Blue Cross 837 to UB92 Corrections User Manual
Contents
1. EMCO3600 43 71 EMPIRE 06 12 03 Empire provider HOME HEALTH HOSPICE PLAN OF TREATMENT SCREEN 25 B CORRECTION ID NUMBER FUNCTIONAL LIMITATION CODES 1 AMPUTATION 4 HEARING 7 AMBULATION A DYSPNEA MINIMAL 2 BOWEL BLADDER 5 PARALYSIS 8 SPEECH B OTHER 3 CONTRACTURE 6 ENDURANCE 9 LEGALLY BLIND ACTIVITIES CODES 1 COMPLETE BED REST 5 EXERCISES PRESCRIBED 9 CANE D OTHER 2 BEDREST BRP 6 PARTIAL WEIGHT BEARING WHEELCHAIR 3 UP AS TOLERATED 7 INDEPENDENT AT HOME B WALKER 4 TRANSFER BED CHAIR 8 CRUTCHES C NO RESTRICTIONS MENTAL STATUS _ _ 1 ORIENTED 3 FORGETFUL 5 DISORIENTED 7 AGITATED 2 COMATOSE 4 DEPRESSED 6 LETHARGIC 8 OTHER PROGNOSIS CODE _ 1 POOR 2 GUARDED 3 FAIR 4 GOOD 5 EXCELLENT MSG MSG ENTER F2 MENU F3 EXIT F7 BKWD F8 FWD F10 SAVE FINALIZE NEXT SCR 00 The Subscriber ID is system generated NOTE Enter the number or the letter that corresponds to the Functional Limitation Activities Permitted or Mental Status Code required You may enter more than one numeric or alphabetic character on the selection line Only one Prognosis code may be entered When you enter the number or letter that corresponds to OTHER on screen 25 B you must enter all applicable information for OTHER under the narrative title Updated Information2. HCPCS PROC CODE PRESENT REVENUE CODE MISSING Screen 05 REV CODE 0001 MUST EQUAL SUM OF ALL TOTAL CHARGE ENTRIES Screen 05 REV CODE 0001 NON COV MUST EQUAL SUM OF ALL NON COV CHGS Screen 05 DATE OF SERVICE IS NOT NUMERIC OR INVALID Screen 05 DATE OF SERVICE PRESENT REVENUE CODE MISSING Screen 05 DATE OF SERV IF PRESENT MUST BE WITHIN STATE FROM THRU DTS This edit does not apply to revenue code 45X Screen 01 05 PROCEDURE CODE PRESENT PROCEDURE DATE MISSING Screen 06 PROCEDURE DATE PRESENT PROCEDURE CODE MISSING Screen 06 PROCEDURE DATE IS NOT NUMERIC OR INVALID Screen 06 DATA ID IF PRESENT MUST EQUAL 1 OR2 Screen 25A START OF CARE DATE NOT NUMERIC OR INVALID The start of care date on the plan of treatment must be equal to or less than the current date Screen 25A CERTIFICATION PERIOD FROM DATE NOT NUMERIC OR INVALID Screen 25A Rev Date 10 08 04 36 Q115071007 Q510071006 Q115071008 Q600071009 Q115071010 Q600071010 Q115071011 Q110071015 Q110071016 Q110071017 CERTIFICATION PERIOD THRU DATE NOT NUMERIC OR INVALID Screen 25A CERTIFICATION PERIOD FROM DATE IS GREATER THAN THRU DATE Screen 25A DATE OF ONSET EXACERBATION OF PRIN DIAG NOT NUMERIC OR INVALID Screen 25A SURG PROC CD PRESENT ON PLAN OF TREATMENT PROC DATE MISSING If surgical procedure code present on the plan of treatment a valid date must be present Screen
3. OTHER PROCEDURE CODES DATES SG SG ENTER F2 MENU F3 EXIT F4 DIAG INQ F5 PROC INQ F7 BKWD F8 FWD F10 SAVE FINALIZE NEXT SCR 00 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 20 EMCO3600 07 80 EMPIRE 06 12 03 Empire provider PHYSICIAN DATA CORRECTION SCREEN 07 PAGE 01 PHYSICIAN INFORMATION RELATES TO PAYER LINE PHYSICIAN NUMBER QUALIFYING CODE ATTEND PHYS NAME LAS FIRST MI OPERAT PHYS NAME LAST FIRST MI OTHER PHYS NAME LAS FIRST MI MSG MSG ENTER F2 MENU F3 EXIT 7 F8 FWD F10 SAVE FINALIZE NEXT SCR 00 The payer line indicator physician information relates to payer line must be entered to crosswalk the data entered on this screen to the correct payer on screen 02 For example if you want to enter physician data relating to two payers i e payer A and B you must enter a payer line indicator A and applicable physician data then press the F6 key next page to prompt a new page enter a payer line indicator B and applicable physician data 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 21 EMCO3600 08 90 91 EMPIRE 06 12 03 Empire provider REMARKS FREE FORMAT CORRECTION SCREEN 08 PAGE 01 TO
4. aM o 837 UB 92 Claim Correction o 837to UB 92 Submission Validation Report o 837 UB 92 Error Codes EMPIRE OMNIPRO BLUE CROSS 837 TO UB92 CORRECTION UTILITIES USER MANUAL LAST REVISION October 8 2004 EMPIRE OMNIPROS BLUE CROSS 837 TO UB92 CORRECTION UTILITIES USER MANUAL 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 2 EMPIRE OMNIPROS 837 TO UB92 CORRECTION UTILITIES USER MANUAL Table of Contents INTRODUCTION 4 INTEGRATED ELECTRONIC SERVICES CONTACT 2 1 1 1 sa seta aoo 5 GETTING STARTED sra balada uda da 500 6 837 TO UB92 CORRECTION UTILITIES cese eene eene eene entres tn seta seta seta sten s ena ense eaae eaae senes eese eose 8 SELECTION 1 837 TO UB92 CLAIM CORRECTION OVERVIEW eee eee errores otn setas nae nae naene 10 KEYBOARD FUNCTION DEFINITION eere eene enne eontra ettet 12 SELECTION 2 SUBMISSION VALIDATION 28 SELECTION 2 SUBMISSION VALIDATION REPORT eese eene enne enata eene setate seta seen setas ens nae nae na
5. 25A SURG PROC DATE ON PLAN OF TREATMENT IS NOT NUMERIC OR INVALID Screen 25A SURG PROC DATE PRESENT ON PLAN OF TREATMENT PROC CODE MISSING If procedure date is present A valid procedure code must be present Screen 25A DATE OF ONSET OF SECONDARY DIAG IS NOT NUMERIC OR INVALID The date of onset or exacerbation of secondary diagnosis on the plan of treatment must be numeric and a valid date Screen 25A FUNCTIONAL LIMITATION CODE IF PRESENT MUST BE VALID This field can only contain 1 9 A or B Screen 25B ACTIVITIES PERMITTED CODE IF PRESENT MUST BE VALID This field can only contain 1 9 A D Screen 25B MENTAL STATUS CODE IF PRESENT MUST BE VALID This field can only contain 1 8 Screen 25B 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 37 Q110071018 Q115071019 Q110071024 Q115071025 Q115071026 Q110071027 Q110071028 Q115071029 Q115071030 Q530071030 Q110071031 Q110072004 837 TO UB92 CORRECTIONS USER MANUAL PROGNOSIS CODE IF PRESENT MUST BE VALID This field can only contain 1 5 Screen 25B VERBAL START DATE NOT NUMERIC OR INVALID Screen 25A MEDICARE COVERED INDICATOR IF PRESENT MUST BE Y OR N Field value is equal to Y N or blank Screen 25A DATE PHYSICIAN LAST SAW PATIENT NOT NUMERIC OR INVALID Screen 25A DATE LAST CONTACTED PHYSICIAN NOT NUMERIC OR INVALID Screen 25A PAT RECEIVING CARE IN FACILITY IF PRESENT MUST BE Y Nor
6. 76X 831 or 85X and the statement covers period from date is equal to or greater than August 1 2000 and only diagnostic therapy and home infusion services are on the claim then the CPT4 HCPCS code associated with each revenue code must be entered If the statement covers from date is equal to or greater than 4 01 99 and less than 8 01 00 and only diagnostic services are on the claim then the CPT4 HCPCS code associated with each diagnostic revenue code must be entered Screen 05 OPT TOB W REV 36X 45X 481 49X 70X 72X 75X 76X REQS CPTA HCPCS If the type of bill is equal to 13X 14X 72X 73X 76X 831 or 85X and the revenue code is equal to 36X 45X 481 49X 70X 72X 75X or 76X then the CPT4 HCPCS code associated with that revenue code must be entered Screen 05 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 41 EB001908 EB002100 EB002101 EB002102 EB002104 EB002105 EB002400 OUTPAT REV CODES 250 8 64X ON SAME BILL REQUIRE CPT4 HCPCS Please note this edit applies to facilities that have negotiated rates with Empire If the type of bill is equal to 13 14X 72X 73X 76X 831 or 85X and the statement covers period from date is equal to or greater than August 1 2000 and the revenue code 0250 pharmacy is present on the claim with a revenue code from the 064X series Home Infusion Therapy then the CPT4 HCPCS codes associated with these revenue codes must be entered For revenue code 0250 a CPT
7. D Screen 25A CERTIFICATION RECERT MODIFIED IF PRESENT MUST C R OR M Valid values are C R or M Screen 25A HH HOSPICE ADMISSION DATE IS NOT NUMERIC OR INVALID Screen 25A HH HOSPICE DISCHARGE DATE IS NOT NUMERIC OR INVALID Screen 25A HH HOSPICE DISCHARGE DATE CAN NOT BE STATEMENT THRU DATE Screen 13 25A TYPE OF FACILITY IF PRESENT MUST BEA S I R ORO Screen 25A DISCIPLINE CODE IF PRESENT MUST SN PT ST OT MS OR AI Valid values are SN PT ST MS or Al Screen 25C Rev Date 10 08 04 38 Q120072005 Q12007206A Q11007206A Q11007206B Q110072018 Q120072043 Q110080004 VISITS RELATED TO PRIOR CERTIFICATION IS NOT NUMERIC Screen 25C FREQUENCY NUMBER IS NOT NUMERIC Screen 25C FREQUENCY NUMBER IF PRESENT MUST BE A VALUE OF 1 TO 9 Field value 1 9 Screen 25C FREQUENCY PERIOD IF PRESENT MUST WK MO Q OR PR Frequency period values are DA WK MO or PR Note If indicating a frequency of Q enter the number of days Screen 25C TREATMENT CODE IF PRESENT MUST BE VALID Treatment code values are A01 A32 01 15 01 09 001 011 01 06 or F01 F15 Screen 25C TOTAL VISITS PROJECTED THIS CERTIFICATION IS NOT NUMERIC Screen 25C PHYS NUMBER QUAL CODE IF PRESENT MUST UP SL SP OR FI Screen 07 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 39 PAYER SPECIFIC EDITS PLAN CODE 00300 AN
8. If the Patient Relationship to Insured field is equal to 01 self the insured s information is automatically be pulled from the patient data on Screen 01 and placed in the insured s data fields on Screen 02 The PF6 key is used to enter data for multiple payers maximum of six At least one payer must have a source of payment code equal to G Blue Cross Note NEWBORN BIRTH WEIGHT IN GRAMS is now located on Screen 01 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 16 EMCO3600 03 40 Empire provider TREATM EMPIRE TR EATMENT AUTHORIZATION OCCURR CORRECTION ENT AUTHORIZATION CODES ENCE 06 12 03 SCREEN 03 PAGE OCCURR ENCE CODES DATES OCCURRENCE SPAN CODES DATES MSG MSG ENTER F2 MENU F3 EXIT F6 NEXT PG F7 BKWD F8 FWD F10 SAVE FINALIZE 01 NEXT SCR 00 Maximum number of pages allowed are 25 up to 350 occurrence codes and dates up to 100 occurrence span codes and dates and up to 6 treatment authorization codes 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 17 EMCO3600 04 41 EMPIRE 06 12 03 Empire provider CONDITION VALUE CODE CORRECTION SCREEN 4 PAGE 01 CONDITION CODES VALUE CODES AMOUNTS MSG MSG ENTER 2 F3 EXIT F6 NEXT PG F7 B
9. LAST NAME IS MISSING OR INVALID Allow only A Z and 1 space and or hyphen Screen 02 PAYER A B C D E OR F INSURED S FIRST NAME IS MISSING OR INVALID Allow only A Z and 1 space and or hyphen Screen 02 PAYER A B C D E F INSURED S MIDDLE INIT MUST A Z OR SPACE Screen 02 PAYER A B C D E F INSURED S SEX CODE MUST BE M F OR SPACE Screen 02 PAYER A B C D E F RELEASE OF INFO IND IF PRES MUST BE VALID Screen 02 PAYER A B C D E F ASSIGN OF BENEFITS IND IF PRES IS INVALID Screen 02 PAYER A B C D E F PAT S RELATIONSHIP TO INSRD IS MISSING INVALID Screen 02 PAYER A B C D E OR F COVERED DAYS ARE NOT NUMERIC Screen 02 Rev Date 10 08 04 32 Q120030021 Q120030022 Q120030023 Q100030024 Q120030025 Q120030026 Q120030027 Q120030028 Q120030029 Q110031007 Q110040004 Q110040008 Q535040008 Q116040009 837 TO UB92 CORRECTIONS USER MANUAL PAYER A B C D E OR F NON COVERED DAYS ARE NOT NUMERIC Screen 02 PAYER A B C D E OR F CO INSURANCE DAYS ARE NOT NUMERIC Screen 02 PAYER A B C D E ORF LIFETIME RESERVE DAYS ARE NOT NUMERIC Screen 02 PAYER A B C D E OR F PROVIDER ID NUMBER IS MISSING Screen 02 PAYER A B C D E F PRIOR PAYMENTS RECEIVED IS NOT NUMERIC Screen 02 PAYER A B C D E OR F ESTIMATED AMOUNT DUE IS NOT NUMERIC Screen 02 SCREEN 02 PAGE 01 PRIMARY PAYER CODE MUST P
10. Other on screen 25 To accomplish this go to screen 25 D and key an S in front of the title Updated Information Other and press ENTER Key all information required to describe Other Function Limitations Activities and or Mental Status 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 24 EMCO3600 44 72 EMPIRE 06 12 03 Provider HOME HEALTH HOSPICE SPECIFIC SERVICE TREATMENT SCREEN 25 C CORRECTION PAGE 01 ID NUMBER DISCIPLINE __ VISITS THIS BILL RELATED TO PRIOR CERTIFICATION __ FREQUENCY NUMBER PERIOD DURATION TREATMENT CODES TOTAL VISITS PROJECTED THIS CERTIFICATION __ MSG MSG ENTER F2 MENU F3 EXIT F6 NEXT PG F7 BKWD F8 FWD F10 SAVE FINALIZE NEXT SCR 00 The Subscriber ID is system generated NOTE Enter the Frequency Period Duration and Treatment codes that apply for each Discipline Use the F6 NEXT PG key to enter additional pages of Discipline Frequency Period Duration and Treatment codes as necessary 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 25 EM
11. When the source of payment code screen 02 record type 30 field 4 is equal to G and the payer identification code screen O2 record type 30 field 5 is not equal to 00300 or 00303 the subscriber id prefix screen 02 record type 30 field 7A must equal 3 alphabetic characters Screen 02 PRINCIPAL DIAGNOSIS CODE MUST BE ENTERED Screen 06 DIAGNOSIS CODE ENTERED IS INVALID NOT ICD 9 CM Screen 06 PRINCIPAL DIAGNOSIS CODE MAY NOT BEGIN WITH E Screen 06 DIAGNOSIS CODES MAY NOT BE REPEATED Screen 06 33X OR 34X BILL VISIT NOT HOURLY CHARGE REVENUE CODES If the Type of Bill TOB is equal to 33X or 34X none of the following hourly charge revenue codes is allowed 422 432 442 552 572 or 582 Home care requires revenue codes for visit charges Screen 01 05 SURGICAL PROCEDURE CODE ON THE PLAN OF TREATMENT IS INVALID TOB 33X 34X 81X 82X the procedure code present must be valid on the ICD 9 CM file Screen 25A STATEMENT FROM AND THRU DATES MUST BE WITHIN SAME MONTH YEAR For bill types 33X 34X 81X 82X the statement covers period from and thru date must be within the same month and year Screen 01 FROM THRU DTE MUST BE WITHIN THE PLAN OF TREATMENT CERT PERIOD For bill types 33X 34X 81X 82X the statement covers period from and thru dates must be within the Plan of Treatment Certification period from and thru dates If data is present on screens 25A 25D for interactive claim entry the
12. p m If you enter a d in error to remove position the cursor under the d hit the space bar to erase then hit enter To refresh the summary list hit the F7 key or F8 key Search Capability on the Claim Correction Summary List Search capability for claim correction summary list allows the user to searching for a specific claim The user may scroll through the summary list F7 or F8 or enter search criteria as desired The key fields for searching are Patient Control Number CERT SSN HIC SUB Id Number and From Date The key fields can be entered on the first summary line in the following combinations to obtain a specific claim for display rather than searching the summary list Patient Control Number CERT SSN HIC SUB ID Number OR Patient Control Number and CERT SSN HIC SUB ID number OR Patient Control Number and From Date OR CERT SSN HIC SUB ID Number and From Date OR Patient Control Number CERT SSN HIC SUB ID Number and From Date Entering the From Date alone is not a valid search If the user enters invalid criteria the following message will appear NO EXACT MATCH FOUND VERIFY DATA ENTERED IN SEARCH FIELDS If the user enters only the From Date the following message will appear SEARCH NOT ALLOWED ON FROM DATE ENTER ADDITIONAL SEARCH FIELD If a match is found the summary list will appear with the topmost line containing the search results i e the specific claim If no match
13. the detail claim data or Enter A d in the select column to delete the patient control number if required This option removes the claim from the correction file twice daily at noon and 11 45 p m To undelete space out the D and hit enter Press F2 To return to Empire OMNIPRO Main Menu Press F3 To return to 837 TO UB92 CORRECTION UTILITY MENU Press F7 To scroll backward Press F8 To scroll forward Select line value and their definitions _ A blank select line Claim is available for correction D Delete Claims flagged for deletion are removed twice daily at noon and at 11 45 p m To undelete a claim space out the D and hit enter A deleted claim cannot be selected unless you undelete the claim Blank out the D and press enter which will allow you to select the claim normally Good Records 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 13 Claims that are corrected e g Good claims are extracted twice daily at noon and at 11 45 p m for entry into the Empire claims processing systems 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 14 EMCO3600 01 20 EMPIRE 06 12 03 Empire provider PATIENT DATA CORRECTION SCREEN 01 PAYER DESTINATION CODE 00303 TOB PCN PATIE
14. 00 00303 SOURCE PYMT CD C PAYER CD MUST 00308 When the payer destination code is Empire Blue Cross 00300 00303 and the source of payment code is equal to C then the payer code must equal 00308 Screen 01 02 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 47 EB005301 EB005301 EB005302 EB005303 EB005304 EB005400 MEDICARE NOT ALLOWED 2ND TO EMPIRE IF PRIOR PAY EST AMT DUE gt 0 Medicare payer 00308 cannot be billed as the second payer on a claim when Empire Blue Cross payer 00300 00303 prior payment and or estimated amount due fields are greater than O Screen 02 MEDICARE NOT ALLOWED 2ND TO EMPIRE IF PRIOR PAY EST AMT DUE gt 0 Medicare payer 00308 cannot be billed as the second payer on a claim when Empire Blue Cross payer 00300 00303 prior payment and or estimated amount due fields are greater than O Screen 02 SC EMPIRE COINS DAYS ENTERED ARE MEDICARE COINS DAYS ENTERED Senior Care Claim The number of co insurance days entered for Empire Payer 00300 or 00303 cannot be greater than the number of co insurance days entered for Medicare Payer 00308 Screen 02 SC EMPIRE LTR DAYS ENTERED ARE MEDICARE LTR DAYS ENTERED Senior Care Claim The number of LTR days lifetime reserve entered for Empire Payer 00300 or 00303 cannot be greater than the number of LTR days entered for Medicare Payer 00308 Screen 02 SC VALUE CD REQ DED COIN LTR IF NO OCC CD B3 C3 OR 24 Seni
15. 4 HCPCS must be present For revenue code 064X a CPT4 HCPCS must be present and appropriate for billing with the 064X code Screen 05 INP SNF HH HOSPICE STATUS 30 DO NOT ENTER DISCHARGE HR For type of bills 111 115 211 215 33X 34X 81X or 82X only spaces are allowed in the discharge hour field when the patient status is 30 Screen 01 ADMIT TO DISCHARGE FINAL BILL PAT STATUS 30 39 NOT ALLOWED If the third digit of the type of bill is equal to 1 or 4 e g 111 or 114 the patient status code can not equal 30 thru 39 still patient Screen 01 INPATIENT HH HOSPICE SNF PATIENT STATUS CODE MUST BE ENTERED If the type of bill is equal to 11X 21X 33X 34X 81X 82X the patient status code must be entered Screen 01 INTERIM BILL FIRST OR CONTINUATION PATIENT STATUS MUST 30 If the third digit of the type of bill ends with 2 or 3 eg 112 or 113 the patient status code must equal 30 still patient Screen 01 PATIENT PRIOR PAYMENTS CAN T EXCEED REV CODE 0001 TOTAL CHGS The patient prior payments paid amount cannot exceed revenue code 0001 total charges sum of accommodation and ancillary total charges Screen 01 05 CONDITION CODE 40 ENTERED STATEMENT FROM DATE MUST THRU DT Screen 01 04 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 42 EB002401 EB002402 EB002405 EB002406 EB003200 EB003203 EB003204 EB003206 EB003207 COND 71 72 73 74 OR 76 R
16. 7 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 40 EB001101 EB001300 EB001400 EB001401 EB001902 EB001905 EB001906 PAYER 00300 00303 TOB 11X PAT S AGE lt 29 DAYS BIRTHWGHT REA This edit applies to inpatient bill types 111 112 113 114 and 115 If the patient s age is less than 29 days admission date minus patient s birthdate the birthweight must be entered unless the patient died patient status of 20 40 41 or 42 or transferred patient status of 02 within 4 days of birth statement covers thru date minus birthdate is less than or egual to 4 Screen 01 PATIENT S CITY MUST NOT CONTAIN NUMERICS Screen 01 OUTPATIENT HH HOSPICE PATIENT DOB AFTER STATE COV FROM DATE For bill types 13X 14X 72X 831 33X 34X 81X 82X the patient s birthdate must be less than or equal to the statement covers period from date Screen 01 INP HH HOSPICE PATIENT S BIRTHDATE IS GREATER THAN ADMIT DATE For type of bill 111 115 33X 34X 81X or 82X the patient s birthdate must be less than or equal to the admission date Screen 01 111 115 ADMIT TYPE 4 PATIENT AGE MUST BE UNDER 1 YEAR For inpatient billing when the type of admission is equal to 4 the patient s age must be less than one year Screen 01 OUTPT TOB DIAGNOSTIC THERAPY HOME INFUS REQ VALID CPT4 HCPCS Please note this edit applies to facilities that have negotiated rates with Empire If the type of bill is equal to 13X 14X 72X 73X
17. 8 04 6 000000 MM MM NN NN IIIIII PPPPPPP RRRRRRR 00 OO MMM NNN NN II PP PP RR RR OO 00 00 OO MMMMMMMM NNNN NN II PP PP RR RR 00 00 00 OO MM MM MM NN NN NN IT PPPPPPP RRRRRRR 00 00 00 OO MM MM NN NNNN II PP RR RR 00 00 00 OO MM MM NN NNN II PP RR RR 00 00 000000 MM MM NN NN IIIIII RR RR WARNING The unauthorized use of any Empire computer data or computer Service and unauthorized possession duplication of or tampering with any computer data or program are criminal offenses ALL VIOLATORS ARE SUBJECT TO PROSECUTION Good Morning Enter User ID gt Date Password gt Time Applid New Password gt Terminal enter twice gt Printer 1 key will release your terminal from CICS Keying Instructions For TAGAS ONNI EO ogging on to OMNIPROS Enter Your User ID 6 characters numeric Enter Your Password up to 8 characters Press Enter To display initial OMNIPRO menu Note The user ID and passwords are supplied to each facility by our office Each facility is reguired to complete the Empire OMNIPRO Interactive Logon Request Form SMC 1016 in order to access the system The PA1 key allows you to exit this screen and return to the initial Empire OMNIPRO screen shown on page 1 1 Providers that use personal computers should configure their keyboard function to utilize the ESC key to correspond with the PA1 function 837 TO UB92 CORRECTI
18. ATED INFO DATA ID 48616 For interactive entry when the Functional Limitation Code entered on screen 25B is selection 8 Other go to screen 25D select the free format narrative Updated Information Other Data ID 48616 This brings you to free format screen 25E key applicable information for Other on this screen Screen 25B 25E 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 51 EB007116 EB007117 EB007118 EB007200 EB007600 EB008000 EB008003 EB008200 FOR REV CD 655 656 658 UNITS MUST STATEMENT COVRS PERIOD This edit applies to Home Health Hospice bill types 33X 34X 81X and 82X When the patient status is equal to 30 the sum of the days units for revenue codes 655 or 656 or 658 must equal the statement covers period thru date minus the from date plus one For all other patient status s the days must equal the thru date minus the from date unless the statement covers from and thru dates are equal in which case the days must equal one Screen 01 05 CORRESPONDING DATA REMARKS ENTERED VALID DATA ID 4 REQUIRED If Corresponding Data Remarks is entered in screen 25 E then a valid Data ID is required Valid data id s 48510 48514 48515 48516 48517 48521 48522 48616 48617 48618 48619 48620 and 48621 Screen 25E PROVIDER NOT AUTHORIZED TO BILL HOME HEALTH HOSPICE CLAIM The provider number must be authorized for submission of home health hospice claims Sc
19. B PATIENT CONTROL NUMBER MEDICAL RECORD NUMBER NAME REMARKS MSG MSG ENTER F2 MENU F3 EXIT F6 NEXT PG F7 BKWD F8 FWD F10 SAVE FINALIZE NEXT SCR 00 Additional free format information may be entered on this screen This screen allows entry of two pages of free format narrative data The following criteria is applicable to Empire Blue Cross outpatient type of bill egual to 13X 14X 72X or 831 claims with sudden and serious illnesses If revenue code is equal to 450 459 51X with an admit type of 1 605 or 606 with non emergency diagnosis please include the following information when relevant The duration of the patient s distress i e duration of vomiting diarrhea fever urinary retention etc o Pain intensity type location and duration If patient complains of chest pains include professional observation and patient s comments o The weight of an infant with symptoms of diarrhea and or vomiting o Bleeding site severity and onset Enter any additional details pertaining to signs symptoms etc 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 22 EMCO3600 42 71 EMPIRE 06 12 03 Empire provider HOME HEALTH HOSPICE PLAN OF TREATME
20. CO3600 45 73 EMPIRE 06 12 03 Empire provider PLAN OF TREATMENT MEDICAL UPDATE NARRATIVE SCREEN 25 D CORRECTION PAGE 01 ID NUMBER SELECTION SCREEN 00 OF 96 SEGMENTS USED TITLE OF NARRATIVE DATA ID NUMBER STATUS MEDICATIONS DOSE FREQUENCY ROUTE 48510 _ DME AND SUPPLIES 48514 _ SAFETY MEASURES 48515 NUTRITUTIONAL REQUIREMENTS 48516 _ ALLERGIES 48517 _ ORDERS FOR DISCIPLINE AND TREATMENTS 48521 _ GOALS REHABILITATION POTENTIAL DISCHARGE PLANS 48522 _ UPDATED INFORMATION OTHER 48616 _ FUNCTIONAL LIMITATIONS REASON HOMEBOUND 48617 _ SUPPLEMENTARY PLAN OF TREATMEN 48618 _ UNUSUAL HOME SOCIAL ENVIRONMENT 48619 TIMES AND REASONS PATIENT NOT AT HOME 48620 _ MEDICAL NONMEDICAL REASONS PATIENT LEAVES HOME 48621 TYPE S TO SELECT AND VIEW NARRATIVE TYPE D TO DELETE NARRATIVE MSG MSG ENTER 2 F3 EXIT F7 BKWD F8 FWD F10 SAVE FINALIZE NEXT SCR 00 The Subscriber ID is system generated NOTE This screen allows you to select the Title of Narrative to enter medical information Type an S select in the space to the left of the Title of Narrative and press the ENTER key This will display screen 25 E a free format data entry screen with the Data ID Number and the Title of Narrative you selected To delete a Title of Narrative key a D delete on screen 25 D in the space to the left of the title you wish to delete and press ENTER All n
21. D 00303 The following edits apply when the Payer Destination Code is equal to 00300 or 00303 EB000401 INVALID TYPE OF BILL ENTERED The third digit of the Type of Bill frequency type code must not equal the letter A through X Y or Z or the number 0 7 8 or 9 Screen 01 EB000402 TOB 13X 14X 72X 831 REVENUE CODE LESS THAN 24X NOT ALLOWED Screen 01 05 EB000604 ONE SERVICE DT OR SAME DT REPEATED STATE FROM THRU MUST EQUAL This edit applies to outpatient bill types 13X 14X 72X and 831 Statement covers from and thru dates must equal if only one revenue code and corresponding service date is entered or more than one revenue code is entered and all of the corresponding service dates are the same This edit does not apply to revenue code 45X Screen 01 05 EB000605 INP SNF HH HOSPICE ADMIT DATE MUST STATEMENT COVERS FROM DATE For type of bill 111 211 331 332 341 342 811 812 821 and 822 the admit date must equal the statement covers from date Screen 01 EB000606 ADMIT DATE IF PRESENT MUST EQUAL OR LESS THAN FROM DATE Screen 01 EB000607 INTERIM BILL CONTINUATION FINAL ADMIT DATE CAN NOT FROM DATE If the third digit of the type of bill is equal to a 3 or 4 e g 113 or 114 the admit date entered must be less than the statement covers from date Screen 01 EB001100 PAYER 00300 00303 IF PRES BIRTHWEIGHT MUST BE 400 7000 GRAMS This edit applies to bill types 11X Screen 01 83
22. ER MANUAL Rev Date 10 08 04 9 Selection 1 837 to UB92 Claim Correction Overview The 837 to UB92 Claim Correction Summary lists all claims available for claim correction The summary screen displays the following information Patient Control Number Last Name CERT SSN HIC SUB ID Number From Date Type of Bill Purge Date and Input Mode All claims should be corrected prior to the purge date Claims that are not corrected by the purge date are removed from the correction file on the purge date given To view claim detail select a claim by entering an s in the select field next to the desired patient control number The screens displayed are similar to the UB92 Claim Correction screens Once on the actual claim correction screens make any corrections necessary and hit F10 to save the changes Once the F10 key has been depressed if the claim is error free a G will appear on the select line next to the corrected claim if additional corrections are necessary the select line will be blank and you have until the purge date displayed to correct the remaining errors The claims that are corrected e g Good claims will be extracted twice daily at noon and at 11 45 p m for entry into the Empire claims processing systems The facility has the option to delete any claims by entering a d in the select field for the specific patient control number This function removes the claim from the correction file twice daily at noon and at 11 45
23. ERIC Screen 05 REVENUE CODES 10X THRU 21X REQUIRE ACCOMMODATION RATE Screen 05 REVENUE CODES 10X THRU 21X REQUIRE DAYS UNITS Screen 05 Rev Date 10 08 04 34 Q555050004 Q120050005 Q560050005 Q120050006 Q560050006 Q120050007 Q560050007 Q120050008 Q560050008 Q120060004 Q120060005 Q120060006 Q575060004 837 TO UB92 CORRECTIONS USER MANUAL REVENUE CODE IS PRESENT TOTAL CHARGES MISSING Screen 05 ACCOMMODATION RATE IS NOT NUMERIC Screen 05 ACCOMMODATION RATE PRESENT REVENUE CODE MISSING Screen 05 REVENUE DAYS UNITS ARE NOT NUMERIC Screen 05 REVENUE DAYS UNITS PRESENT REVENUE CODE MISSING Screen 05 REVENUE CODE TOTAL CHARGES ARE NOT NUMERIC Screen 05 TOTAL CHARGES PRESENT REVENUE CODE MISSING Screen 05 REVENUE CODE NON COVERED CHARGES ARE NOT NUMERIC Screen 05 NON COVERED CHARGES PRESENT REVENUE CODE MISSING Screen 05 HCPCS CPT4 CODE ENTERED IS INVALID Screen 05 HCPCS MODIFIER ENTERED IS INVALID Screen 05 NATIONAL DRUG CODE ENTERED IS INVALID Currently not in use Screen 05 TOTAL CHG REV CODE 0001 CAN T BE ONLY REV CODE BILLED Screen 05 Rev Date 10 08 04 35 Q580060004 Q565060005 Q585060009 Q585060010 Q115061009 Q590061009 Q595061009 Q600070013 Q600070014 Q115070014 Q110071004 Q115071005 Q115071006 837 TO UB92 CORRECTIONS USER MANUAL TOTAL CHARGE REVENUE CODE 0001 IS MISSING Screen 05
24. EV CODE 82X 85X OR 88X REQUIRED This edit applies to outpatient bill types 13X 14X 72X and 831 If condition code 71 72 73 74 or 76 is entered then at least one revenue code from one of the following ranges must be entered 82X 83X 84X 85X or 88X Screen 01 04 05 CONDITION CODES MUST NOT BE REPEATED Screen 04 COND CD 80 81 82 83 84 OR 85 PRESENT OCC CD 24 REQUIRED Screen 03 04 OCC CD 24 PRESENT COND CD 80 81 82 83 84 OR 85 REQUIRED Screen 03 OCCURRENCE CODES MUST NOT BE REPEATED Screen 03 INP SNF HH HOSPICE OCC SP 71 78 THRU DT MUST BE lt OR ADMT DT This edit applies to bill types 111 115 211 215 33X 34X 81X 82X When occurrence span code 71 or 78 prior stay information is entered the corresponding occurrence span thru date must be less than the admission date Screen 01 03 OCC CD 01 06 OR 11 OCC DT AFTER STATE FROM DT NOT ALLOWED The corresponding occurrence date for occurrence code 01 thru 06 or 11 must not be greater than the statement covers from date Screen 01 03 OCC CODE 24 ENTERED OCC DATE AFTER TODAY S DATE NOT ALLOWED When occurrence code 24 is entered the corresponding occurrence date must be less than or equal to the current date Screen 03 OCC CD 01 06 11 DATE FROM DATE VAL CD 45 HR AFTER ADMIT HR This edit applies to outpatient bill types 13X 14X 72 and 831 If the corresponding occurrence date for occurrence code 01 thru 06 and 11 i
25. GC or G All spaces All alphas First position equal to space An embedded space Special characters Low values Data not greater than zero All 1 s 2 s 3 s 4 s 5 s 65 7 s 8 s 9 s or 0 s Literals equal to unknown unk individual self none 123456789 or 1234567890 Screen 02 ID BODY LENGTH INVALID AS ENTERED FOR SUBSCRIBER If the subscriber ID has no prefix positions 1 2 or 3 not alpha the subscriber ID body length must be no less than 6 and no greater than 9 positions If the subscriber ID prefix is equal to G GC OR YLG the subscriber ID body length is determined by Empire s Group Control File and the subscriber ID body may contain alphas If any of the first 3 positions of the subscriber ID are equal to alpha characters the subscriber id will be considered to have a prefix The prefix can be from 1 to 3 alpha characters the body begins with the first numeric after the alpha prefix If the prefix does not equal G GC YLG the body size must be no less than 4 and no greater than 14 alphanumeric characters Screen 02 00300 00303 SUB ID PREFIX IS INVALID 3 NUMERICS NOT ALLOWED The subscriber id prefix can not equal three numerics Screen 02 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 49 EB006007 EB006700 EB006701 EB006702 EB006705 EB007100 EB007101 EB007102 EB007103 BLUE CARD OUT OF AREA SUBSCRIBER 3 ALPHA PREFIX MISSING
26. KWD F8 FWD F10 SAVE FINALIZE NEXT SCR 00 Maximum number of pages allowed is 20 up to 400 condition codes and 480 value codes and amounts 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 18 EMCO3600 05 50 60 61 EMPIRE 06 12 03 Empire provider REVENUE CENTER CORRECTION SCREEN 05 PAGE 01 REV HCPCS MOD RATE SER DATE DAY UNIT TOT CHARGE NC CHARGE MODIFIERS 3 4 __ NATIONAL DRUG CODE MODIFIERS 3 4 __ NATIONAL DRUG CODE MODIFIERS 3 4 __ NATIONAL DRUG CODE MODIFIERS 3 4 __ NATIONAL DRUG CODE MODIFIERS 3 4 __ NATIONAL DRUG CODE MODIFIERS 3 4 __ NATIONAL DRUG CODE MODIFIERS 3 4 __ NATIONAL DRUG CODE MODIFIERS 3 4 __ NATIONAL DRUG CODE MSG MSG ENTER 2 F3 EXIT F6 NEXT PG F7 BKWD F8 FWD F10 SAVE FINALIZE NEXT SCR 00 Current state maximum number of pages allowed is 28 up to 224 revenue lines 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 19 EMCO3600 06 70 EMPIRE 06 12 03 Empire provider t MEDICAL DATA CORRECTION SCREEN 06 PRINCIPAL DIAGNOSIS CODE ECODE ADMITTING DIAGNOSIS CODE OTHER DIAGNOSIS CODES PRINCIPAL PROCEDURE CODE DATE
27. NT NAME LAST FIRST MI _ PATIENT ADDRESS STREE CITY STATE ZIP SEX _ DATE OF BIRTH STATEMENT FROM THRU ADMISSION DATE HR OF ADMISSION _ SOURCE OF ADMISSION _ DISCHARGE HOUR __ PATIENT STATUS NEWBORN BIRTH WEIGHT IN GRAMS PATIENT PRIOR PAYMENTS PATIENT ESTIMATED AMOUNT DUE MEDICAL RECORD NUMBER MSG MSG ENTER F2 MENU F3 EXIT F7 BKWD F8 FWD F10 SAVE FINALIZE NEXT SCR 00 The payer destination code is auto populated with the value of 00303 and is not be alterable 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 15 EMCO3600 02 30 31 EMPIRE 06 12 03 Empire provider PAYER DATA CORRECTION SCREEN 02 PAYER INFORMATION LINE A PAGE 01 PRIMARY PAYER CODE SOURCE OF PAYMENT CODE _ PAYER ID PLAN CODE CERT SSN HIC SUBID PAT RELATIONSHIP TO INSURED __ INSURANCE GROUP NUMBER INSURED GROUP NAME PAYER NAME PROVIDER ID NUMBER INSURED S NAME LAST FIRST _ SEX _ INSURED S ADDRESS STREET CITY STATE __ ZIP RELEASE OF INFO _ ASSIGNMENT OF BENEFITS _ DAYS COVERED NONCOVERED COINSURANCE LIFETIME RESERVE PRIOR PAYMENTS ESTIMATED AMOUNT DUE PAYER IDENTIFICATION IND __ CONTRACTOR NUMBER MSG MSG ENTER F2 MENU F3 EXIT F5 BC GROUP F6 NEXT PG F7 BKWD F8 FWD F10 SAVE FINALIZE NEXT SCR 00
28. NT SCREEN 25 A CORRECTION ID NUMBER PATIENT NAME DATA ID _ START OF CARE DATE CERT PERIOD FROM THRU DATE OF ONSET OF PRINCIPAL DIAGNOSIS SURGICAL PROCEDURE CODE DATE SURGICAL PROCEDURE PERFORMED DATE OF ONSET OF SECONDARY DIAGNOSIS 1 2 VERBAL START OF CARE DATE DATE PHYSICIAN LAST SAW PATIENT DATE LAST CONTACTED PHYSICIAN MEDICARE COVERED _ PATIENT RECEIVED CARE IN 1861 FACILITY _ CERTIFICATION RECERTIFICATION MODIFIED _ ADMISSION DATE DISCHARGE DATE TYPE OF FACILITY MSG MSG ENTER F2 MENU F3 EXIT F7 BKWD F9 DEL F8 FWD F10 SAVE FINALIZE NEXT SCR 00 Screen 25A is automatically generated when the type of bill on screen 01 is equal to 33X 34X 81X or 82X The Subscriber ID is system generated o The Patient Name is system generated Screens 25 A thru 25 E accommodate entry of the Home Health Hospice Plan of Treatment Attachments NOTE If the deletion of a Home Health Hospice Plan of Treatment is necessary the F9 DEL Delete key will delete all data from screens 25 A thru 25 E When the F9 DEL key is pressed a pop up window is displayed with the message You are about to delete the Plan of Treatment Attachment in this claim Press F9 to confirm deletion or press ENTER to return to the claim This will eliminate the possibility of deleting the attachment data in error 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 23
29. ONS USER MANUAL Rev Date 10 08 04 7 837 to UB92 Correction Utilities EMCO0050 EMPIRE 06 11 03 220817 OMNIPRO 11 53 47 SELECTION 1 ELECTRONIC MAIL 2 EDICARE PART A 4 EDICAL QUICKLINK 6 EMPIRE UTILITIES 8 837 TO UB92 CORRECTION UTILITIES 9 EMPIRE INTERNAL UTILITIES 10 UB 92 QUICKLINK 11 YS SERVICE CENTER ENTER SELECTION gt 28 CLEAR LOGOFF Keying Instructions For OMNIPRO Main Menu Enter Selection Code 8 837 TO UB92 CORRECTION UTILITIES Press Enter To display 837 TO UB92 CORRECTION UTILITY MENU Press Clear To exit OMNIPRO Main Menu 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 8 EMCO0120 EMPIRE 06 11 03 Empire provider 837 TO UB92 CORRECTION UTILITY MENU 1 58 10 1 CLAIM CORRECTION 2 SUBMISSION VALIDATION REPORT ENTER CTION NEM NTER CLEAR LOGOFF F2 MENU Keying Instructions For 837 to UB92 Correction Utility Menu Enter Selection Code 1 CLAIM CORRECTION OR Enter Selection Code 2 SUBMISSION VALIDATION REPORT Press F2 or F3 To return to Empire OMNIPROSY Main Menu Press Clear To exit OMNIPRO Main Menu Note The provider number displayed in the upper left corner is the number associated with the OMNIPRO logon 837 TO UB92 CORRECTIONS US
30. Plan of Treatment Certification Period must be entered Screen 01 25A 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 50 EB007104 EB007107 EB007110 EB007111 EB007112 EB007113 EB007114 REVENUE CODE NOT ALLOWED WITH REVENUE CODES 655 656 OR 658 For bill types 33X 34X 81X and 82X the following revenue codes are not allowed to be billed with revenue codes 655 or 656 or 658 41X 44X 55X 60X 64X 650 651 652 657 659 66X Screen 05 DUPLICATE FUNCTIONAL LIMITATION CODES NOT ALLOWED Screen 25B DUPLICATE ACTIVITIES CODE NOT ALLOWED Screen 25B DUPLICATE MENTAL STATUS CODES NOT ALLOWED Screen 25B FUNCT LIMITATION OTHER EXPLAIN IN UPDATED INFO DATA ID 48616 For interactive entry when the Functional Limitation Code entered on screen 25B is selection B Other go to screen 25D select the free format narrative Updated Information Other Data ID 48616 This brings you to free format screen 25E key applicable information for Other on this screen Screen 25B 25E ACTIVITIES PERMIT OTHER EXPLAIN IN UPDATED INFO DATA ID 48616 For interactive entry when the Functional Limitation Code entered on screen 25B is selection D Other go to screen 25D select the free format narrative Updated Information Other Data ID 48616 This brings you to free format screen 25E key applicable information for Other on this screen Screen 25B 25E MENTAL STATUS CD OTHER EXPLAIN IN UPD
31. Screen 02 SCREEN 02 PAGE 02 PRIMARY PAYER CODE MUST 5 IF PRESENT Screen 02 SCREEN 02 PAGES 03 06 PRIMARY PAYER CD MUST T IF PRESENT Screen 02 PAYER A B C D E F INSURED S STATE IF PRESENT MUST BE VALID Screen 02 TYPE OF BILL IS MISSING OR INVALID Screen 01 OCCURRENCE CODE IF PRESENT MUST BE VALID Screen 03 OCCURRENCE CODE PRESENT OCCURRENCE DATE MISSING Screen 03 OCCURRENCE DATE IS NOT NUMERIC OR INVALID Screen 03 Rev Date 10 08 04 33 Q535040009 Q110040028 Q535040028 Q115040029 Q115040030 Q535040029 Q510040029 Q110041004 Q110041016 Q120041017 Q540041017 Q120050004 Q545050004 Q550050004 837 TO UB92 CORRECTIONS USER MANUAL OCCURRENCE DATE PRESENT OCCURRENCE CODE MISSING Screen 03 OCCURRENCE SPAN CODE IF PRESENT MUST BE VALID Screen 03 OCCURRENCE SPAN CODE PRESENT SPAN FROM OR THRU DATE MISSING Screen 03 OCCURRENCE SPAN FROM DATE IS NOT NUMERIC OR INVALID Screen 03 OCCURRENCE SPAN THRU DATE IS NOT NUMERIC OR INVALID Screen 03 OCCURRENCE SPAN FROM OR THRU DATE PRESENT SPAN CODE MISSING Screen 03 OCCUR SPAN FROM DATE IS GREATER THAN OCCUR SPAN THRU DATE Screen 03 CONDITION CODE IF PRESENT MUST BE VALID Screen 04 VALUE CODE IF PRESENT MUST BE VALID Screen 04 VALUE AMOUNT IS NOT NUMERIC Screen 04 VALUE AMOUNT PRESENT VALUE CODE MISSING Screen 04 REVENUE CODE IS NOT NUM
32. and 21X Screen 01 ADMIT START DATE PRESENT ADMISSION HOUR MISSING Applicable to inpatient bill types 11X and 21X Screen 01 ADMISSION HOUR IF PRESENT MUST BE VALID Screen 01 STATEMENT FROM DATE IS MISSING OR INVALID Screen 01 STATEMENT FROM DATE IS GREATER THAN THRU DATE Screen 01 STATEMENT THRU DATE IS MISSING OR INVALID Screen 01 PATIENT STATUS DISP CODE IS NOT NUMERIC OR INVALID Screen 01 DISCHARGE HOUR IF PRESENT MUST BE VALID Screen 01 PATIENT PAYMENT RECEIVED IS NOT NUMERIC Screen 01 PATIENT ESTIMATED AMOUNT DUE IS NOT NUMERIC Screen 01 NEWBORN BIRTH WEIGHT IS NOT NUMERIC Screen 01 PAYER A B C D E OR F SOURCE OF PAYMENT CD MISSING OR INVALID Screen 02 Rev Date 10 08 04 31 Q100030005 Q100030007 Q100030008 Q110030010 Q100030012 Q100030013 Q100030014 Q110030015 Q110030016 Q110030017 Q100030018 Q120030020 837 TO UB92 CORRECTIONS USER MANUAL PAYER A B C D E OR F PAYER IDENTIFICATION IS MISSING Screen 02 PAYER A B C D E OR F CERT POLICY HIC ID NUMBER IS MISSING Screen 02 PAYER A B C D E OR F PAYER NAME IS MISSING Screen 02 PRIMARY PAYER CD MUST P 5 OR T PRIMARY SECONDARY TERTIARY Valid values are P S or T Primary Payer Code is used to identify the primary payer for the claim P and if present the secondary S and tertiary T payers Screen 02 PAYER A B C D E OR F INSURED S
33. arrative for that title will be deleted 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 26 EMCO3600 46 73 EMPIRE 06 12 03 Empire provider PLAN OF TREATMENT MEDICAL UPDATE NARRATIVE SCREEN 25 E CORRECTION PAGE 01 01 OF 96 SEGMENTS USED DATA ID NUMBER MSG MSG ENTER F2 MENU F3 EXIT F4 POT SEL 25 0 PG F7 BKWD F8 FWD F10 SAVE FINALIZE NEXT SCR 00 The Data ID Number and Title of Narrative will be system generated to match the selection made on screen 25 D NOTE This screen is a free format entry area Enter all information that pertains to the Title of Narrative and Data ID Number you selected on screen 25 D The F6 NEXT PG key can be used to enter additional pages of free format information if needed for the Title of Narrative selected Once the data has been entered you may save the claim or use the F4 POT SEL 25 D to go back to screen 25 D and select another narrative title for entry of additional information In the upper right corner of the screen under PAGE the number of Segments Used out of a total of 96 is displayed There are six segments available per screen Currently we can store up to 96 segments of data If more than 96 segments are entered the data will not be stored and the message Maximum amount of narrative entered 96 segments allowed per claim is dis
34. be entered on screens 07 Screen 07 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 29 COMMON EDITS Q100020003 Q100020004 Q100020005 Q100020006 Q100020007 Q115020008 Q110020010 Q11002001 1 Q100020012 Q100020014 Q110020015 Q10002016A 837 TO UB92 CORRECTIONS USER MANUAL PATIENT CONTROL NUMBER IS MISSING Screen 01 PATIENT S LAST NAME IS MISSING OR INVALID Only A Z and 1 space and or hyphen allowed Screen 01 PATIENT S FIRST NAME IS MISSING OR INVALID Only A Z and 1 space and or hyphen allowed Screen 01 PATIENT S MIDDLE INITIAL MUST BE A Z OR SPACE Screen 01 PATIENT S SEX IS NOT M MALE OR F FEMALE Screen 01 PATIENT S DOB IS MISSING OR INVALID Screen 01 TYPE OF ADMISSION IF PRESENT MUST BE VALID Screen 01 SOURCE OF ADMISSION IF PRESENT MUST BE VALID Screen 01 PATIENT S STREET ADDRESS LINE 1 IS MISSING OR INVALID Screen 01 PATIENT S CITY IS MISSING OR INVALID Screen 01 PATIENT S STATE IS MISSING OR INVALID Screen 01 PATIENT S ZIP CODE IS MISSING Screen 01 Rev Date 10 08 04 30 Q115020017 Q500020018 Q505020018 Q110020018 Q115020019 Q510020019 Q115020020 Q110020021 Q110020022 Q120020023 Q120020024 Q12002208C Q100030004 837 TO UB92 CORRECTIONS USER MANUAL ADMISSION START DATE IS NOT NUMERIC OR INVALID Screen 01 ADMISSION HOUR PRESENT ADMIT START DATE MISSING Applicable to inpatient bill types 11X
35. dit applies only to interactive OMNIPRO Physician data entered on screen 07 must correspond with payer information located on claim entry Screen 02 The payer line indicator will link the additional entry screens with the appropriate payer For example if Payer B is plan code 00303 attending physician data is required the payer line indicator on Screen 7 must equal B Screen 07 PAYER LINE INDICATOR ENTERED HAS NO MATCHING PAYER ON SCREEN 2 This edit applies only to interactive OMNIPRO A payer line indicator of A B C D E or F may be entered on screen 07 if a corresponding screen 02 payer entry is present If a payer line indicator is entered and no matching screen 02 payer entry is found this edit will be prompted Screen 07 1ST TWO POSITIONS OF PAYER ID MUST BE ZERO FOR SOURCE OF PAY G Screen 02 INFORMATION FOR THIS PAYER LINE HAS ALREADY BEEN ENTERED This edit applies only to interactive OMNIPROSY A payer line indicator may not be repeated on more than one page of screen 07 For example payer line indicator A may not be entered on screen 07 pages 1 and 2 Screen 07 ALL PAYER LINES FOR THIS SCREEN HAVE BEEN FILLED F6 INVALID This edit applies only to interactive OMNIPROSY This message will be prompted if the F6 NEXT PG key is depressed on screen 07 and all available pages have been filled For example if payer line A and B is completed on screen 02 only payer line indicators A and B may
36. e statement covers from date must equal the statement covers thru date This edit does not apply to revenue code 45X or when 36X is billed with 71X or 76X or when 49X is billed with 71X or 76X Screen 01 05 REV CODES 360 369 450 490 710 720 UNITS ENTERED MUST 1 This edit applies to outpatient bill types 13X 14X 72X and 831 Screen 01 05 REV CODE 51X 8 ADMIT TYPE 1 ENTER UNITS 1 This edit applies to outpatient bill types 13X 14X 72X and 831 Screen 01 05 REV CODE 45X ENTERED OCC CD 01 06 OR 11 REQUIRED This edit applies to outpatient bill types 13X 14X 72X and 831 Screen 01 03 04 05 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 45 EB004500 REV CD DATE OF SERVICE MUST BE WITHIN STATEMENT COVERS DATES The date of service for a revenue code must be egual to or greater than the statement covers period from date and less than or egual to the statement covers period thru date This edit does not apply to revenue code 45X Screen 01 05 EB004501 OUTPATIENT HH HOSPICE ENTER DATE OF SERVICE FOR REVENUE CODE For bill types 13X 14X 72X 831 the date of service must be entered for every revenue code entered except revenue code 0001 For bill types 33X 34X 81X 82X the date of service must be entered for every revenue code except 10X 21X Screen 05 EB004502 SERVICE DATES FOR THIS REV CODE MUST BE WITHIN THE SAME MONTH This edit applies to outpatient bill types 13X 14X 72X and 831 The
37. ene 28 BLUE CROSS UB 92 ERROR CODES eee sor aon nna ene ba so se DU va sa sv bv NS s e 29 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 3 Introduction The Empire OMNIPROSY Blue Cross 837 to UB92 Corrections User Manual is designed to assist with the correction of claims submitted in the X12 837 format and converted to UB 92 format The manual contains 837 to UB92 corrections screens and instructions online validation report screens and 837 to UB92 error codes The 837 claims that are selected for correction must be free of any 837 IG errors This means that the claims must be HIPAA compliant according to the X12 837 Institutional Implementation Guides IG for versions 004010X096 and 004010X096A1 Claims that are IG compliant i e contain no IG errors and fail for 837 IGE external code set errors or selected 837 business errors will be converted to the UB92 format These claims will be available for correction in Selection 8 837 TO UB92 CORRECTION UTILITIES on the OMNIPRO Main Menu Selection 8 will offer the following features CLAIM CORRECTION and the SUBMISSION VALIDATION REPORT Under the Claim Correction feature 837 claims will be available to be corrected and submitted as UB92 claims the next business day after processing of the 837 file The claims that are corrected e g Good claims will be extracted twice daily at noon and at 11 45 p m for entry into the Empire claims processing s
38. following revenue codes may be billed for multiple dates but the dates must be within the same month for the same revenue code 300 333 335 339 341 342 349 359 380 387 389 390 399 400 402 409 420 424 429 434 439 444 449 460 471 482 489 51X only when admit type 3 610 619 730 740 820 859 880 889 909 911 929 941 945 949 977 979 Screen 01 05 EB004600 ONLY ONE REV CD BILLED FROM THRU MUST BE SAME UNITS MUST 1 This edit applies to outpatient bill types 13X 14X 72X and 831 If only one revenue code is entered and is not equal to one of the revenue codes listed below then the units of service for the revenue code must equal one and the statement covers from and thru dates must be equal All inclusive revenue codes 300 333 335 339 341 342 349 359 380 387 389 390 399 400 402 409 420 424 429 434 439 444 449 460 471 482 489 51X only if admit type 3 610 619 730 740 820 859 880 889 909 911 929 941 945 949 977 979 Screen 01 05 EB004601 SUM OF REV CD 10X 21X DAYS MUST BILL PERIOD FOR PAT S STATUS This edit applies to inpatient bill types 111 115 and 211 215 When the patient status is equal to 30 the sum of the days for revenue codes 10X thru 21X must equal the statement covers period thru date minus the from date plus one For all other patient status s the days must equal the thru date minus the from date unless the statement covers from and thru dates are equal in
39. iagnosis Code Inguiry Located on screen 25 E used to go to screen 25 D Plan of Treatment Selection Screen Located on screen 02 displays Group Control Inguiry Located on screen 06 displays ICD 9 CM Procedure Code Inguiry Screen refresh displays a new page ofthat screen when applicable for entry of additional data Scroll backward to a previous screen Scroll forward to the next screen Displays the narrative of a specific ICD 9 CM Diagnosis or Procedure code The PF9 key is only available on the Diagnosis Code Inquiry Screen or Procedure Code Inquiry Screen Located on screen 25 A used to the Home Health Hospice 25 A Plan of Treatment Attachment Sends the claim to the correction file submits the claim for processing keyboard to utilize the Print Screen key to correspond with the PA2 function key Logoff the application screen exit OMNIPRO Process the data entered on the screen Rev Date 10 08 04 12 EMCO EMPIRE 06 12 03 Empire Provider 837 TO UB92 CLAIM CORRECTION SUMMARY 12 22 54 PATIENT CONTROL CERT SSN HIC SUB ID FRO PURG INP NUMBER NUMBER DATE TOB DATE MDE ENTER F2 MENU F3 EXIT F7 BACKWARD F8 FORWARD Keying Instructions For Claim Correction Summary Enter An s in the select column for the appropriate patient control number to display
40. is found an error message will be displayed as well as the search criteria that was entered all other summary lines will be blank The user will be able to rekey the search criteria or if a search is not desired press the F7 key The summary list will then be displayed and the user can scroll to select a claim 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 10 Additional Functionality Exit Pop Up Window exit pop up window is available on all correction screens to confirm the exit with out saving any corrections made When the F2 or F3 key is pressed a message will appear stating You haven t saved your current claim To exit without saving the changes F2 or F3 key again To remove the exit pop up window and return to the current claim press enter EMCO2600 07 80 EMPIRE 12 09 03 Empire provider number PHYSICIAN DATA CORRECTION SCREEN 07 PAGE 01 PHYSICIAN INFORMATION RELATES TO PAYER LINE A PHYSICIAN NUMBER QUALIFYING CODE SL ATTEND PHYS 4 999999 NAME LAST SMITH FIRST JOHN MIA OPERAT PHY LLIN MI OTHER PHYS WARNING MI YOU HAVEN T SAVED YOUR CURRENT CLAIM F2 F3 OK TO EXIT ENTER RETURN TO CLAIM 5 5 ENTER F2 MENU F3 EXIT 6 F7 BKWD F8 FWD F10 SAVE FINALIZE NEXT SCR 00 Next Screen The Next Screen function allows the user
41. or Care Claim Enter the Medicare coinsurance deductible or lifetime reserve amounts If there is no value code entered on the claim for deductible coinsurance or lifetime reserve and there is no occurrence code or 24 that indicates that the Medicare benefits are exhausted or that Medicare has denied the claim the claim will reject with this edit Screen 03 04 SUB ID PREFIX YLG GC OR REAS VALID GROUP IN GROUP FLD If the subscriber ID prefix is equal to G GC OR YLG the group number must be present and must be a valid number on Empire s Group Control File Screen 02 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 48 EB005401 EB005402 EB006002 EB006003 YLG GC OR PREFIX GROUP REG FROM 1 TO 4 NUMBERS ALLOWED If the prefix equals G GC or YLG the group number must be present and must not contain any of the following conditions Less than 1 numeric more than 4 numerics non numeric data including special characters and low values leading spaces or blanks an embedded space literals equal to unknown unk individual self or none Group number must be entered exactly as it appears on the Group Control file no leading zeros Screen 02 SUBSCRIBER ID FORMAT IS INVALID This edit will reject the claim if the Subscriber ID contains one or more of the following conditions note this edit does not apply to a Subscriber ID that has a prefix equal to YLG
42. played 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 27 Selection 2 Submission Validation Report This selection displays the total number of Good claims extracted and forwarded for adjudication per cycle date EMCO6250 INSTITUTIONAL VALIDAT CYCLE DATE 052203 SUB CNT O 031421737 DATE RECD 05 22 03 TOTAL CLAIMS CORRE CTE SG ENTER F2 MENU F3 EXIT EMPIRE RETURN SUMMARY PROVIDER 999999 CLAIM TYPE U92 SUBMISSION STATUS ACCEPTED 000000002 ION SUMMARY R EPORT HU 05 23 03 12 09 29 UBMITTER INTERACT2 ETURN CAT CLM PUT MODE H 10 CYC DT Keying Instructions For Institutional Validation Summary Report Enter A valid cycle date in MMDDYY format and hit the enter key to display a submission validation report Press F2 To return to Empire OMNIPROSY Main Menu Press F3 To return to the 837 to UB92 Correction Utilitiy Menu Press F10 Upon initial entry hit F10 to view the first available validation report When viewing a validation report hit F10 to scroll forward to the next available validation report 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 28 Blue Cross UB 92 Error Codes GENERAL OMNIPRO EDITS G0000003 G0000004 G0000005 G0000006 G0000007 PAYER LINE INDICATOR MUST A B C D E ORF This e
43. reen 02 03 HOSPICE CERTIFICATION OF TERMINAL STATUS MISSING DATA ID 48522 If the type of bill is equal to 81X or 82X the certification of terminal status a statement that indicates the patient has a terminal illness must be indicated under data id 48522 Goals Rehabilitation Potential Discharge Plans Screen 25E TOB 11X OR 21X MUST ENTER ADMITTING DIAGNOSIS CODE This edit applies to inpatient bill types 111 115 and 211 215 Screen 01 06 PROCEDURE CODE ENTERED IS INVALID NOT ICD 9 CM Screen 06 PROCEDURE DATE MUST BE WITHIN STATEMENT FROM AND THRU DATES Screen 01 06 PAYER 00300 00303 TOB 11X OR 21X ENTER ATTEND PHYS NUMBER Applicable to type of bill 11X and 21X only Screen 07 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 52 EB008201 PAYER 00300 00303 TOB 11X 21X ATTEND PHYS FIRST amp LAST NAM REA Applicable to type of bill 11X and 21X only Screen 07 EB008300 PAYER 00300 303 OPER PHYS NAME REGUIRES ENTRY OF OPER PHYS NO Screen 07 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 53
44. s equal to the statement covers from date then the accident hour entered in the value code 45 amount field must be less than or equal to the admission hour Screen 01 03 04 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 43 EB003300 EB003301 EB003800 EB003801 EB003802 EB003803 EB003900 EB003901 EB003902 EB003903 EB003904 13 14 72 831 OCC CD 40 DT NOT AFTER STATEMENT FROM DT For outpatient billing when occurrence code 40 is entered the corresponding occurrence date must be greater than the statement covers from date Screen 01 03 TOB 13X 14X 72X 831 OCC CD 41 DATE NOT WITHIN STATEMENT DATES When occurrence code 41 is entered the corresponding occurrence date must be egual to or greater than the statement covers from date and less than or egual to the statement covers thru date Screen 01 03 PAYER ID 00300 00303 INSD S STREET ADDRESS MISSING OR INVALID Screen 02 PAYER ID 00300 00303 INSURED S CITY IS MISSING OR INVALID Screen 02 PAYER ID 00300 00303 INSURED S STATE MUST BE ENTERED Screen 02 PAYER ID 00300 00303 INSURED S ZIP CODE MUST BE ENTERED Screen 02 VALUE CODE ENTERED REQUIRES VALUE AMT GREATER THAN ZERO This edit does not apply to value codes 02 and 45 All other value codes entered require value amounts greater than zero Screen 04 VALUE CD 45 ENTERED AMOUNT MUST 0000 2300 ENTER AS DOLLARS Value code 45 requires the acciden
45. t hour to be entered as dollars to the left of the dollar cents delimiter decimal point Only values 00 thru 23 are allowed Screen 04 VALUE CODE 45 ENTERED OCCURRENCE CODE 01 06 OR 11 REQUIRED Screen 03 04 VALUE CODE 14 ENTERED OCCURRENCE CODE 02 REQUIRED Screen 03 04 VALUE CODE 15 ENTERED OCC CODE 04 OR COND CODE 02 REQUIRED Screen 03 04 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 44 EB003905 EB004000 EB004200 EB004201 EB004203 EB004205 EB004206 EB004207 EB004210 VALUE CD 45 ENTERED AMOUNT IN CENTS POSITION MUST EQUAL 00 The accident onset hour should not be entered in the cents position of the value amount field The two position hour should be entered as dollars in the 6th and 7th position of the value amount field Screen 04 VALUE CODES MUST NOT BE REPEATED Screen 04 REVENUE CODE ENTERED IS INVALID Screen 05 TOB 13X 14X 72X 831 ONLY REV CD 0001 ALLOWED WITH REV CD 24X Screen 01 05 REV CODES 82X 85X 88X REQUIRE COND CODE 71 72 73 74 OR 76 This edit applies to outpatient bill types 13X 14X 72X and 831 The entry of any revenue code from the 82X 83X 84X 85X or 88X ranges requires the entry of one of the above condition codes Screen 01 04 05 REV CODES 36 49 70 72 STATE FROM DT MUST THRU DT This edit applies to outpatient bill types 13X 14X 72X and 831 If a revenue code from any of the above categories is entered th
46. to go directly to any screen desired The NEXT SCR field is located in the lower right corner of every screen Enter the screen number you wish to go to and press enter This will take you directly to that screen Payer Line Indicator A payer line indicator field located on screen 07 and is used to crosswalk data to the correct payer entered on screen 02 For example if you want to enter physician data on screen 07 relating to two payers i e payors A and B on screen 02 you must enter a payer line indicator of A and applicable physician data then press the F6 key next page to prompt a new page enter a payer line indicator of B and applicable physician data 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 11 Keyboard Function Definition The following function keys when displayed at the bottom of select 837 to UB92 Correction screens assist in the operation and navigation between various menus and screens The function keys are labeled on each keyboard They are usually located on the top of the keyboard This may vary based on selected equipment manufacturers Function Keys and their definitions F2 MENU F3 EXIT F4 DIAG ING F4 POT DEL 25 D F5 BC GROUP F5 PROC ING F6 NEXT PG F7 BKWD F8 FWD F9 NARRATIVE F9 DEL F10 SAVE FINALIZE CLEAR ENTER 837 TO UB92 CORRECTIONS USER MANUAL This key returns you to the Main Menu Exit the screen or menu Located on screen 06 displays ICD 9 CM D
47. which case the days must equal one Screen 01 05 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 46 EB004700 EB004701 EB005000 EB005100 EB005203 EB005204 EB005207 11 OR 21X MUST ENTER AT LEAST 1 ACCOM REV CD 10X 21X Inpatient claims must contain at least one Accommodation Revenue Code 10X 21X This edit applies to inpatient bill types 111 115 and 211 215 Screen 01 05 TOB 11X OR 21X REV CODES 10X 21X DAYS X RATE MUST REV TOT CHG This edit applies to inpatient bill types 111 115 and 211 215 Screen 01 05 AT LEAST ONE FIELD OF PAYER INFORMATION MUST BE COMPLETED Record Type 30 and Screen 2 are mandatory for claims processing Data must be entered in at least one field to activate the appropriate edits Screen 02 PAYER 00300 00303 SCREEN 2 PROV MUST PROV ON SCREEN 1 For interactive claim entry when a payer entered on Screen 2 is equal to Empire Blue Cross plan code 00300 or 00303 the corresponding provider number entered must match the provider number displayed on Screen 1 Screen 02 MEDICARE PAYER 00308 MUST NOT BE BILLED ALONE Medicare payer 00308 data must be billed prior to the Empire Blue Cross payer 00300 00303 data Screen 02 PAYER DEST 00300 00303 PAYER CD 00308 SOURCE PYMT MUST C When the payer destination code equals 00300 or 00303 and the payer code is equal to 00308 then the source of payment code must equal C Screen 01 02 PAYER DEST 003
48. ystems The feature for the Submission Validation Report will display the number of Good claims that were extracted for the day Please note There are some 837 business edits that will not be selected for correction on OMNIPRO as follows e Any edits related to validation of the provider number A valid provider number is mandatory for 837 to UB92 corrections e Any edits related to adjustment claims Adjustments are excluded from 837 to UB92 corrections e Any edits related to negative amounts e Edit for 837 Reference Designator 06 Transaction Type Code must equal CH 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 4 Integrated Electronic Services Contact Inquiries regarding this publication or general questions concerning electronic claim submission should be addressed to Phone 1 866 889 7322 Fax 1 416 774 4778 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 08 04 5 Getting Started WARNING THE UNAUTHORIZED USE OF ANY EMPIRE COMPUTER DATA OR COMPUTER SERVICE AND UNAUTHORIZED POSSESSION DUPLICATION OF OR TAMPERING WITH ANY COMPUTER DATA OR PROGRAM ARE CRIMINAL OFFENSES ALL VIOLATORS ARE SUBJECT TO PROSECUTION SELECT gt 1 OMNIPRO Available N NOTIFY TERMINAL WHEN APPLID AVAIL Q QUEUE LOGON WHEN APPLID AVAIL Keying Instructions For Accessing OMNIPRO Main Menu Enter Selection Code 1 OMNIPRO M Press Enter 837 TO UB92 CORRECTIONS USER MANUAL Rev Date 10 0
Download Pdf Manuals
Related Search