, the EXT Provider Super
User profile, and click Yes when asked to
confirm the change.
Matt will now click on the On-line Claims
Entry option on the portal.
This takes you to the Claim Submission screen
where Matt will choose Submit Professional.
The first required field Matt will complete
is the NPI and taxonomy code for the billing
provider.
31:02
The first required question is "is the billing
provider also the rendering provider?"
Matt will select the No radio button.
Matt will now enter a Rendering/Performing/Servicing
provider NPI and taxonomy code.
You will notice that ProviderOne moves your
cursor for you from field to field.
The next required question Matt will answer
"is this service the result of a referral?"
He will click the No radio button.
Next up is telling ProviderOne who the service
was provided to, so Matt will enter a client
id number from the ProviderOne Services Card
including the WA.
32:12
For this demonstration, this is a generic
ID for test purposes.
Matt is then going to expand the Additional
Subscriber/Client Information area by clicking
the red plus.
He will enter the last name, date of birth
and gender.
The next required question will be completed,
Is this claim for a Baby on Mom's Client
ID? Matt will answer No.
He will also need to answer the next question,
"Is this a Medicare Crossover Claim?"
Matt will click the No radio button.
33:15
For purposes of this demo, we will skip over
the next 5 red plus signs and answer the last
required question, "Is this claim accident
related?" He will click the No radio button.
The next field is the place of service dropdown.
Matt will click the number 1 to choose office.
The diagnoses fields are next and he will
enter one in without any decimal points.
In case you are interested, this is one of
the new ICD10 diagnosis codes for, Struck
by a duck
After diagnosis, Matt is now in the Service
Line area and he will enter the from and to
dates.
34:26
He will skip place of service since he entered
it above and move to the Procedure Code field.
He will enter a 99213 for an office visit.
If a modifier was needed for your billing,
this is where you would enter a modifier.
Matt will next enter the submitted charges.
The diagnosis pointer is next and he will
choose 1 from the first dropdown.
We need to enter the number of units we are
billing for so he will enter 1.
Because this is a simple office visit, we
are skipping the remaining plus marks and
fields and Matt will click the Add Service
Line Item button.
35:26
He will use the service hyperlink at the top
of the claim screen to return to the service
line area to verify his entries.
Matt is happy with his entries so he will
return to the top of the claim screen to submit
the claim by clicking the Submit Claim button.
ProviderOne is asking if there is any backup
documentation to attach to this claim. Matt
will click Cancel.
This is a good time to make a note of the
TCN number assigned to your claim for future
reference and you can verify the dates and
billed amount.
Matt will finalize this claim by clicking
the Submit button in the bottom right corner.
The system returns you to the top of the claim
form and clears out all the information entered.
36:35
The claim form is ready for you to submit
another claim if needed.
This completes the live demonstration of submitting
a professional claim through the Direct Data
Entry feature of ProviderOne.