EDI 837P (Professional) is the standard format used by health care professionals and suppliers to transmit health care claims electronically in the United States.
CMS 1500 is the standard paper claim form when a paper claim is allowed by a funder.
The EDI 837P and CMS-1500 form can be used to bill various government (Medicaid, Medicare, etc.) and private insurers.
This guide is designed to assist you with configuring your Penelope database to successfully generate an EDI file that you can then upload to a Funder or Clearinghouse. This guide assumes that you have already configured general settings in your Penelope database including the core Billing module functionality.
For additional information about the core Billing module functionality please see the Billing Module Configuration Guide.
EDI 837P
In this guide:
Configure the Transmission tab for the ClearingHouse
Getting started
In this section:
About using the billing module for EDI 837 submissions
Configuring Penelope for use with EDI Submissions
Configure your agency identifying information
Configure blue book types for CMS
Configure Presenting Information (Diagnosis Codes)
Configure a Service Unit for use with EDI Files
Configure a Funder/Clearinghouse with EDI information
About using the billing module for EDI 837 submissions
Penelope is compatible with the EDI 837P protocol.
EDI 837P (Professional) is the standard format used by health care professionals and suppliers to transmit health care claims electronically in the United States.
CMS 1500 is the standard paper claim form when a paper claim is allowed by a funder. The EDI 837P and CMS-1500 form can be used to bill various government (Medicaid, Medicare, etc.) and private insurers.
Note: EDI refers to “Electronic Data Interchange” and CMS refers to “the Center for Medicare and Medicaid Services”.
Configuring Penelope for use with EDI submissions
Note: "Enable CMS and EDI Additional settings for the EDI component" of the Billing module must be enabled.
For the purposes of configuring Penelope for use with EDI submissions, we recommend that you enable the “Test” 837 Usage option. This setting allows you to create test EDI files for submission to your Funder or Clearinghouse.
Prerequisite: You must be logged in to Penelope using a System Administrator account.
1. In the System Setup section, click Billing.
2. On the Setting tab, click Edit.
3. In the General section, ensure the Use CMS option is selected.
4. In the EDI Settings section, complete the following fields depending on your agency’s needs:
Configure your agency identifying information
For the purposes of generating an EDI file, your agency name, identification numbers, and address are used to populate the Billing Provider loops.
Prerequisite: You must be logged in to Penelope using a System Administrator account.
1. In the System Setup section, click Agency.
2. On the Profile tab, click Edit.
3. In the General section, complete the following fields as required by your funders:
4. In the Contact Information section, complete the following fields:
5. Click Save
Configure your sites
A Site in Penelope is a physical location where service is provided. Depending on your agency, you may have one or more Sites configured in Penelope. For example, a small agency operating out of one location may have a single “Head Office” (or equivalently named Site) while larger organizations may have several Sites representative of each location they provide service at. Both Workers and Individuals (your clients) are assigned to a Site in Penelope meaning that they work at or receive services at their assigned Site. Events also take place at a Site. When you book an Event in Penelope, you also specify which Site the Event takes place at.
Note that the Event Site is automatically populated based on the “Default Site when booking Service Event” setting on Event setup page though this can be manually changed. This setting allows you to determine if the Site defaults to the Presenting Participant Site (i.e. the site the Individual is assigned to) or the Primary Worker Assigned Site. The Site information that can pull through to the EDI file includes the Site name, Place of Service code, and Address details. While configuring your Sites is required, the Site information will not necessarily appear in the EDI file. Per EDI standards, the following will occur:
• The Billing Rendering Provider is always submitted (i.e. your Agency name and address)
• The Service Rendering Provider (i.e. the Event Site name and address) is submitted only if it is different from the Billing Rendering Provider (meaning the Site name/address will only appear in the EDI file if the Event Site address is different than the Agency address)
This impacts the Claim (Loop 2310B) and Line (Loop 2420A) For information about specific Place of Service Codes, please review the following table: www.cms.gov/medicare/coding/place-of-service-codes/place_of_service_code_set.html
Before you begin: This topic assumes that you have already configured one or more Sites in Penelope. For more information about setting up a new Site, please see review the following help topic: /hc/en-us/articles/40122490845463-Adding-Sites.
Prerequisite: You must be logged in to Penelope using a System Administrator account.
1. In the System Setup section, click Site.
2. On the Site Setup page, in the Agency Site section, select the site name you want to configure.
3. Click Edit.
4. In the General section, complete the following fields as required by your funders:
5. In the Contact Information section, complete the following fields:
6. Click Save.
7. Repeat steps 2-6 for each remaining reference number.
Configure Blue Book types for CMS
To submit Referring Provider Specialty Information in the 2310A loop of your EDI file, you must first create CMS-compatible Blue Book Types.
You can then create Blue Book entries using the CMS-compatible Blue Book types (ensuring that you populate the CMS Information with the appropriate Identification Numbers) and Log referrals using the CMS-compatible Blue Book types for your clients.
Prerequisite: You must be logged in to Penelope using a System Administrator account.
1. In the System Setup section, click Blue Book.
2. On the Blue Book Setup page, in the Field Setup section, next Blue Book Type, click Drop Down.
3. In the Active Values section, click Add.
4. In the Value field, type a name for the Blue Book type. For example, Referring Physician.
5. In the Entity Type section, choose Organization or Individual.
6. Click the Has CMS option.
7. Click Save.
8. Repeat Steps 3-7 for any additional CMS-compatible Blue Book types.
Configure Presenting Issues (diagnosis codes)
To include a diagnosis code for a client in an EDI file, you must configure the Presenting Issues feature in Penelope. Presenting Issues appear in three locations in Penelope: the Intake Wizard and Case pages (if you indicate a client has a Presenting Issue in the Intake Wizard, that information populates the Case page) and the Service File page. While the Intake Wizard/Case information is typically used to indicate a true “presenting issue” (i.e. the often self-diagnosed reason the client is coming for service), the EDI file uses the Presenting Issue indicated at the Service File level to populate the 2300 loop with a diagnosis code.
Step 1: Configure how you view Presenting Issues
The Presenting Issues Setup page includes an option to customize the label for Presenting Issues in the database. By default, “Presenting Issue” is used at the Intake Wizard and Case levels while “Problem Area” is used at the Service File level. As an example, you may prefer to refer to use “Presenting Issue” at Intake and “Diagnosis Code” at the Service File.
You can also configure your preference for how the Suggest Lookup lists for Presenting Issues appear in Penelope. You can choose between showing the ICD (or equivalent) code or the Group label.
Prerequisite: You must be logged in to Penelope using a System Administrator account.
1. In the System Setup section, click Presenting Issue.
2. On the Setting tab, click Edit.
3. In the Naming section, in the Service File's field, type your preferred label (for example, Diagnosis Code).
4. In the Intake’s field, type your preferred label for the Intake Wizard and Case pages. 5. In the Input section, select your preferred Suggest Lookup style (to allow staff to type the numerical value of the Diagnosis Code in the Suggest Lookup field, you must choose the ICD Codes option).
6. Click Save.
Step 2: Create your Presenting Issue Groups
Presenting Issue Groups are a way of grouping similar Presenting Issues/Diagnosis Codes together. You use the groups to specify where the associated Presenting Issues are available in Penelope (i.e. the Intake Wizard, Service File, or both). For example, you may want to make a general list of self-diagnoses issues available at the Intake Wizard while only making proper diagnoses available at the Service File.
You can also use the Presenting Issue Groups as a filtering option in applicable Reports. By default, two groups are available: 1-General and DSM-IV.
Depending on your preferences, you can rename the existing groups (by clicking the Group Name and changing the value) or create new groups using the following task.
1. On the Presenting Issue page, in the Field Setup section, click Presenting Issue Group.
2. In the Active Values section, click Add.
3. In the Value field, type a name for the group.
4. From the Class drop-down, choose whether you want the group of Presenting Issues to be available for selection on the Intake Wizard, Service File, or both.
5. Click Save.
6. Repeat Steps 2-5 for any additional groups.
Step 3: Create a list of Diagnosis Codes
1. On the Presenting Issue page, click the Presenting Issue tab.
2. In the Active Values section, click Add.
3. In the Presenting Issue field, type a name for the diagnosis.
4. From the Group drop-down, choose which Presenting Issue Group this diagnosis belongs to.
5. Complete one of the following options:
a. If your agency or any of your funders use ICD-9 or DSM-IV codes, in the ICD-9 field, input the ICD-9 or DSM-IV code. Bonterra Software 12
b. If your agency or any of your funders use ICD-10 or DSM-V codes, in the ICD-10 field, input the ICD-10 or DSM-V code.
6. Click Save.
7. Repeat Steps 2-6 for any additional groups.
Configure a Service Unit for use with EDI files
Service Units are the units of service provided by your agency that you wish to track and/or bill for. They are added to a client’s cart by the worker(s) involved in delivering a given service and then used to populate the Service Line (2400 loop) of an EDI file with the Procedure Code, fee, unit, and quantity. A client’s cart can contain zero, one, or many Service Units. If there are charges that apply to the Service Unit (as per the setup of the unit), once the Event Status is changed to “Show,” the unit can be billed. If you are running v4.7.1.0 and higher of Penelope, you can create $0 Service Units that bill to a Funder. Before you begin: This guide assumes that you have already created your Service Units and focuses on the configuration aspects specific to EDI file generation. For more general information about how to work with Service Units for Billing, please see the Billing Module Configuration Guide here: /hc/en-us/articles/40122467527191-Billing-Module-Configuration-Guide.
Prerequisite: You must be logged in to Penelope using an account with access to the Setup sidebar.
1. On the homepage, in the Setup sidebar, click Service Unit List.
2. In the Service Unit List, click the Service Unit you want to modify for use with EDI.
3. Complete the following fields (the fields required for EDI are highlighted in bold text):
4. Click Save.
5. Repeat Steps 2-4 for all remaining Service Units you need to modify for use with EDI submissions
Configure a Funder/Clearinghouse with EDI information
You must create a Funder profile for each Funder and/or Clearinghouse that you want to track and submit claims to in Penelope. On the Funder profile, an EDI tab is available with settings required to submit claims to that Funder/Clearinghouse using an EDI 837P file. Depending on your agency’s submission process, you will need to configure the Transmission tab, the Submission tab, or both:
• If you send your EDI claims directly to a Funder, you must configure both the Transmission and Submission tabs with applicable EDI information for that Funder.
• If you send your EDI claims to a Clearinghouse, you only need to fill out the Submission tab for that Funder.
Configure the Transmission tab for the Clearinghouse
In this section
Configure the Submission tab for the Funder
Configure the Submission tab for the Funder.
Step 1: Add the Funder or clearinghouse Prerequisite: You must be logged in to Penelope using an account with access to the Setup sidebar and the ability to create Funders. 1. On the homepage, in the Setup sidebar, click Add Funder. 2. In the Funder Profile page, complete the following fields (the fields required for EDI are highlighted in bold text):
3. Click Save.
Step 2: Configure the EDI Transmission tab
Complete this task if you upload your claims directly to a Funder or to a Clearinghouse.
Before you begin: The specific text and selections that you make for the EDI Transmission section will depend on the requirements set forth by your Funder/Clearinghouse. Please contact them for direction on what values you should use when completing the configuration.
Prerequisite: You must be logged in to Penelope using an account with access to modify Funders. 1. Navigate to the Funder you want to update with EDI submission information. 2. Click the EDI tab. 3. On the Transmission tab, click Edit and complete the following fields:
4. Click Save.
Step 3: Configure the EDI Submission tab Complete this task for all Funders (even if you upload the claims to a Clearinghouse). Before you begin: The specific text and selections that you make for the EDI Submission section will depend on the requirements set forth by your Funder/Clearinghouse. Please contact them for direction on what values you should use when completing the configuration.
Prerequisite: You must be logged in to Penelope using an account with access to modify Funders. 1. Navigate to the Funder you want to update with EDI submission information. 2. Click the EDI tab. 3. On the Submission tab, click Edit and complete the following fields:
4. Click Save. 5. If any Secondary Identification Codes are required by your Funder/Clearinghouse, in the Sec. Identification Codes section, click Add. 6. In the Code field, type the Secondary Identification Code. 7. From the Qualifier drop-down, select the Secondary Qualifier type. 8. Click Save and repeat for any additional Secondary Identification Codes.
Configure policies About Policies By default, fee-based cart items in an Event will bill to the FFS Individual indicated on the Service File. To have fee-based cart items bill to a Funder instead, you’ll need to create Policy “templates” (i.e. Public and Group Policies) as well as custom policies for individual clients (i.e. Private Policies). A Policy indicates the types of services and coverage rates that a Funder will pay for a client. Policies should be configured and then assigned to Service Files before beginning the invoicing/EDI file creation process. In the table below, you’ll find a description of when to use each type of policy. Depending on your agency’s needs, you will need to set up one or several Public and/or Group Policies templates as well as any Private Policies for individual clients.
Policy type When to use
Create policy templates You can create Policy templates for both Public and Group Policies. Private Policies do not have templates and are created for individual clients (you create a Private Policy in the file of each client who has that type of policy). Information configured in a Policy template is used to populate client Public and Group Policies. Create a Public Policy template Prerequisite: You must be logged in to Penelope using an account with access to the Policy set up. 1. Navigate to the Funder you want to create a policy template for. 2. In the Public Policy Setup sidebar, click Add. 3. On the Public Policy Setup page, complete the following fields:
4. Click Next. 5. On the Service Units page, complete the following actions; a. In the Service Unit field, select a service the Funder provides coverage for. b. In the By drop-down, choose if the Funder provides coverage by a specific dollar amount ($) or a percentage of the full fee (%). c. In the Rate field, type the dollar amount or percentage covered. d. In the Co-Pay field, type the Co-Pay amount. If the Funder does not require a Co-Pay, type 0. e. Click the icon. f. Repeat A-E for any additional services the Funder provides coverage for that you want to include in this specific Policy Coverage. 6. Click Next. 7. On the Public Policy Setup Summary page, confirm the values you configured. To make changes, click Back and adjust as needed. Otherwise, click Finish. Create a Group Policy template The settings that you configure for a Group Policy template are applicable to all clients who will use this Policy
Prerequisite: You must be logged in to Penelope using an account with access to the Policy set up. 1. Navigate to the Funder you want to create a policy template for. 2. In the Group Policy Setup sidebar, click Add. 3. On the Public Policy Setup page, complete the following fields:
4. Click Next. 5. On the Policy Coverage page, complete the following fields:
6. Click Next. 7. On the Service Units page, complete the following actions; a. In the Service Unit field, select a service the Funder provides coverage for. b. In the By drop-down, choose if the Funder provides coverage by a specific dollar amount ($) or a percentage of the full fee (%). c. In the Rate field, type the dollar amount or percentage covered. d. In the Co-Pay field, type the Co-Pay amount. If the Funder does not require a Co-Pay, type 0. e. Click the icon. f. Repeat A-E for any additional services the Funder provides coverage for that you want to include in this specific Policy Coverage. 8. Click Next. 9. On the Group Policy Setup Summary page, confirm the values you configured. To make changes, click Back and adjust as needed. Otherwise, click Finish.
Configure your EDI reference numbers Complete the following task if your Funder or Clearinghouse requires additional reference numbers when submitting your EDI files. You must add a reference number for each Funder or Clearinghouse that requires them. In some cases, there may be additional steps required such as running a script on your database to enable the field to appear in the EDI file. For more information, please contact our Technical Support team. Prerequisite: You must be logged in to Penelope using a System Administrator account. 1. In the System Setup section, click Agency. 2. On the Profile tab, in the EDI Reference Numbers Setup section, click Add. 3. In the Reference Number field, type the EDI Reference number. 4. From the Identifier drop-down, select the type of reference number. 5. From the Funder drop-down, select which funder the reference number is applicable to. 6. Click Save. 7. Repeat steps 2-6 for each remaining reference number. Configure a Worker Profile for use with EDI files The Rendering Provider loops (Service, Claim, and/or Line) in the EDI file can be populated with information on the Profile and Clinical tabs of a Worker Profile. The following information from a Worker Profile can be included in the EDI file: • Worker name • Worker PINs • Worker NPI number • Worker Site (Name, Addr 1, Addr 2, City, State, Zip Code) Prior to configuring a Worker Profile for use with EDI files, you need to determine who the Rendering Provider(s) are for your agency as this affects the information you will populate the Worker Profile > Clinical tab with: • Is your agency the Rendering Provider? If yes, does this apply for all workers or a select group of workers? • Do individual workers have their own NPI numbers and should be considered the Rendering Provider? • Do any workers share the NPI number of another worker (for example, in supervision scenarios)? If the agency should be considered the Rendering Provider for the EDI submission, the Rendering Provider field on the Worker Profile > Clinical tab should be left blank. You can also specify that one or more workers share another worker’s credentials (for example, a supervisor’s NPI number, etc.) or the worker’s own information Prerequisite: You must be logged in to Penelope using an account with access to modify Worker Profiles. 1. Navigate to the Worker Profile you want to update. 2. On the Profile tab, confirm that the First Name, Last Name, and Site fields are accurate. To make any changes, click Edit, modify as needed, and click Save. 3. On the Clinical tab, click Edit. 4. Complete the following fields (the fields required for EDI are highlighted in bold text):
5. Click Save. 6. If additional identification numbers are required by your funder/clearinghouse(s), in the Worker Pins section, click Add. 7. From the Funder drop-down, choose which Funder the PIN is applicable to. 8. In the PIN field, type the identification number. 9. From the Qualifier drop-down, choose which the identifier type. 10. Click Save. After you finish: Repeat for all remaining Workers.
Preparing client files for use with EDI submissions About preparing client files for use with EDI submissions This section includes tasks that should be completed for all clients you will be submitting claims for using and EDI file. Most tasks in this section will need to be completed on an ongoing basis for new clients at your agency. Configure an Individual Profile for use with EDI files To avoid errors when generating an EDI file, ensure that the following information is populated in the Individual Profile for any clients you will be submitting EDI claims for: • First/Last Name • Date of Birth • Gender • Addr. 1/2 • City • State • Zip Code These fields populate the 2010BA and/or 2010CA loops. Add a policy for a client 1. You can create a Policy for a specific client from the Individual Profile, Case, or Service File levels. To begin creating the Policy, complete on of the following actions: • From the client’s Individual Profile, on the Policy tab, click Add. • From the client’s Case or Service File, in the Billing Information sidebar, click Add Policy. Choose the client’s name you’re creating the Policy for. 2. In the Funder field, begin typing the name of the funder the client has a policy with. Select the name from the Suggest Lookup list.
3. From the Select Policy list, complete one of the following options: • To create a policy from an existing Public or Group Policy template, choose the appropriate Policy template from the list of available Policies. • To create a Private Policy for the client, click the New Private Policy option.
4. Click Next.
Public Policy If you choose “Public Policy”, complete these steps: 1. On the Public Policy Setup page, complete the following fields:
2. Click Next. 3. On the Policy Member page, complete the following fields:
4. Click Next. 5. On the Policy Coverage page, complete the following fields:
6. Click Next. 7. On the Coverage Service Units page, select which Service Units the client has coverage for under this Policy. 8. Click Next. 9. On the Public Policy Setup Summary page, confirm the values you configured. To make changes, click Back and adjust as needed. Otherwise, click Finish.
Private Policy If you choose “Private Policy”, complete these steps: 1. On the Public Policy Setup page, complete the following fields:
2. Click Next. 3. On the Policy Member page, complete the following fields:
4. Click Next. 5. On the Policy Coverage page, complete the following fields:
6. Click Next. 7. On the Service Units page, complete the following actions; a. In the Service Unit field, select a service the Funder provides coverage for. b. In the By drop-down, choose if the Funder provides coverage by a specific dollar amount ($) or a percentage of the full fee (%). c. In the Rate field, type the dollar amount or percentage covered. d. In the Co-Pay field, type the Co-Pay amount. If the Funder does not require a Co-Pay, type 0. e. Click the icon. f. Repeat A-E for any additional services the Funder provides coverage for that you want to include in this specific Policy Coverage. 8. Click Next. 9. On the Private Policy Setup Summary page, confirm the values you configured. To make changes, click Back and adjust as needed. Otherwise, click Finish.
Group Policy If you choose “Private Policy”, complete these steps: 1. On the Policy Member page, complete the following fields:
2. On the Group Policy Setup Summary page, confirm the values you configured. To make changes, click Back and adjust as needed. Otherwise, click Finish
Activate the Policy for use in a Service File To make a Policy available for billing use in a Service File, you must add the Policy to the Billing Sequence for applicable Service Files. 1. On the Policy page, in the Billing Sequence sidebar, click the (-) icon to the left of the Service File the newly created Policy is applicable for. 2. In the Unused Policies section, locate the name of the Policy you just created and click the icon to right of the Policy name. 3. Click the Recalc. Service Units option. 4. Click Save.
Policy fields with loop mappings
Configure a Service File for use with EDI files Add a diagnosis code for a client A diagnosis code is required for clients when submitting EDI claims. A diagnosis code can be specified for a client when adding the Service File or it can be added/modified at a later date. This topic reviews how to add and/or modify a diagnosis code on an existing Service File. Prerequisite: You must be logged in to Penelope using an account with access to add and modify Service Files. 1. Navigate to the Service File you want to update. 2. In the Participants section, click [Add Diagnosis Code] (or your agency’s equivalent, for example [Add Presenting Issue]). Note: If diagnosis code(s) have already been added for the client, the name and code will appear instead.
3. In the Diagnosis Code 1 (or equivalent) field, begin typing the diagnosis for the client and select from the Suggest Lookup list.
4. If applicable, add up to two other diagnoses. 5. Click Save.
Configure General CMS information (Optional) You can configure a client’s Service File to include additional information in an EDI file for their claims based on your Funder and/or client requirements. Depending on the field, the information will populate the specified loop in an EDI file. Prerequisite: You must be logged in to Penelope using an account with access to Service Files. 1. Navigate to the Service File you want to update. 2. On the CMS tab, click Edit. 3. Complete the following fields as needed:
4. Click Save.
Add Funder-specific CMS information (Optional) If required by your Funder, you can add Funder-Specific information for individual client Service Files. The information in this section is not commonly required and you should only configure it if specifically directed by your Funder. Prerequisite: You must be logged in to Penelope using an account with access to Service Files. 1. On the Service File > CMS tab, in the Funder Specific section, click Edit. 2. Complete the following fields as needed:
3. Click Save. 4. Repeat Steps 1-3 for any other Funder Specific information.
Create a CMS-compatible Blue Book entry (Optional) Only Blue Book entries with “Has CMS” enabled and CMS Information populated can be included as Referring Providers in an EDI file. This topic includes information specifically about creating Blue Book entries where the “Has CMS” option has been enabled. Please see the following tutorial for complete details on creating Blue Book entries: /hc/en-us/articles/40122493014807-Add-a-Blue-Book-Entry. 1. Begin creating the Blue Book entry in any of the following ways: a. On the home page, in the Links sidebar, click Add Blue Book. b. From the Referral sidebar on a client file (Case, Service File, Service Event, etc.), click Add. 2. From the Type drop-down, choose one of your CMS-enabled Blue Book types. 3. Fill in other Blue Book entry details as required (name, contact information, etc.) and click Save. 4. On the Blue Book entry page, in the CMS Information section, click Add.
5. From the Primary Qualifier drop-down, choose the identification type. 6. In the Identification field, type the identification number for the Blue Book entry.
7. Click Save.
Add a referring provider for a client (Optional) To populate the 2310A Loop in an EDI file with a Referring Provider, you must add a provider to the “Referring Physician” section of a Service File > CMS tab. Note that you can only set one Referring Provider per Service File. A Referring Provider can be set on a client’s Service File in any of the following ways: Option 1: Manually add a Referring Provider to the Service File Prerequisite: You must be logged in to Penelope using an account with access to Service Files. 1. Browse to the Service File and click the CMS tab. 2. In the Referring Physician section, click Add. 3. Complete one of the following tasks: • To add an existing “Has CMS” Blue Book entry, from the Pre-Defined drop-down, choose the desired option (Note: Only Blue Book entries with “Has CMS” enabled and CMS Information populated will appear in this list).
• To add a new Referring Provider, in the Type section choose Organization or Individual. Complete the remaining fields.
4. Click Save. 5. To add one or more Secondary Qualifiers (if applicable), in the Referring Physician section, click Add. 6. From the Secondary Qualifier drop-down, choose the type. 7. In the Identification field, type the qualification identification number. 8. Click Save. 9. Repeat Steps 5-8 for any additional Secondary Qualifiers.
Option 2: Set a default Referring Physician for a Worker Prerequisite: You must be logged in to Penelope using an account with access to modify Worker Profiles. On a Worker Profile > Clinical tab, you can set a default “Referring Physician” for that Worker. Any newly opened Service Files assigned to that Worker automatically include the specified Referring Physician on that Service File’s CMS tab. If needed, the Referring Provider can also be manually changed later from the client’s Service File > CMS tab.
Option 3: Add an Inbound Referral and “Use For CMS” Prerequisite: You must be logged in to Penelope using an account with access to Service Files. At the Service File and Service Event levels, you can add an Inbound Referral for a client using a Blue Book entry with an applicable “Has CMS” Blue Book type. Once the Referral Entry is created, choose the “Use For CMS” option to update the Service File’s CMS tab with the Blue Book entry’s CMS details. Note: If the Referring Physician section of the Service File > CMS tab was previously populated, clicking “Use For CMS” will overwrite the previous entry.
Modify the CMS values of a cart item (Optional) Prerequisite: You must be logged in to Penelope using an account with access to Service Events. The CMS section of a line item in the Cart automatically populates with values set on the Service Unit, Event Site, etc. levels. You can manually adjust these values if needed. 1. On the Event page, click the Cart tab. 2. In the CMS section, click Edit
3. Modify any of the following fields as needed:
Testing your EDI configuration Checklist: Testing your EDI configuration Prior to submitting real claims to your Funder or Clearinghouse, we highly recommend creating a test submission to work out any peculiarities for your particular setup. Use the following as a guideline for creating a test EDI submission. £ Ensure you have fully configured the EDI component of the Billing module (including your Funder(s)/Clearinghouse) as outlined above. £ Create one or more test clients with Policies billing to each Funder/Clearinghouse you plan to test. £ Book Events with cart items billing to each Funder/Clearinghouse you plan to test (remember, to successfully invoice an event, the attendance must be recorded!). £ Create Batch Invoice(s) and generate the EDI file(s) using the process in the “Generate an EDI file” topic below. £ Review the EDI file(s) for any errors and make corrections as indicated. £ Upload the test EDI file(s) to your Funder or Clearinghouse. £ Make corrections to your configuration based on their feedback. £ Repeat steps as required until you get the all-clear from your Funder/Clearinghouse. At that time, switch the EDI feature to Production mode!
Generating EDI files Generate an EDI file Complete this process to test your EDI configuration as well as create EDI files for real client data going forward. Before you begin: If you are creating a test EDI file, ensure that you have created sufficient test data (clients with policies, Service Events with attendance set to show, etc.) to use. 1. On the homepage, in the Links sidebar, click Generate Invoices in Batch mode. 2. In the Batch Information section, complete the following fields:
a. In the Batch Name field, type a name for your batch. For example, “Test Batch” or “Medicaid – Week 4”. b. In the Batch/Invoice Date field, select a date for the batch (defaults to today’s date). c. From the Batch Site drop-down, choose which Site the Batch is being generated from (defaults to the logged in Worker’s site). d. Choose the “Default” Invoice Method. 3. In the Batch Selection Criteria section, choose any criteria to narrow the list of Events that you’d like to choose from for your Batch. For example, only invoices billing to a specific Funder.
4. Click View Units. 5. In the Results section, select the Events you want to include in the invoice. 6. Click Create.
7. On the Batch page, click Post Batch. 8. In the EDIs section, click Create EDI 837
9. On the 837 page, in the Transaction Set Purpose, choose one of the following options: a. If this is the first submission, click Original. b. If this is a resubmission, click Reissue. 10. From the Claim Frequency drop-down, choose one of the following options
11. From the View List drop-down, choose Eligible. 12. Click Create. 13. In the EDIs section, click the EDI file.
14. In the Status section, review if the file was generated successfully and if there are any errors reported. If there are errors reported, click the Error tab to troubleshoot. See “Appendix 1: Troubleshooting common errors in an EDI file” below for more details. Once you’ve corrected any errors, regenerate the EDI file. 15. If you are ready to upload your EDI file to your Funder/Clearinghouse, in the Attachments section, click the EDI file name to download the file to your computer. 16. Upload the file to your Funder/Clearinghouse and return to the Penelope page to “Mark as Sent”.
Enabling EDI production mode Switch to production mode Once you have successfully submitted a test EDI claim to your Funder/Clearinghouse, you can complete the following tasks to enable “Production Mode”: Step 1: Enable 837 Production Usage 1. On the System Administration side of Penelope, navigate to the Billing Setup page. 2. Click Edit. 3. In the EDI Settings section, next to 837 Usage, click Production. 4. Click Save. Step 2: Enable Production File Creation for your Funder/Clearinghouse(s) For each applicable Funder and/or Clearinghouse, complete the following task: 1. Navigate to the Funder Profile page. 2. On the EDI tab, click the Transmission tab. 3. Click Edit. 4. Click the Production File Creation option. 5. Click Save
Appendices
Appendix 1: Troubleshooting common errors in an EDI file
Appendix 2: Example EDI file with loop mapping Note: Segment items highlighted in green text represent variables populated by fields in Penelope. All other segment text represents standard EDI code
Appendix 3: CMS settings On the System Administration side of Penelope, you’ll find a CMS tab. Generally speaking, you do not need to modify any of the settings on either the Setting or CMS Defaults tabs. This information is included for reference purposes only. Setting tab The CMS Setup > Settings tab is automatically populated with the settings you configured as part of the general configuration settings. For reference, a description of these fields is listed below:
CMS Default tab The CMS Setup > CMS Default tab includes configuration options to populate default values on the Service File and Service Event Cart line items for all clients in the database. Typically, we do not recommend modifying these settings. For reference, a description of these fields is listed below:
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