Insurance Codes – EMC tab

Use this tab to define Electronic Medical Claims (EMC) settings, such as billing format; receiver information; special handling rules for voided, late, and replacement electronic claims; the submitter ID format; and so on. Also, this tab allows you to defer claims for unsigned orders, unsigned supplemental orders, and pre-claim reviews and automatically adjust claims if the DCN has not been determined for the original claim.

EMC Format

• Select the electronic billing program file.

Receiver ID (File Recipient)

• Select the receiver ID for the recipient.

Receiver ID (Payer)

• Enter the identification code published by the payer or intermediary used to route electronic data to them.

Receiver Name (Payer)

• Enter the identification name published by the payer or intermediary used to route electronic data to them.

Payer Type

• Select the appropriate payer type for the pay source.

POT Indicator

• Select the appropriate plan of treatment indicator.

User ID

• Enter the user ID.

Password

• Enter the corresponding password.

EMC Template

• Select the corresponding template.

Clearing House

• Select your agency’s clearinghouse.

Submitter ID

• Enter the submitter ID number for the pay source.

ERA ID

• Enter the electronic remittance identification number.

Receiver Code

• Enter the receiver code.
  • This field should be used by agencies who post Medicare remittance files electronically and whose fiscal intermediary returns a different value than Provider ID and Submitter ID in the GS03 segment of the remittance file. If the Medicare FI returns a value other than the Provider ID or Submitter ID, the new value can be entered in this field.

Special Handling

• Select the special handling rules for electronic voided, late, and replacement claims as your fiscal intermediary requires.

NOE

• Select the appropriate notice of election.

Mnemonic

• Enter the needed mnemonic option.

Print CR/LF at the end of each segment.

• Select this checkbox to include a carriage return or line feed at the end of each segment.

Request Paper EOB

• Select this checkbox to receive a hardcopy EOB for claims submitted using this form.

Test Submission Indicator

• Select this checkbox if this is a claims submission test only.

Form Must be Printed

• Select this checkbox to print claims for this pay source before closing the cycle.

EMC Deferment Options

Select the deferment options for the EMC files as needed:

• Defer claims when orders are not signed – Defers electronic claims if orders associated with the services for the claims are unsigned.
• Defer claims when supplemental orders are not signed – Defers electronic claims if unsigned supplemental orders are associated with services for the claims.
• Defer claims when physician is not PECOS enrolled – Defers electronic claims if physicians are not PECOS enrolled.
  • The claim is not included in the EMC file if MD#1 in Patient > General > Admissions & Status is not PECOS enrolled on the From Date of the claim when Resource > General > PECOS Enrollment > HHA = No.
  • The claim is not included in the EMC file if MD#1 in Patient > General > Admissions & Status is not PECOS enrolled on the From Date of the claim OR if MD#1 is not enrolled as of the Occurrence Code 27 Date (if present on the claim) when Resource > General > PECOS Enrollment > Hospice = No.
• Defer claims when CTI is not signed – Defers electronic claims when CTIs covering each day of the generated claim are not signed for the particular admission and if at least one CTI intersecting with a claim from and thru dates is not signed.
  • If the status of CTIs is set to Signed, then the claims can be submitted.
  • This setting is available for insurances of the B (Benefit) and H (Hybrid) modes.
• Defer claims when F2F document is not signed – Defers electronic claims when the face-to-face document is not signed for the particular admission.
  • The claims can be submitted in the following cases:
    • Type is set to Perform (document signed), and status is set to Signed.
    • Type is set to Created, and status is set to Signed.
  • This billing rule is available for insurances of R (Regular) and P (Episodic) modes.
• Do not defer Episodic Initial claims when orders are not signed – Sends RAP/Interim electronic claims for unsigned orders. RAP/Interim claims do not require signed orders. You can use this option if you select the Defer claims check box when orders are not signed.
• Defer Episodic Final claims when OASIS is not exported – Defers PPS or EPS Final electronic claims if OASIS assigned to a patient is not exported. The claim is not deferred if no OASIS is assigned to a patient.
• Defer adjustment claims when NY FFS DCN is not determined for the original claim. Defer New York Medicaid adjustment claims without a DCN (Document Control Number) available when the adjustment or replacement claim is created. This situation occurs when the initially submitted claim is updated with a DCN through the ERA processing or manual update. The adjustment claim requires a DCN to meet the formatting requirements for New York Medicaid. Once a DCN is applied to the original claim, the claim is released and available in the Late EMC window.
  • A deferred claim may be printed as a hardcopy in Claims > Process a Cycle > Closed Claims. However, it is denied if a hardcopy adjustment claim is submitted without a DCN.
• Defer episodic final claim when the UTN is missing – Defers the final claim when the UTN number is missing.
• Defer episodic final claim when the UTN is not approved – Defers the final claim when the pre-claim review was not approved.

Rules for Submitter ID

In this section, you can define rules for the submitter ID format:

• Write the submitter ID in records 01 and 99, instead of the Federal Tax ID – Include the submitter’s ID in records 01 and 99 instead of the Federal tax ID in the submission file. This option is available if the submitter ID is entered in the Submitter ID field on the EMC tab.
• Write the submitter ID in record 01, pos 163 - 189 – Include the submitter ID in record 01, positions 163 - 189 in the submissions file. If you submit to any fiscal intermediary except Cahaba, select this checkbox unless your fiscal intermediary specifies it.