NAPO Billing Explanation
9 June 1999
Administration Preferences
To activate the NAPO billing rule checking you need to ensure that the Administration preferences is set to turn this feature on.
1. File Menu --> Administration
2. Go to page 3 of the Administration corner.
3. Click on the Preferences button
4. Go to the Billing page.
5. Ensure that the NAPO checkbox has an ‘X’ in it.
To successfully use MediFile to generate invoices to the patient and/or a vendor you need to first set up the rules for the vendor, and Fee Code. Once you have done this you can use the invoice dialog to generate an invoice. This document describes how to perform these items.
Setup of Vendor Record
For each vendor that you want to invoice, you need to have an address record for.
From the Task Menu select Address Book.
To Create a new record: From the File menu select New.
The address book record consists of 3 pages of information. Some of the information is required for it to work properly with the specialized requirements of the NAPO billing. This document will specifically identify those. Other information like the address, phone, and contact people are at your discretion.
Nothing on page one or two are required for NAPO billings, although you should fill in the page one address information.
On Page 3 (Billing Agency Info) you need to fill in information.
The numbered items are the areas where you need to fill in information.
Area 1: Click on this checkbox to have this agency included in the various Agency popups in MediFile.
Area 2: Enter a unique billing key for this agency. MediFile will check to ensure it is unique. It is best to use a key that makes sense for the agency. Therefore for an agency like Alberta Aids to Daily Living, a good billing key would be AADL.
Area 3: This is a text entry area where you can enter information the describes the billing rules, and any other information that will assist staff in entering billings for patients, or in explaining the billing rules to patients.
This information can be viewed from the Appointment scheduler by simply clicking on the Agency billing rules icon. It looks as follows:
This is located in the lower right corner of the appointment scheduler screen.
This button is located in other areas of the MediFile as well. This is placed in various places that you might need to access this information. For example you may be talking to a patient on the phone. You could be in their record getting other information and explaining things to them. You may then want to refer to the rules for the agency that the patient gets their services paid by. This same button is located in the Patient Master Record.
Billing Rules Information button is located in the upper left portion of the Patient Master Screen.
Area 4: Press this button to enter the specific rules for the agency. In this area you can have virtually unlimited rules. Through this area you can add rules specific for each part (Fee Code) in MediFile. This dialog is explained later.
Billing Agency Rule Definition Button
In setting up the Agency Rules the Rules Detail is used. The screen shown next is what is used to define the rules for that agency. You can have virtually an unlimited number of rules for each agency. This provides maximum flexibility for billing purposes. You are limited to the type of rules, to the ones that have been programmed into MediFile. A list of the types of rules are available to you when you are setting up the rules.
When one of the rules is ‘broken’ an Alert Message will be presented to the user. This message is defined in this document. The user will need to specifically dismiss the Alert message. At this stage MediFile will not reject the item from the invoice. This was intended, as there may be some exceptions that the user needs to over ride the rules. This will then let the user print out the invoice with the item on it. MediFile will have done its job of alerting the user of the billing rule being broken.
In this document we are providing the definition of how to set up each of the rules. This is a pre-manual document. This means that this describes the method of defining the rules, what they mean, and all the possible rules to be defined at the time this document was written.
Dialog Description
There are essentially four areas within the dialog.
1 - Assigned Rules: This is the area with three columns of information. It shows the rule, specific information about the rule, and detail for the rule. This area displays the rules as currently defined for the Agency.
2 - Rule Modifying area: This area permits you to enter a rule, specific, and Detail information when modifying an existing rule, or creating a new rule.
3 - Button control: This area contains the button to work within the area. Each button has a specific tasks.
Button Actions
Insert: This button will insert the rules as indicated in the Rule Modifying Area into the Assigned Rules area. If no rule in the Assigned Rules area is highlighted the rule will be placed at the top. If a rule is highlighted the rule will be placed just above the highlighted rule.
New: This button does the same as the Insert button, except that it appends the rule to the end of the rule list.
Delete: This button deletes the currently highlighted rule.
HSC: This button brings up the search editor. You can enter in the search parameters for the HSC (fee code) file. If the search finds more than one HSC record then the whole selection of the HSC records will be brought into the area. If it finds only one, then it will bring in just that one HSC.
They will be brought in with Max # as the rule, and the HSC as the Specific rule. Of course these can be modified, and deleted. The intended use for this is when first setting up an agency. This will quickly bring in a large selection of HSC for defining the rules.
Caution should be used when using this button. Very large selections of records can be found and therefore rules created. Depending on the amount of memory in your computer, this may be too large of a selection.
Update: Clicking on this button will cause the rules as displayed in the Rule Modifying area to be placed into the rule display area, replacing the rules for the currently highlighted rule.
Rule Definition
Rule: Authorization
In the Agency record if an Authorization number is required for each Invoice.
Specific: -
Detail: Yes
If no Authorization is required you can leave out the Authorization rule, or enter a detail value of anything other than ‘Yes’.
The authorization number is invoice specific. It is not for a patient, or for a specific line item. Therefore if each line item needs a different authorization number then a separate invoice would need to be printed out for each line item. In the same idea, if the same authorization number can be used for multiple invoices, then the same authorization number can be entered in each of the multiple invoices.
The authorization number is to be entered in the screen area with ‘Authorization #’ beside the field. This field can take any combination of letters and numbers up to 11 characters.
If a line item is entered without an Authorization number when one is required by the Agency then the user will be given an Alert with the following Message:
"Authorization Number Required - GetAgencyRule"
There is no checking done to ensure that this is a valid authorization number. As long as something is entered into the Authorization field, MediFile will not alert a problem.
Rule: Year End
If there are any rules that will define a quantity or Max dollar value within a specific time this rule should be defined. If it is not defined MediFile will use a year from the current date.
Specific: -
Detail: Month that the Calendar Year Starts
Specific checking for this rule will not be done. This rule will be used in other rule checking.
Rule: Max Dollars
If there is a maximum dollar value that the patient will pay within a specific time period under the plan then this needs to be set.
Specific: The time period This can be a value of (Month, or Year)
Detail: The Maximum Dollar Value Enter the numerical maximum value
If this rule applies MediFile will find all billings to this patient during the last financial year (as determined for this agency using the Year End rule). If the patient has paid for product greater than the indicated amount this alert will be displayed. Understand that MediFile can only identify what invoices a patient has paid for in the current period. Therefore it will total all product purchased by the patient during the period and check that value against the maximum value indicated here.
If a Maximum dollar value paid by the patient has been reached, an Alert will be show to the user that indicates this. The user of the system will need to take appropriate action in the invoice.
"Maximum $ for Patient has been reached"
Rule: Max #
If there is a maximum number of an item that an agency will pay for within the year use this rule. Note that this rule is very similar to the ‘Max Quantity 1 Year’ rule. The difference is that this rule is simply the Maximum number of this item within the year as defined by the Year End item.
Specific: Item Number
Detail: The Maximum Quantity
MediFile will determine if there is a ‘Year End’ for this agency. If not it will just go back 365 days. MediFile will then search for all billings to this Agency in the past year for this patient. It will determine the number of items that have been purchased. If the maximum number of items have been reached the following message will be shown:
‘Max # Already Exceeded’
Rule: Max Quantity 2 Years
If there is a maximum number of an item that an agency will pay for within a 2 year plus one day use this rule. This is the maximum number of this item that the agency will pay for in the proceeding 2 years plus one day.
Specific: Item Number
Detail: The Maximum Quantity
MediFile will search all sales for this patient, billed to this agency in the last 2 years plus 1 day. Currently it is actually using 731 days - this will be changed to become actual years. MediFile will total up the total quantity for this item. If the number exceeds the maximum quantity permitted MediFile will alert you.
Max Quantity 2 Years Already Exceeded"
Rule: Max Quantity 1 Year
If there is a maximum number of an item that an agency will pay for within a 1 year plus one day use this rule. This is the maximum number of this item that the agency will pay for in the proceeding 1 year plus one day.
Specific: Item Number
Detail: The Maximum Quantity
MediFile will search all sales for this patient, billed to this agency in the last 1 year plus 1 day. Currently it is actually using 366 days - this will be changed to become actual year plus 1 day. MediFile will total up the total quantity for this item. If the number exceeds the maximum quantity permitted MediFile will alert you.
"Max Quantity 1 Year Already Exceeded"
Rule: Upgrade
If the specific item is an upgrade from another item that the agency will not pay for this should be defined here. The concept here is that the Agency will be billed for the standard item, and then the patient or other agency can pay for the difference in price between the standard item and the actual item delivered.
Specific: Item Number Upgrading From
Detail: Item Number Upgrading to
For this rule MediFile will look at the rules contained in the Agency file. If the item being sold is contained in this list as an upgrade item MediFile will search for the ‘Standard’ item identified in the rules. The search will be done by first looking for that item in the Fee Code file with that Agency identified. If one is not found MediFile will just look for that Fee Code with the Agency indicated as AOPL.
If the standard item is not found an Alert message as indicated here will be shown:
‘This is flagged as an Upgrade - Standard item not found’
If the standard item is found the Item shown in the invoice will be changed and the following Alert message will be shown.
‘This is an Upgrade - Standard Item entered’
Rule: Vendor #
For some agencies there is an agency number assigned to the professional providing the services. This number is specific to each person, and to the agency. To use this the the person must have an area account record as well.
Specific: MediFile site providing the service - Area Account Code
Detail: Vendor # assigned to this MediFile Site
When entering a part number, MediFile will determine if a Vendor number is required for this vendor. If vendor number is required MediFile will determine which vendor number to use depending on the area account that is being billed from. If the vendor number for this area account is not determined then the following alert will be displayed.
‘Rules indicate Vendor # Required, couldn't determine’
If the vendor number is found, it will be placed in the Facility Number field of the billing file. By doing this the invoice template can automatically place this field in the invoice.
As this is the method MediFile determines which vendor # to use, there needs to be the appropriate vendor number entered into the rules for each area account you are likely to bill to this agency from.
The vendor number will show up on the Invoice Dialog in the upper right corner, as shown here.
Setting up the HSC Record
The HSC (Health Service Codes) file contains all the Fee Codes (Part Numbers) that can be used in generating an invoice. These fee codes will have been imported into MediFile for you. The import may not contain all the HSCodes. From time to time you may need to create a new record in this file.
To work with the NAPO billing system there is some information that you need to add to the record for it to work.
1: File menu --> Administration
2: From the HSC popup select HSC.
3: File --> New
4. Enter the information for this HSC. Enter the code (up to 10 characters), description, fee for the agency this code will be used for. Ensure to add the Agency for which this Fee Code and price combination applies for. When you are creating an invoice MediFile will look for the Fee Code you enter and the Fee Code for the Agency that you have indicated for the invoice. Therefore it is important that you indicate which agency the Fee Code / price combination is for.
If MediFile cannot find a fee code record with the same fee code and agency combination it will look for a fee code record with that fee code and an agency of ‘AOPL’.
Ensure to add the Agency that the fee for the fee code applies. The diagram above shows the information that you need to fill in. The Max Fee/Year does not apply to NAPO, as this can be different for each agency and therefore is not used here.
Creating an Invoice for Services
Invoices for NAPO services are created from the Appointment Scheduler. Creating and use of the appointment scheduler are covered in the MediFile user manual. This document is not intended to show how to use those features of MediFile.
1: Create an appointment for the patient. Ensure it is connected to a patient record. As well indicate the agency that if financially responsible for the services and products provided. Double click on the appointment record to select it.
2: Click on the invoice button. This is the dollar symbol button.
3: This will bring up the invoice working dialog. Fill in the information as appropriate.
1: Enter the invoice type. If this is going to be an invoice to AADL, select invoice.
2: Enter in a different Invoice number if you require one. MediFile will have assigned one for you.
3: You can change the date seen to a previous date if required
4: You can change the date billed if needed.
5: Enter the Agency file number.
6: Enter an authorization number if required. For example for AADL you do require an authorization number so ensure to enter one. If you don’t though MediFile will alert you of this if you have set this rule in the Agency record.
7: Enter the Facility number for this area account / Agency. MediFile will try to fill this in for you if you have this setup in the rules for the agency, and area account properly.
8: Select the Agency that you are billing for. In the case of AADL, select that agency.
Entering Service Line Items
1. Click once on the line item area to activate the add / delete buttons
2. Click on the ‘+’ button. to create a new line item.
3. Select Fee Code from the type of item being invoiced for. Because of the complex rules for invoicing NAPO’s items need to all be Fee Codes. Select Fee Code from the selection list. Since this item is the 1st item in the list it will already be highlighted. You can click on the item, or press the enter key. Either way will place Fee Code into the type field.
4. Enter the Part No (Fee Code) for the item you are billing for.
Once you enter the code and tab out of the field MediFile will first search for the fee code in the fee code file. It searches for the fee code record with that code and for the specified agency. If the agency is not one in the Billing Agency type, it will look for the AOPL agency fee code.
Once the fee code record is found, MediFile will check all the rules as entered in the Agency record. It will give you an alert for any problems it found.
MediFile will then enter the description as indicated in the Fee Code File - Short description. It will default to 1 item, and enter the price as indicated in the Fee Code File.
If you would like to over ride the price, or change the description you can do that here.
Some of the Alerts and their meaning are shown here:
‘Rules indicate Vendor # Required, couldn’t determine
This alert indicates that the vendor’s rules indicate that a vendor number is required. MediFile could not determine what the vendor number was. This would mean that you have not set the vendor # up for that area account in the vendor record.
‘This is an Upgrade - Standard Item & its price entered. Ensure to bill Patient for difference’
This alert indicates that the item you have selected is not specifically covered by the agency. This has to be specifically set up in the vendor record for this alert to show up. MediFile is telling you that the part no you have chosen is an upgrade item. You will need to bill the difference in another invoice to the patient.
‘Authorization Number Required - GetAgencyRule’
This indicates that the vendor record requires an authorization number and you have not entered one.
‘Max # Already Exceeded’
This indicates that the maximum # of items has already been exceeded in the last 12 months for this item, as limited by this agency.
‘Max # Will Be Exceeded by 3’
This is similar to the alert above. In this case MediFile is telling you that they have not currently exceeded their limit, but if they purchase the quantity indicated in this invoice as entered it will exceed by the number indicated in the alert.
‘Max Quantity 1 Year Already Exceeded’
This indicates that the maximum # of items has already been exceeded in the last 12 months plus a day for this item, as limited by this agency.
‘Max Quantity 1 Year Will Be Exceeded by 3’
This is similar to the alert above. In this case MediFile is telling you that they have not currently exceeded their limit, but if they purchase the quantity indicated in this invoice as entered it will exceed by the number indicated in the alert.
‘Max Quantity 2 Years Already Exceeded’
This indicates that the maximum # of items has already been exceeded in the last 24 months plus a day for this item, as limited by this agency.
‘Max Quantity 2 Years Will Be Exceeded by ‘
This is similar to the alert above. In this case MediFile is telling you that they have not currently exceeded their limit, but if they purchase the quantity indicated in this invoice as entered it will exceed by the number indicated in the alert.
‘Maximum $ for Patient has been reached. $700.00 already billed.’
This alert means that the patient has already billed the agency for the amount shown, and it exceeds the amount they are limited to.
‘This is flagged as an Upgrade - Standard item not found’
This is an upgrade item, but MediFile cannot find the standard item that is indicated in the agency rule description.
Printing the Invoice
Once you have entered the items you are going to bill, click on the 4D Write button. This button will bring up a window to work on a 4D Write document.
From the 4D Write File menu select Open. Using the file open dialog select the invoice template you want to use. In the case of the AADL template, the template has been set up to automatically place up to 6 items per billing card. It will create the number of billing cards required to bill all the line items.
Format the 4D Write Invoice by adding, deleting what ever you need to do to make it print in the way you want it to look.
From the File menu select print document.
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