Buckle up, this is a deep dive.

To understand the nature of the question, it is important to first understand that when my organization sends claims, each day usually has more than one service line for the same code, because clients attend more than one "group" in one day and the services are billed separately. So as a result, we have multiple service lines, for the same client, on the same day, with the same code.

When posting payments, my organization requires payments to be applied in proportion to the number of units to which that payment is being applied.

With this in mind, I am trying to find a way to prevent Procentive the following universal problems:

—Automatically adjusting off money that I want to leave as a balance

—Applying co-pays more than once on treatment days where we bill 2 separate "chunks" of time rather than all units on a single service line

—Improperly allocating funds respective to unit counts (This is my biggest issue with procentive overall. see below)

When, for example, the allowed amount (B6) is 50% of what was submitted, The claim is sent as 3 units and 1 unit of the same code, but the remit bundles these into one lump sum for 4 units. So, Procentive will:

-Put all the money on the line with 3 units

-Adjust the remaining balance

-Adjust 100% of the remaining 1 unit. 

In this scenario, I need to manually tab through every field in payment entry mode to ensure that 3/4 of what was paid goes on the line with 3 units, and 1/4 goes to the line with 1 unit. The only time Procentive gets this right is when B6=100% of submitted charges. Adjustments, specifically, are causing the imbalance. 

(Using the "allocate payment" dialog is not a viable solution, it only works when [B6=100%] OR [there is only 1 CAS code AND all claims paid are in a contiguous time span AND only one client account is being paid on the remit.])

I don't know if this is something that can be fixed on the user end (I have tried messing around with the "rules" for the payment entry mode, and while useful for other tasks, I could not solve any of these problems using them, or any other settings within procentive.) This is a major time drain when payment posting, especially when there are copay/coinsurance/deductible involved. To speed things up I usually just apply the copay to one line where possible, but the payment per unit rule is not something I can do differently. 

Am I overlooking something that I could be utilizing? Can systems engineers write new code to address this? Do we need to change our billing process entirely if we want to avoid this problem? I have been trying to find a solution to this for over a year and I am completely stumped.

Has anyone noticed unusual delays in payment processing and ERA's from UCare in recent weeks? 

Has anyone else seen denied claims from BCBS pmap (LMN... policy) and been told it is because the member is in a Restricted Recipient Program? 

This note is from MNits regarding this type of policy/program:

Restricted Recipient Program:

Some MHCP recipients are required to receive the following services from specific providers: Inpatient Hospital, Pharmacy, Physician Services, Mental Health, Outpatient.

The frustrating thing is that you do not know the member has this "restriction" unless you actually call BCBS or first check Availity and then check MNits. It is NOT indicated on Availity at all. So when a client gives you their BCBS pmap card and you check Availity for active coverage, you then have look at the image of the card to get their MA #, then login to MNits to see if they have this type of program. 

Also, the BCBS rep told me authorization is NOT an option for this type of program and our only option for possible payment would be to appeal for medical necessity. 

Help anyone! Thanks, Sara

We bill R25-CCDTF as secondary for qualifying clients. I have noticed that I am updating the COB and it leaves our clearing house correctly but in MNITS and on our ERA from MN DHS they are paying the full (original) rate...

Currently I go out and update the rates in MNITS via a replacement claim. I have a call in to them but wanted to see if anyone else has come across this???

Is anyone getting reimbursed the full amount billed for 90837?

Is anyone else having any luck bringing up remits in Ucare?  I am unable to bring up yesterdays remit on Ucare's site.

Is anyone else experiencing slow ERA loading time since the update? Some of our ERA's take from 3-5 Minutes to load (this is a very large ERA).  Is anyone else experiencing this? 

We have also been noticing slow time on Payments module as well....

Is anyone else still receiving a short pay on claims from BCBS PMAP? I bill for H2012 UA HK and the DHS rate for 1 hour is $65.26. BCBS PMAP prior to January 2019 paid $67.21 a hour. Now I am receiving $32.39/$32.38 a hour across the board. I have asked for "Project" to be opened to capture my incorrectly paid claims and have not been successful with customer service at Amerigroup. Our Provider Rep doesn't respond back to any emails or phone calls. Any advice or what is everyone else doing?