Maintain Products and Product Matches

The following procedures allow you to add, view, edit, or delete products and product matches in Contract Manager.

Use this procedure to add a new payor product and associated product match to the system.

Procedure

  1. To access the Product Maintenance page, select Go To > Contract Maintenance > Product Maintenance. 
  2. In the Product drop-down list, select Add New Product.
  3. In the Product Match drop-down list, select Add New Product Match.
  4. Type the appropriate information into the data fields in both the Product and Product Match areas of the page.
    • Your facility is set up to use either a payor name or payor code. You cannot populate both a payor name and payor code in this section.
    • The Payor Code or Payor Name must be unique for the facility.
    • For more information about each field on this page, refer to the Field Description table below.

You must select the Reprice using DRG Severity Codes check box to consider severity of illness in the reprice.

  1. Click Add Product Match and Product. The Add was successful! message appears.
  2. Optionally, you can select one of the following actions while on this page:

Use this procedure to view or edit an existing product for your facility.

Procedure

  1. To access the Product Maintenance page, select Go To > Contract Maintenance > Product Maintenance. 
  2. In the Product list, select a product name from the list.
  3. Or if you are uncertain about which contract you need to view or edit:
    • Type the appropriate selection criteria in one or more fields in the Product section
    • Click Display Products.
    • The Product Maintenance page lists at the bottom of the page all the products that meet your criteria.

Note: If you leave the selection criteria fields blank, the search will return records for every contract in the system. 

  1. Click a link in the Product Name column to load that product record into the fields for editing.
  1. View or edit the appropriate information, and then click Update Product. The Update was successful! message appears.
  2. Optionally, you can select one of the following actions while on this page:

Click Multi Product Maintenance to edit multiple products at once for your facility.

See Multi-Product Management for additional information.

Use this procedure to delete an existing product for your facility.

Procedure

  1. To access the Product Maintenance page, select Go To > Contract Maintenance > Product Maintenance. 
  2. In the Product list, select a product name from the drop-down list. The product information appears.
  3. Click Delete Product. The product and its associated product matches are erased from the system, and the Delete was successful! message appears.
  4. Optionally, you can select one of the following actions while on this page:

Use this procedure to add a new product match to an existing product.

Procedure

  1. To access the Product Maintenance page, select Go To > Contract Maintenance > Product Maintenance. 
  2. Select a product from the Product drop down list to upload its information into the fields.
  3. In the ProductMatch list, select Add a New Product Match.
  4. Type the appropriate information for the new product match in the data fields.
    • Your facility is set up to use either a payor name or payor code. You cannot populate both a payor name and payor code in this section.
    • The Payor Code or Payor Name must be unique for the facility.
  5. Click Add Product Match. The Add was successful! message appears.
  6. Optionally, you can select one of the following actions while on this page:

Use this procedure to edit an existing product match.

Procedure

  1. To access the Product Maintenance page, select Go To > Contract Maintenance > Product Maintenance. 
  2. Select a product from the Product drop down list to upload its information into the fields.
  3. In the ProductMatch list, select the product match you want to modify.
  4. Edit the appropriate data fields in the Product Match area, and then click Update Product Match. The Update was successful! message appears.
  5. Optionally, you can select one of the following actions while on this page:

Use this procedure to remove a product match to a product.

Procedure

  1. To access the Product Maintenance page, select Go To > Contract Maintenance > Product Maintenance. 
  2. Select a product from the Product drop down list to upload its information into the fields.
  3. Select a product match from the Product Match drop-down list. Its information appears in the Product Match fields.
  4. Click Delete Product Match. The product match is erased from the system, and the Delete was successful! message appears.
  5. Optionally, you can select one of the following actions while on this page:

The following table describes the fields on the Product Maintenance page. The URL for this page is inventory_product_maintenance.asp.

Field

Description

Product

Product

Name of the insurance product selected

Product Name

Complete name of the product selected

Product Description

Description of the product

Product Type

The type of product: HMO, PPO, Indemnity, Medicare, Self Pay, Medicaid, MediCal, TRICARE or Do Not Process

Reimbursement Limit

The maximum rate of reimbursement, expressed as a number

Contract

Name of the contract profile

Clearinghouse

The name of the clearinghouse that is the file source for this product; the default value for this field is None Selected.

Ignore Claim Disposition 204

Selecting this check box prevents Medicare OPPS accounts with Claim Disposition 204 to produce a write-down.

Note: This option is available only for selected facilities. The product flag PRODUCT.IGNORE_204 must be set to Y.

Non-Covered Charges

The following options govern how Non-Covered Charges are treated when repricing the product:

  • Added to calculated expected reimbursement – This option removes the non-covered charges from the billed charges prior to calculating the Expected Insurance Payment and Expected Discount amount, and then the Non-Covered Charge amount is added to the Total Expected Reimbursement.

  • Not added to calculated expected reimbursement – This option removes the non-covered charges from the billed charges prior to calculating the Expected Insurance Payment and Expected Discount but does not add non-covered charges back to either expected amounts.

  • Ignored - full value of all charges is used to calculate reimbursement. Any non-covered portions are ignored.

Disable Write-Downs?

An option allowing you to disable write-downs

100% Write-Down

Drop down list allowing you to send 100% write-down for the product. The options are Yes and No

Process Re-Billed Line Item Claim

Selecting this check box enables additional line item evaluation of the claim to determine if it is being re-billed with line items previously denied by the payer.

  • If the lines match those of a previous claim, the claim is identified as a re-bill of duplicate line items and not priced.
  • If the line items do not match those of a previous claim, the claim is priced and will it replace the previous claim with corresponding dates of service.

Ignore GA Modifier

Select the GA Modifier option:

  • Select No to price line items with a GA modifier at $0.00 and the full responsibility goes to the patient.
  • Select Yes so that line items with a GA modifier go through the reimbursement tool and price accordingly.

Process 121 Claims for Managed Care

Selecting this check box allows Contract Manager to process non-Medicare Bill Type 121 claims at the product level for managed care payers.

Note: This option is not used by Professional facilities.
This option does not affect Medicare Bill Type 121 claims.

Process 141 and 131 Claims

Selecting this check box allows Contract Manager to process 13x and 14x claims correctly when they have different admit dates & dates of services or the same admit dates & dates of services for an account, and there is already a BILLMAST record for one of them(13x or 14x).

  • A141 claim with the same admit dates and the same dates of service as a 131 BILLMAST record for that account will process and debrief to a separate BILLMAST record.
  • A 141 claim with the same admit dates and different dates of service as a 131 BILLMAST record for that account will process and debrief to a separate BILLMAST record.
  • 141 with different admit dates and different dates of service as a 131 BILLMAST record for an account will process and debrief to a separate BILLMAST record.

Note: This option is not used by Professional facilities.

Process Split Bill Claims

Product-level option for processing split bill claims so they are recognized as multiple claims from a single episode rather than treated as replacement claims.

  • Outpatient Claims - Separate (BILLMAST) records are created for each claim in that episode.
  • Inpatient Claims - One (BILLMAST) record is created combining all of the claims in that episode.

Hospital UB-04 Claims

The following criteria will be evaluated for Hospital UB-04 claims. If the values are all the same and the billed charges are different, claims will price separately as multiple claims from a single episode.

  • Patient Number
  • Admit Date
  • Service From / Service To Dates
  • Plan ID

Hospital CMS-1500 Claims

The following criteria will be evaluated for Hospital CMS-1500 claims. If the values are all the same and the billed charges are different, the claims will price separately as multiple claims from a single episode.

  • Patient Number
  • Admit Date
  • Service From / Service To Dates
  • Plan ID
  • POS
  • Provider ID

Allow Claim Replacement

Selecting this option allows claim level facilities to replace an OP claim with an IP claim or an IP claim with an OP claim for the same or overlapping dates of service. The replacement claim becomes the claim of record.

  • When an Inpatient claim is denied and charges are resubmitted on an outpatient claim, the outpatient claim is the claim of record and the account is not overstated by the Inpatient claim.
  • When an outpatient claim is denied and charges are resubmitted on an inpatient claim, only the Inpatient claim is the claim of record and the account is not overstated by the outpatient claim.
  • Transactions and remittance advices (RAs) for the claim will continue to be matched with billing record regardless of changes from IP to OP or OP to IP.

Note: This option may not be applicable for all payors. Please check with your representatives.

This option is not designed to be used with late charge (XX5) or interim (XX2, XX3, XX4) claims.

Existing accounts will not be corrected by an update reprice. To address existing accounts, manually apply a ‘Void’ override to reverse the replaced claim.

Ignore Reimbursement Limit For Penny Claims

Selecting this option allows penny claims to be excluded from the reimbursement logic so that these claims are priced and create billing records.

Note: This option does not display for facilities utilizing Claim Level Processing logic at this time.

GY Non-Covered Charge Date

Indicates that non-covered GY charges are accepted for this contract. This field can only be edited on the Contract Profile Maintenance page. For more information, refer to View or Edit a Contract Profile.

S.A.D. Discount

Indicates whether the Self-Administered Drug (SAD) discount logic was applied to the contract profile. Yes indicates SAD discount logic was applied. No indicates this logic was not applied.

Product Match

Product Match

Drop down list allowing selection of a product match

Payor Code

Payor code associated with the product

Reporting Name

Name for reporting purposes

GZ Non-Covered Transaction Code

Medicare transaction code used to write off the non-covered write-off charges. MEDICARE ONLY

GY Non-Covered Transaction Code

Medicare transaction code used to identify the amount of non-covered charges for self-administered drugs to be billed to the patient. MEDICARE ONLY

GA Non-Covered Transaction Code

Medicare transaction code used to identify the discount amount and the amount of non-covered charges to be billed to the patient. MEDICARE ONLY

Exclude Non-billable Charges

An option to exclude non-billable charges when calculating reimbursement; you can select Yes or No. This field is only available for Tenet users.

MCR Part-B Inpatient Transaction Code

Transaction code used to cover Medicare Part-B inpatient charges

MCR Part-B Transaction Code

Transaction code used to cover all other Medicare Part-B charges

Patient Type

Patient type assigned to the account: Inpatient/Outpatient

Insurance Group Number

Group number of the insurance product

Bill Type

Bill type

Financial Class

Financial class code

Provider Number/NPI

Provider’s tax ID number.

Hospital Service Type

Service type code

Provider Number/NPI

Ten-digit National Provider Identification (NPI) number.

Taxonomy Code

Provider/specialty type associated with the account

Rank

Hierarchy to determine which service type to look at first for a match. Preceding or following spaces are removed from the entered rank value. For example, if the you enter “ 1" or “1 “, the value is treated as “1” to prevent reprice errors.

Employer Name

Name of the employer associated with the product

Rank

Determines the order in which to reimburse service types on a claim.

A lower number indicates a higher rank. For example, when a claim qualifies for two service type definitions – one ranked 10 and the other ranked 100 – the service type ranked 10 is reimbursed before the one ranked 100.

Active

Indicates if the current profile is active or not

GL Code

General ledger code; identified the specific account to which a payment or discount is posted; this is a required field

Effective Date

Effective date for the product

Termination Date

Date the contract is no longer effective or is terminated

Comment

Additional questions or comments about the contract