TES - Ingenix Claims Manager

1
TES- Ingenix Claims Manager Medi-Cal TAR Edits

• UCSF

2
Agenda

• 1100 AM 1110 AM
• Overview
• 1110 AM 1130 AM
• MCA - TAR Auths and TES TAR Edits
• 1130 AM 1150 AM
• Ingenix Claims Manager Edits
• 1150 AM-1200 PM
• QA

3
Background

• Business Problem
• Coding
• Established Vs New Patient codes
• LCDs
• CCI
• Procedure/Modifier/Diagnosis combinations
• Etc
• Authorizations
• Missing
• Not in System
• Modified at time of service

4
Background

• Business Solution
• Coding
• Ingenix Claims Manager
• TES edits
• Authorizations
• MCA Authorizations
• TES Edits

5
MCA TAR Authorizations
6
TAR Auths (Status)
7
TAR Auth Details - 1
8
TAR Auth Details - 2
9
Linking TAR Auth to Visit

• Action Code C

10
TES Edits for missing or incomplete TAR

• ?T look up

11
Ingenix Claims Manger (ICM)

• TES Encounters sent to Ingenix Claims Manager
  (ICM) Nightly
• ICM utilize standard and custom edits across
  claims
• ICM Edits returned that night to TES work files

12
CONSTRAINTS AND ASSUMPTIONS

• ICM edits will be rolled out in phases
• Three Pilots
• Dept. of Medicine
• Dept. of Radiology
• Dept. of Surgery
• Medicare, and Commercial then Medi-Cal
• TES redesign limited to Work File definitions and
  Edits
• PFS will determine if new edit will hold SMS
  bound charges too

13
Current Status

• Hardware Implementation
• Interface Set Up
• Establish Edit Design Team

14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
Executive Wrap Up

• Q A