Last Update: March 14, 2001
This report was developed in early 2001. The particulars were marshaled by a "Claims Tracking Sub-Group" of the MACSIS Project Team. The effort was coordinated by Peg Eichner, the group included Barb Miller and Jennifer McIntosh of Montgomery County, Bill Evans and Johnna Fraser of Franklin County, Tom Chambers of Richland County, Pat Coates of Heartland East, and Michelle Glanville of Lucas County MH.
This Claims Status Report displays the number of claims and associated dollar amounts owed to a Provider as a result of the claims having been received into the MACSIS system during the respective reporting period (a calendar month) regardless of their current "payment" status. "Received" into MACSIS means either submitted electronically or manually entered in the reporting period noted at top of the report.
It is envisioned that this report can be used by a Provider to ascertain the current status of claims received by MACSIS processing batch. The Board (Company) assigned to pay claims is assigned on the basis of the client's county of residence (Group in MACSIS terms). Follow-up Questions about this report and data are best applied to your respective County Board.
This report is only a "snapshot" of the MACSIS database as of the run date on the report. Any discrepancies in the the number of claims (or amounts) expected should be discussed with the Provider's (home) Board -- such things can and will happen for a number of reasons, including but not limited to:
The PDF report pages are produced by a SAS (C) program running against the weekly Master File. You will need Acrobat Adobe Reader to read these reports effectively. The following definitions and comments apply (italicized information relates to definition of the data in terms of the database vendor (Diamond 725 from HSD)).
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The 12 digit number assigned by the Board to identify a Provider.
In Diamond 725 terms, Provider Number. Lead zeroes have been removed. Note: This is NOT Vendor Number.
The five byte code identifying the Board (Company) responsible for pricing the claims. The Board/Company assigned to a claims is based on the client's county of residence (as defined by MACSIS). Note: If Company has a value of "OHIO" then the claim pricing/adjudication had problems because the client was not eligible on the date of service of the claim. Claims falling under the "OHIO" Board are claims in the process of being corrected due to member ineligibility issues. These should be (re) adjudicated and thereby paid or denied by the client's "home" Board.
Company refers to "Company Code" as found on the Claims Detail Record.
The Batch Id which is assigned a file during MACSIS Claims EDI process. Please note that all of a Board's individual Provider files are combined into a single EDI Batch on a weekly basis. This Batch ID will not match any individual Provider file. Also claims entered manually into the MACSIS database will not automatically have an assigned Batch ID -- those will be summarized under a "Manual" label.
This Batch ID is found on the Professional Claim Header (JUTILHM0) record -- it identical to the Hublink file name for claims submitted electronically.
The code indicating the adjudication status of the claim.
This field refers to Claim Status (CBCLAIMSTAT in Diamond or CLMSTAT in SAS) for Service Lines (i.e., Detail records). Values can be P (Payable), D (Denied), A (Adjustment), N (No Check), C (Capitated), S (Staff), and F (Fund). The initial status is established in record creation (EDI or Manual).
The code indicating the payment status of the claim within MACSIS.
This field refers to Processing Status (CBAPSTAT in Diamond, PROCSTAT in SAS) -- literally Accounts Payable Status of the Claim Detail Record. Note: This value is repeated in the Accounts Payable File (ACPAY) under a different name. Values can be U (Unposted), F (Final), H (Hold), P (Paid), N (Paid, No Check).
NOTE: The most like combinations of Claims and Processing Status that one is likely to observe are:
The number of claims in the Batch under each of the Status categories displayed.
A summary of the "quantity" or units of service of the included claims as provided in the Professional Claims Detail Record (JUTILDM0).
Cost of service as submitted in the NSF file from the Provider.
Approved unit cost derived from the Diamond PROCP record.
Client sliding fee for payment or flat fee payment.
Third-party insurance payments.
Deducted payments for grant funding or non-fee-for-service equivalencies.
Total amount due Provider.
In MACSIS language, neither Loop 1 nor Loop 2 events are reflected in the material presented here.