This page guides Billing Managers & Team Leads on how to best set up your RCM configuration for your organization’s unique needs. Through workflow customization and best practices on championing these within your team, your organization will reap the benefits of a well-organized RCM workflow.
Audience
Billing Managers and Billing Team Leads share the same responsibilities of creating, implementing, and managing the Queues, Statuses, and Issues (QSI) for an Organization's billing team. Both roles are responsible for making sure Billing Collection and Payment Posting team members adhere to the QSI process created.
Process Overview
QSI's provide a unique workflow that billers can easily adopt to keep claim follow-up organized and provide their organization with insight into the key issue. Your Implementation Specialist will pre-configure your managing organization with Queues, Statuses, and common Issue Types. However, it is recommended that clients review the lists to determine if any are missing from their organization's standard workflow and continue to add/remove/modify customized QSI's as needed.
QSI Customization
Let's review where to create custom QSIs!
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Navigate to the Managing Org Admin > Configuration > Claim Queue Types > Create Claim Queue Type.
- Navigate to the Managing Org Admin > Configuration > Claim Statuses > Create Claim Status Type.
- Navigate to the Managing Org Admin > Configuration > Claim Issue Sources > Create Claim Issue Source.
- Navigate to the Managing Org Admin > Configuration > Claim Issue Types > Create Claim Issue Type.
Helpful Hints for Customizing QSIs
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Step
Helpful Hints
Adding Queues
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Create queues based on the teams at your organization. If you are a highly staffed outlet, you may have a specific Appeals department that could have its own queue.
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See Best Practices for Updating Claim Workflow for what each default queue means.
- For more information on creating queues, click here.
Adding Statuses
- Create simple and specific statuses for your claims based on where it is in the lifecycle. That way, there is no confusion when it comes to which status is the best one to use.
- Simple and specific statuses will also ensure your team can notate correctly on the claim.
- For more information on creating statuses, click here.
Adding Issues Sources
- Create issue sources based on the different departments in your organization where issues can arise.
- Issue sources should be simple to ensure you can easily match them to the different issue types that you have created.
- For more information on creating issue sources, click here.
Adding Issue Types
- Create issue types based on the different billing scenarios that delay reimbursement on a claim.
- Remember, issue types should be simple and specific to ensure team members can quickly determine the most accurate combination for their notes.
- See Default Settings below for how the different issue sources relate to the different issue types.
- For more information on creating issue types, click here.
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Set Default Account Settings
The Account Settings section instructs the RCM on when and how to apply QSIs automatically based on the current state of the claim in the revenue cycle. These settings can be edited by navigating to Managing Organization Admin > Configuration > Account Settings.
Available Defaults under Account Settings
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Default Claim Queue for First Claim Instance
Payer Queue
Assign this to the queue where Billing Collections will look to find claims to follow up on for the first time.
Default Claim Queue Upon Claim Resubmit
Payer Queue
Assign this to the queue where Billing Collections will look to find claims to follow up on after a claim is resubmitted.
Default Claim Queue Upon EOB Receipt
Review Queue
Assign this to the queue where Payment Posters will look to find claims to follow up on after payment is received.
Default Claim Queue Upon Claim Rejection
Resubmit Claim Queue
Assign this to the queue where Billers will look to find claims to correct after they have been rejected.
Default Claim Queue Upon Payer Hold
Payer Queue
Assign this to the queue where Billing Collections will look to find claims to follow up on after a claim was marked as held.
Default Claim Queue Upon Unbalanced Payment
Unbalanced Payment Queue
This queue is automatically created and works in tandem with the Out of Balance Work Center for Payment Poster to review.
Default Claim Queue Upon Balance Ignore
Balanced Ignored Queue
This queue is automatically created and works in tandem with the Out of Balance Work Center for Payment Poster to review.
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Default Claim Status for First Claim Instance
Payer - Original Claim Processing
Select a status that tells Billing Collections this is the first time this claim is being followed up.
Default Claim Status Upon Claim Resubmit
Payer - Resubmitted
Select a status to tell Billing Collections this is the first follow-up after resubmission. This allows them to review the claim notes and ensure the payer processes the correction accurately.
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Days to Follow-Up on Claim Submit for First Instance
30 Days
Set a follow-up date default that will allow the payer enough time to process your claim before you follow up for the first time. We recommend between 20-30 days.
Days to Follow-Up Upon Claim Resubmit
15 Days
Set a follow-up date default that will allow the payer enough time to process your resubmitted claim before you follow up.
Maximum Charge for New Multi-Day Claim ($)
$10,000
Set the maximum charge amount a claim can be created within the RCM.
ICD-10 Requirement Effective Date
10/1/2015
Always set this for 10/1/2015 when ICD-10 became required.
Set Default Issue Types
Tagging resubmissions with issues helps users quickly identify the reason and context behind a resubmission. Refer to the list below of default claim issue types your RCM will be configured with at the time of creation.
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These issues can be altered by navigating to the Managing Organization Admin > Configuration > Claim Issue Type.
Source
Type
Billing
Demographics Error - Data Entry Address
Billing
Demographics Error - Data Entry Client Name
Billing
Demographics Error - Data Entry Dob
Billing
Demographics Error - Data Entry Gender
Billing
Duplicate Claim
Billing
Incorrect Coding Used - Admit Discharge Date
Billing
Incorrect Coding Used - Bill Type
Billing
Incorrect Coding Used - Cpt/Hcpc Code Used
Billing
Incorrect Coding Used - Rev Code
Billing
Incorrect Diagnosis - Diagnosis Used Invalid
Billing
Incorrect Member ID - Data Entry Error
Billing
Incorrect Payer - Submitted To Medical vs Behavioral
Billing
Incorrect Payer - Submitted To Wrong Payer
Billing
Incorrect Provider - Incorrect Facility
Billing
Original Reference Number Invalid
Billing
Submitted In Error - After Client Discharged
Billing
Submitted In Error - Before Client Admitted
Billing
Submitted In Error - Not On Census
Payer
Claim Not On File - Electronic
Payer
Claim Not On File - Paper
Payer
Delayed Processing - Paper Claim Processing
Payer
Delayed Processing - Payer Did Not Specify Reason
Payer
Delayed Processing - Payer System Issue
Payer
Medical Records Requested
Payer
Medical Records Under Review
Payer
Paper Claims Not Accepted For Minnesota Address
Payer
Payer Keying Error
Provider
Enrollment Not Completed Prior To Billing
Provider
Provider Address Incorrect At Payer
Provider
Provider Not Registered With Payer
Provider
Tax ID Not On File With Payer
UR
Auth Keying Error
UR
Auth Not On File With Payer
UR
Authorization Incorrect At Payer
VOB
COB Not Completed
VOB
Coverage Terminated
VOB
Maximum Benefits Reached
VOB
No OON Coverage
VOB
Non-Covered Service
VOB
Timely Filing
Write-Off
All Appeals Exhausted
Write-Off
Coverage Terminated
Write-Off
Max Benefits Reached
Write-Off
No OON Coverage
Write-Off
Non-Covered Service
Write-Off
Timely Filing
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- EOB Requested (Payer): Tagging a claim with this issue type lets the user know the reason this claim is still outstanding. The EOB was requested from the payer, and the team is having issues receiving it from the payer in a timely manner.
- Incorrect Authorization Number: This tag will help identify data entry issues when authorization numbers are being entered into the utilization plans.
- Incorrect Electronic Payer Set for Patient: This tag can help identify claims that were initially sent to the incorrect payer. Identifying these types of claims will help identify gaps in the VOB process.
- Medical Records Under Review: Claims that are tagged with this issue can help identify a waiting period when the payer is reviewing the medical records that were sent in.
- No OON Coverage: Tagging a claim with this issue will highlight specific questions that the team can start asking during the VOB process. If this issue keeps coming up, the manager will know there are improvements to be made with the VOB calling process.
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NPI/Tax ID Not Registered with Payer: Tagging claims with this issue will help to identify the claims that aren't able to process because the provider is not on file with the payer. If the credentialing is assigned to a specific individual, they can reprocess all claims with this tag once the credentialing is complete.
- Recommendation: Use the Issue queue with these claims. A biller will be able to filter by the Issue queue when looking at overdue claims to see the list of claims that need to be resubmitted once the issue is resolved.
Set Payer Rates
Setting Payer Rates helps ensure accurate reimbursement, financial planning, and contract compliance to manage the revenue cycle effectively. By establishing payer rates, an organization can optimize cash flow and reduce the likelihood of payment disputes.
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Add Payer Rates
Practice Admin > Payers > Payer > Payer Rates
- Create Payer Rate
- Select Service
- Select Service Billing Profile
- Enter Amount
- Enter Contract Status
- Enter Effective Date
- Enter Review Date
- Select Create
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Create payer rates based on your contracted and non-contracted rates with certain payers.
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As you collect more data, you can start identifying trends around OON reimbursements to add OON expected rates.
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The RCM reports that will show payer rates are:
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