Insurance Billing Automations [In Beta]

Healthie enables providers and organizations to create CMS 1500s and to optionally submit them to an RCM or Clearinghouse.

We are currently launching and beta testing new functionality that will streamline insurance billing processes by automating several administrative tasks, including: 

• Set a Price for CPT Codes [Beta Test]
• Set Custom Self-Pay Rate or Link a CPT Code with Appointment Type [Beta Test]
• Automatically Create a CMS 1500 After an Appointment [Beta Test]
• Automatically Submit CMS 1500s [Beta Test]
• Disabling Auto-Submission of CMS 1500s for Individual Clients or Client Groups [Beta Test]

Set a Price for CPT Codes [Beta Test]

Organizations would like a way to set prices for their in-use CPT codes in order to customize and streamline pricing. You can now set both custom provider pricing per CPT code and custom provider pricing per appointment, as different providers within an organization may require tailored pricing for specific appointments or appointment types.

Learn how to set pricing for CPT codes here.

Set Custom Self-Pay Rate or Link a CPT Code with Appointment Type [Beta Test]

We have further expanded upon Healthie's functionality to set custom prices for an appointment type by including additional options: setting custom self-pay rate or linking CPT Code with a Fee Per Unit for the appointment type. This is especially valuable for Healthie customers who work on insurance billing.

This functionality enables organizations to either set appointment type pricing by custom price (this is a self-pay rate) or link a CPT code with any appointment type. The latter will result in a CPT code automatically being added to a charting note for an appointment, or a CPT code automatically being added to a CMS 1500 for an appointment.

Learn more about setting a custom self-pay price or associating CPT codes with Appointment Types here.

Automatically Create a CMS 1500 After an Appointment [Beta Test]

We have further expanded upon Healthie's functionality to have a CMS 1500 automatically created after an appointment's status has been set to "Occurred," which will save time for Healthie customers who work on insurance billing from manually needing do so.

This functionality will enable providers and/or organization administrators who balance many administrative activities to streamline creation of CMS 1500s and gain the ability to automate a large portion of the insurance process.

In order to streamline and automate the process of creating insurance claims, Healthie will now populate more information into a CMS 1500 form, including:

• Rendering Provider info, including coinciding Qualifications, NPI, Other ID Qualifier, and Other ID where available. This will be automatically filled in with the associated appointment primary provider.
• Billing items (if you've designated CPT code prices, as outlined above)
  • If a CMS 1500 is automatically created after an appointment the following fields will be automatically filled in based on data associated with the appointment:
    • CPT Code
    • Units
    • Fee
    • Date of Service

Note: CMS 1500s must be filled in accurately - errors, accidental or otherwise can directly impact the insurance company’s payment of services.

When you navigate to Settings > Business > Insurance, you will see a separate CMS 1500 Settings section, which will only be visible if the Enable CMS 1500 Claims option within the Insurance Settings section is toggled ON.

Once you click on the Edit button for the CMS 1500 Settings section, you will be presented with two setting options, the first it to enable automatic claim creations.

When this option is toggled "ON", it enables the ability to create a CMS 1500 which will appear in your CMS 1500 Overview Page, and be populated with the following data:

• Client Name
• Active insurance policy on file
• CPT Procedure Code for the appointment, alongside pricing for CPT code
• Service Date
• Created Date

Note: In order for a CMS 1500 to be automatically created, the client must have an active insurance policy on file within Healthie AND the Appointment Status must be marked as “Occurred” within the dropdown menu. The CMS 1500 can also be automatically created IF the client has insurance on file AND the appointment does not have any Insurance (either it's missing a CPT Code or the price for the CPT Code or neither) NOR self-pay pricing set. You are able to see the above screen when you navigate to Calendar > Appointment block > Session Details.

If these two requirements are met, the CMS 1500 will be instantly created and submitted to the clearinghouse on Sunday at 11:59 PM EST. If either of those two requirements are NOT met, a CMS 1500 will not be automatically created.

This automation does NOT apply to group sessions, but rather for individual client appointments only.

Automatically Submit CMS 1500s [Beta Test]

When you navigate to Settings > Business > Insurance, you will see a separate CMS 1500 Settings section, which will only be visible if the CMS 1500 Claims option within the Insurance Settings section is turned on. You can toggle the CMS 1500 Claims setting ON by clicking on Edit Insurance Settings. 

Once you click on the Edit button for the CMS 1500 Settings section, you will be presented with two setting options, the second option will enable the automatic submission of CMS 1500s.

In order for the “Automatically submit CMS 1500s” setting to be enabled, an organization must have their integration with a clearinghouse or RCM enabled. You have the ability to electronically submit a single CMS 1500 to one of the following clearinghouses: Office Ally, Change Healthcare, or Candid Health.  If your organization does not have a clearinghouse integration enabled, you will not be able to see the “Automatically submit CMS 1500s” section.

The "Automatically submit CMS 1500s" option will automatically queue created CMS 1500s to be sent at the end of the week on Sundays at 11:59 PM EST. You will have a chance to review the CMS 1500 before it is submitted and can edit or delete the CMS 1500 if necessary. When Healthie auto-submits your client's CMS 1500 to a clearinghouse or RCM, you will see the "Scheduled" status auto-populated for the CMS 1500 in your CMS 1500 list (Billing > CMS 1500s).

In the event that you wish to instantly submit a CMS 1500 claim (Billing > CMS 1500s) to the available clearinghouse, clicking on "Submit CMS 1500 to Clearinghouse" instead of "Save and Close" will allow you to be able to submit just this one claim (not a batch). On the other hand, "Save and Close" will queue up your CMS 1500 (if there are no errors in your fields) to be submitted along with the remainder of the batch to the clearinghouse on Sunday at 11:59 PM EST.

Note:

• When you change the CPT code and unit count, the price will automatically update in the CMS 1500 if a price/fee has already been set for this new CPT code OR if the provider has set a custom appointment price that overrides this CPT code price/fee.
• If when editing the CMS 1500, the Appointment Type is missing the CPT code but has a price listed, then the CPT Code will NOT show in the full list of CMS 1500s before submission.
• The “Scheduled” status cannot be manually applied whereas the other CMS 1500 Status options can be. Once the “Scheduled” CMS 1500 is sent to the clearinghouse on Sunday at 11:59 PM EST, the Status will be automatically updated to “Sent.”
• If a CMS 1500 is CREATED on a Sunday, it will not be submitted that same day, but rather will be submitted with the following week’s batch on the following Sunday at 11:59 PM EST.

Disabling Auto-Submission of CMS 1500s for Individual Clients or Client Groups [Beta Test]

A provider or organization admin is able to adjust settings to disable automatically submit CMS 1500s for an individual client or Client Group even when “Automatically submit CMS 1500” settings are enabled for their organization.

For an individual client, this will allow you to temporarily or permanently disable the automation on a client level, and to choose whether clients are excluded or included in the automation process. Follow these steps:

• Navigate to Client Profile > Actions tab > Info > Settings and scroll down to the section titled "Insurance Settings." "Do not automatically submit CMS 1500s for this client" will only be visible if the "Automatically submit CMS 1500s" setting is toggled to ON. If the "Do not automatically submit CMS 1500s" setting is enabled for a client, it overrides the global setting for “Automatically submit CMS 1500s” and all CMS 1500s that are created for this client (whether automatically or manually), will NOT be automatically submitted to a clearinghouse.

Providers can temporarily or permanently disable the “Automatically submit CMS 1500s" automation on a client group level, as well as choose whether groups are excluded or included in the automation process. Follow these steps:

• Navigate to Clients (left navigation sidebar) > Client Groups > [...] > Edit Group Settings and scroll down to the section titled "Insurance Settings." "Do not automatically submit CMS 1500s for this group" will only be visible if the "Automatically submit CMS 1500s" setting is toggled to ON. If the "Do not automatically submit CMS 1500s" setting is enabled for a client group, it overrides the global setting for “Automatically submit CMS 1500s” and all CMS 1500s that are created for this client group (whether automatically or manually), will NOT be automatically submitted to a clearinghouse. If you want to submit any CMS 1500s for clients in the client group, you will have to do so manually.

When you navigate to the bottom of a client's CMS 1500 form, you will see the two buttons “Save and Close” and “Submit CMS 1500 to Clearinghouse.” Please note that the latter will only be available if your organization has an integration enabled with Office Ally, Candid, or Change Healthcare - if your organization does NOT have an active clearinghouse integration, only the “Save and Close” button will be visible to you . If you click on the "Save and Close" button, your CMS 1500 will be saved and you will be routed back to your CMS 1500 list (Billing > CMS 1500s).