29 Oct A hospital practice you work for has switched the clearinghouse the PM software uses for claim submissions and responses. Management wants to make sure that patient accounts refle
835 Analytical Assignment
835 data file_Student assignment 2022.xlsx
Payer Response Data Guidelines 2022.pdf
Payer Response Assignment Guidelines
Assignment: A hospital practice you work for has switched the clearinghouse the PM software uses for claim submissions and responses. Management wants to make sure that patient accounts reflect claim processing appropriately so that auto-posting may be implemented. All blanks should be completed with numerical data. Must submit your response in Excel (XLS, XLSX) format.
Purpose: Electronic data is transmitted from healthcare organizations to payers using 837 and 835 file formats to submit claim information and receive payment responses. If you completed the readings and lecture video for this module, you should have an understanding of how communication occurs and how data may sometimes be incomplete. This assignment will allow you to use the analytical skills that are necessary to be successful in healthcare to review received data when received data is missing.
Background: Total billed charges increase when labs, radiology, or other tests, imaging, or procedures are performed. These items can be applied to deductible(s) and/or co-insurance. Review the chart below and complete the missing information so that you can have complete data to compare for the EDI 835 file processing review. A base level 3 (99283) charge is $1900.If you do not know how to use Excel, consider the BATC courses. Schedule time to discuss how to do this during my office hours so that you get the help you need to be successful.
Learning Intentions:
- How to analyze payer responses with missing data.
- Use basic Excel functions to confirm math equations and data.
- Understand types of charges and relevancy of processing.
- Confirm accuracy of provided information.
- Understanding how to read an 835
Success Criteria: Your submission must be in Excel format. Appropriate formulas should be used when warranted. Understanding types of charges, what they mean, and how patient responsibility works will allow you to complete this successfully. Use concepts learned in Week 1 and Week 2 to complete this assignment.Excel:
- Create a formula that will allow you to confirm totals. (For your understanding and to complete questions regarding patients)
- Complete Patient 1 missing data (20 points)
- Complete Patient 2 missing data (20 points)
- Complete Patient 3 missing data (20 points)
- Complete Patient 4 missing data (20 points)
- Complete Patient 5 missing data (20 points)
Sheet1
| Billed Charges | Allowed Charges | Co-insurance | Deductible | Co-pay | Insurance Pay | Patient Responsibility | ||
| Patient 1 | $1,900 | $250 | $250 | $500 | $0 | |||
| Patient 2 | $2,750 | $585 | $0 | $300 | $100 | |||
| Patient 3 | $2,385 | $780 | $222 | $100 | $100 | $322 | ||
| Patient 4 | $5,790 | $3,700 | $1,000 | $500 | $250 | |||
| Patient 5 | $3,800 | $1,750 | $0 | $0 | $350 | |||
| Totals | $16,625 | $7,065 | $1,407 | $850 | $1,500 | 3908 | 3157 |
,
Payer Response Assignment Guidelines
Assignment: A hospital practice you work for has switched the clearinghouse the PM software uses for claim submissions and responses. Management wants to make sure that patient accounts reflect claim processing appropriately so that auto-posting may be implemented.
Purpose: Electronic data is transmitted from healthcare organizations to payers using 837 and 835 file
formats to submit claim information and receive payment responses. If you completed the readings and
lecture video for this module, you should have an understanding of how communication occurs and how
data may sometimes be incomplete. This assignment will allow you to use the analytical skills that are
necessary to be successful in healthcare to review received data when received data is missing.
Background: Total billed charges increase when labs, radiology, or other tests, imaging, or procedures are performed. These items can be applied to deductible(s) and/or co-insurance. Review the chart below and complete the missing information so that you can have complete data to compare for the EDI 835 file processing review. A base level 3 (99283) charge is $1900. If you do not know how to use Excel, consider the BATC courses. Schedule time to discuss how
to do this during my office hours so that you get the help you need to be successful.
Learning Intentions:
• How to analyze payer responses with missing data.
• Use basic Excel functions to confirm math equations and data.
• Understand types of charges and relevancy of processing.
• Confirm accuracy of provided information.
• Understanding how to read an 835 reponse.
Success Criteria:
Your submission must be in Excel format. Appropriate formulas should be used when warranted. Understanding types of charges, what they mean, and how patient responsibility works will allow you to complete this successfully. Use concepts learned in Week 1 and Week 2 to complete this assignment. Excel:
• Create a formula that will allow you to confirm totals. (For your understanding and to
complete questions regarding patients)
• Complete Patient 1 missing data (20 points)
• Complete Patient 2 missing data (20 points)
• Complete Patient 3 missing data (20 points)
• Complete Patient 4 missing data (20 points)
• Complete Patient 5 missing data (20 points)
,
Explanation of Payments/Benefits (EOPs/EOBs), also known as Electronic Remittance Advices (ERAs) when received through a clearinghouse, come across as an 835ANSI file, and are not always clean. Many factors of this file have to be correct (Patient Name, ID, Billed Charges, Allowed/Adjusted amounts, DOS, and a few other items), but sometimes you will see that the patient's responsibility does not match the listed deductibles, CIs and CPs. This assignment took an example of how data can be incomplete, or incorrect, and how a healthcare professional would need to provide data so that informatics has complete data to review against their HL7 interfaces.
Billed Charges = Allowed Charges + Adjusted (Contractual Agreements) Charges
Allowed Charges = Insurance Payment + Patient Responsibility
Patient Responsibility = Ded + CI + CP
PR can never be more than allowed charges. Watching the video that was recently added to Module 5 will show you how/ where data has transferred over incorrectly or inaccurately for the purpose of an EOP.
To learn a bit more, please read the provided links. The third link is from a PM software that handles billing and posting and provides good information. The final link is a real patient who experienced the issue and had to resolve it on their end with the carrier.
https://whatismedicalinsurancebilling.org/2010/11/payment-posting-and-eob.html
https://www.verywellhealth.com/understanding-your-eob-1738641
https://prognocis.com/eobs-and-payment-posting/
https://www.city-data.com/forum/health-insurance/2372307-bill-doesnt-match-eob.html
I hope these links help fill in any missing gaps you have and further help you understand why data processing should be accurate and understood before becoming responsible for handling interface data.
