Manual Exhibit 5-1-D

SAMPLE REPORTS
(Summary Listing)

1. Cancelled Claims Report [Chief Executive Officer (CEO)]. To monitor cancelled or deleted claims from RPMS. Claims are cancelled when a claim is determined as un-billable or all potential billing has been completed. When a claim is cancelled, it is permanently removed and no further editing or approval of the claim can occur. The End User will have to populate a field noting why the claim is being cancelled for this report to be accurate. The report will provide management with a tool to monitor accuracy, ensuring staff are consistent with following appropriate standards and there is a mechanism for sufficient justification and reasonableness when claims are cancelled.

 
2. Adjustments Report [CEO]. To monitor all write-offs for proper justification, accuracy, reason codes, and compliance with Debt Collection legislation/ regulations/policies.

 
3. Days to Collection Summary Report [CEO]. To monitor the account process from patient check-in to PCC data entry to creating batches and posting of payments in order to identify delays, problems, and overall turn around time for collection on third party claims.

 
4. Current Procedural Terminology (CPT) Code Level Report [CEO]. To identify over- and under-coding for all CPT code levels by date range, provider, payer, and allowance category and to assist with trend analysis.

 
5. Third-party Table Maintenance Site Parameter Report [CEO]. To track specific Table Maintenance changes that were done to the Third-party Billing Site Parameter File. This report will assist with monitoring edits to the Payment Site fields, which identifies for the Payers where to send the checks. The Site Parameter changes affect all third-party claims.

 
6. Incomplete Coding Report-Inpatient [Health Information Management (HIM)]. To monitor inpatient visits that are not coded or are missing important data to complete the coding process resulting in third party-claims not being submitted to payers.

 
7. Incomplete Coding Report-Outpatient [HIM]. To monitor outpatient visits that are not coded or are missing important data to complete the coding process resulting in third-party claims not being submitted to payers.

 
8. Incomplete PCC Visits by Provider Report-Inpatient [HIM]. To monitor incomplete visits by Provider and delays in PCC data entry for inpatient visits (which in turn delay claim submission and the collection of third-party revenue).

 
9. Incomplete PCC Visits by Provider Report-Outpatient [HIM]. To monitor incomplete visits by Provider and delays in PCC data entry for outpatient visits (which in turn delay claim generation and the collection of third-party revenue).

 
10. PCC Incomplete/Error Report [HIM]. To monitor incomplete visits in PCC, identify missing required data elements, and correct “orphan visits” (which in turn delay claim generation, missed charges, and the collection of third-party revenue).

 
11. Incomplete PCC Visits by Ancillary Department Report [HIM]. To monitor incomplete visits by other departments such as radiology, laboratory, etc., resulting in PCC data-entry delays (which in turn delay claim generation and the collection of third party revenue).

 
12. Patient Errors/Warning Audit Detailed Report [Business Office/Patient Registration]. To monitor patient registration entry errors (incorrect and missing data) that delay and/or cause claim denials for third-party eligible patient services.

 
13. Benefit Coordinator Productivity Report [Business Office/Benefits Coordinator]. To monitor the productivity of the Benefits Coordinator to ensure third-party resource applications are properly completed and timely filed.

 
14. Exception Report-Patients Under 18 [Business Office/Benefits Coordinator].  To identify patients under 18with no third-party coverage who may be eligible for the Medicaid Children’s Health Insurance Program (CHIP). If eligible, applications must be processed to the appropriate local agency.

 
15. Exception Report-Patients Over 65 [Business Office/Benefits Coordinator].  To identify patients over 65 with no third-party coverage who may be eligible fro the Medicaid benefits.  if eligible, applications must be processed to the appropriate agency.

 
16. Brief Claims Listing Report [Business Office/Management]. To monitor unbilled claims created in RPMS that have not been approved.

 
17. Bills Awaiting Export Report [Business Office/Management]. To monitor third-party claim forms that have not been printed or electronically submitted for payment.

 
18. Incomplete Claims Status Report [Business Office/Management]. To monitor claims that are not approved because of missing or inaccurate data. The information on the claim is returned to coding, provider, PCC, HIM, or others for various reasons.

 
19. Batch Statistical Report [Business Office/Management]. To monitor collection hatches (including incomplete batches) within a facility database to ensure posting is current and accurate. Negative balances can also he identified and should be researched as to why there are negative balances to any one account.

 
20. Transaction Report [Business Office/Management]. To allow the end user to list transactions by collection batch, batch item, transaction date range, A/R entry clerk, and provider. This report can also be used to monitor the accuracy of data entry for adjustments.

 
21. Zero Pay/Adjustment Correspondence Rpt. [Business Office/Management].  To identify, monitor, and ensure the timeliness of batching and posting zero pay/adjustment correspondence.

 
22. Period Summary Report [Business Office/Management]. To monitor and compare billed, adjusted, and posted amounts for services provided to actual reimbursement received for each type of service for a specific time period.

 
23. Age Summary Report [Business Office/Management]. To provide summary information on all open balance bills by insurer or Clinic. The report summarizes the outstanding bill totals by age category.

 
24. Summary A/R Bill and Transaction Synchronization (ASYNC) Report [Business Office/Management]. To allow the end user to see which bills are not in synchronization with the transaction history after a patch is installed. The users are expected to work these accounts. They will NOT automatically receive a transaction to make them balance.

 
25. Bills Listing Report [Business Office/Management]. To provide detailed information on bills uploaded from the Third-party Billing package. The report may be sorted by Date Range, Clini/Visit Type, Billing Entity, and Provider.

 
26. Bill Negative Balance List [Business Office/Management]. To monitor inaccurate posting amounts entered by the A/R posting staff or refunds processed to Finance.

 

 

1.  Cancelled Claims Report [CEO]
Third Party RPMS Application

This report has not been released in a national version of RPMS Third-party Billing as of the date of this policy. The screens are provided below but may vary slightly when development is completed. The new features will be included in Third-party Billing V2.5 P8.

BRIEF LISTING of CLAIMS with a Cancelled Status for ALL BILLERS                                    Page 1
APR 1,2005
[For ALL BILLING SOURCES at SANTA MARIA HOSPITAL with VISIT DATES from 03/01/2005 to 03/05/2005]

Patient HRN Active Insurer Claim Number Visit Date REASON

Biller:    Jones, Sandra
Visit Location: SANTA MARIA HOSPITAL
Visit Type: INPATIENT
 

JONES, BABY BOY 88888 MEDICAID 870318 03/04/2005 ELIG NOT FOUND
SPOT, BABY BOY 89000 MEDICAID 869254 03/01/2005 ELIG NOT FOUND
ROST, MICKEY 99999 MEDICAID 871343 03/04/2005 ELIG NOT FOUND
PITTS, JOHN 22222 MEDICAID 868577 03/03/2005 ELIG NOT FOUND
GUEST, MY 99333 MEDICAID 869932 03/04/2005 ELIG NOT FOUND
VICK, RUSTY 88111 MEDICAID 868576 03/01/2005 ELIG NOT FOUND
WISEMAN, LES 88881 MEDICAID 868152 03/03/2005 ELIG NOT FOUND

 Total:  7

2. Adjustments Report [CEO]
Accounts Receivable RPMS Application

This report has not been released in a national version of WMS Accounts Receivable application as of the date of this policy. The screens are provided below but may vary slightly when development is finalized. The new features will be included in a future release of AR V1.8.

APR 15, 2005             Transaction Detail Report                  Page 1

Bill Number Transaction Date Insurer Amount Billed Transaction Amount Type

Visit Location:  SANTA MARIA HOSPITAL
Transaction Type: PAYMENT
Visit Type: ZERO-PAY CLAIM
 

           
252545C-SM 11/26/2003 ARIZONA MEDICAL 172.00 172.00 PAYMENT
478464A-SM 01/18/2003 ARIZONA MEDICAL 416.00 172.00 PAYMENT
    Subtotal     -------
588.00		 -------
344.00		  

Visit Type:  INPATIENT

           
561321B-SM 10/20/2003 BC/BS OF TEXAS     80.00      0.00 PAYMENT
112655C-SM 01/16/2004 BC/BS OF TEXAS 2,284.00   965.00 PAYMENT
313324A-SM 05/10/2004 MAILHANDLERS BENE. 3,705.12 2,419.00 PAYMENT
118324A-SM 06/14/2004 MEDICARE    765.00 2,175.00 PAYMENT
      Subtotal     -------
6,834.12		 -------
5,559.00		  

Transaction Type:  CO-PAY
          Visit Type:   INPATIENT

           
562631A-SM 10/20/2003 BC/BS OF TEXAS 80.00 15.00 CO-PAYMENT
Subtotal:      

-------
15.00

  

Transaction Type:  WRITE-OFF
                   Visit:   INPATIENT

           
456465A-SM 07/20/2003 PRUDENTIAL HEALTH    565.20    565.20 OVER U/C
546465A-SM 08/18/2003 MEDICARE    172.00      34.00 MEDICARE
459912A-SM 09/10/2003 MEDICARE    172.00      34.00 MEDICARE
465194A-SM 09/16/2003 MEDICARE 4,623.00 1,562.00 OVER U/C
456879A-SM 09/18/2003 MEDICARE    172.00      34.00 MEDICARE
    Subtotal:     ---------
5,876.20		 ---------
2,263.20		  

Total:		    
13,378.32
8,181.20		  

3.  Days to  Collection Summary Report [CEO]
Accounts Receivable RPMS Application

This Accounts Receivable report has not been released at a national level as of the date of this policy.  It will be released in a future release of Accounts Receivable V1.8.

WARNING:  Confidential Information, Privacy Act Applies

DAYS TO COLLECTION SUMMARY REPORT
MAY 31, 2004

(FOR BILLS APPROVED FOR VISITS FROM MAY 1, 2004 TO MAY 5, 2004)
Total Billed = 750.00
Numbered of Canceled Bills = 3              Canceled Bill Amount = 500.00

 PAGE:1
 

VISIT LOCATION:    WESTERN OREGON SERVICE UNIT
ALL VISIT TYPES:    ALL
BILLING ENTITY:     ALL
PROVIDER:                ALL

CANCELED BILLS INCLUDED BELOW

DATE VISIT/Check-In Number
Check-In		 Total Billed AVG Days
to PCC		 AVG Days
to Bill		 AVG Days AVG Days
Bill		 AVG Days
BATCH		 AVG Days
PYMT
5-1-2004 10 50.00 50 60 70 80 90 100
5-2-2004 20 100.00 40 50 60 70 80 90
5-3-2004 30 150.00 20 30 60 65 75 121
5-4-2004 40 200.00 15 20 25 30 120 230
5-5-2004 50 250.00 2 10 25 20 90 300
  -------
-------
150		 -------
-------
750.00		 -------
-------
3		 -------
-------
40		 -------
-------
55		 -------
-------
40		 -------
-------
85		 -------
-------
150

END OF REPORT:  05  31  04 @ 11:00PM

4.  Current Procedural Terminology (CPT)
Code Level Report [CEO]
Third Party Billing RPMS Application

BILLED MEDICAL PROCEDURES for ALL BILLING SOURCES
APR 1, 2005
[With VISIT DATES from 03/01/2005 to 03/32/2005]
Provided by JONES, DAVEY
[With PROCEDURE RANGE from 99201 to 99499]

 		 PAGE:1
 
Code Procedure Description Count Amount Billed Percent
99211 OFFICE/OUTPATIENT VISIT, EST  2 70.00 0.0%
99212 OFFICE/OUTPATIENT VISIT, EST  8 572.00 6.0%
99213 OFFICE/OUTPATIENT VISIT, EST 68 5,935.00 63.0%
99214 OFFICE/OUTPATIENT VISIT, EST 12 1,558.00 16.0%
99221 INITIAL HOSPITAL CARE   1 199.00 2.0%
99222 INITIAL HOSPITAL CARE   1 268.00 2.0%
99231 SUBSEQUENT HOSPITAL CARE   2 158.00 1.0%
99232 SUBSEQUENT HOSPITAL CARE   2 286.00 3.0%
99238 HOSPITAL DISCHARGE DAY   2 266.00 2.0%
  Total: ---------
---------
98		 ---------
---------
9,312.00		 ---------
---------
 

5.  Third-party Table Maintenance Site Parameter Report [CEO]
Third-party RPMS Application

This report has not been released in a national version of RPMS Third-party Billing as of the date of this policy, but it will be available in the next release. The screens may change when the development is finalized.

THIRD PARTY RPMS TABLE MAINTENANCE SITE PARAMETER EDITS
APR 1, 2005
[With VISIT DATES from 03/01/05 to 03/31/05]
[Edited by ALL EMPLOYEES for ALL SITES for PRINTABLE NAME OF PAYMENT SITE and FACILITY TO RECEIVE PAYMENTS MAILING ADDRESS - Before and After Changes Made]		 PAGE:1
 
SITE:

SANTA MARIA HOSPITAL
POST OFFICE BOX 213
ALBUQUERQUE, NM 87110
-------------------------------------------
BEFORE CHANGES MADE
DATE: 03/17/2005

Name.....: Santa Maria Hospital
Street.....: POST OFFICE BOX 213
City........: ALBUQUERQUE//
State......:  NEW MEXICO//
Zip Code: 87110//

  
-------------------------------------------
AFTER CHANGES MADE
DATE: 03/17/2005

<-----------------PRINTABLE NAME OF PAYMENT SITE--------->
Name.....: SANDRA JONES, BOM, SANTA MARIA HOSP
Street.....: POST OFFICE BOX 213
City........: ALBUQUERQUE//
State......:  NEW MEXICO//
Zip Code: 87110//

AFTER CHANGES MADE

 EMPLOYEE: JONES, SANDRA

BEFORE CHANGES MADE
DATE: 03/17/2005

 

 

Select LOCATION to Edit:    SANTA MARIA HOSPITAL     PORTLAND
SANTA MARIA   

MAILING ADDRESS:
MAILING ADDRESS-CITY:
MAILING ADDRESS-STATE:
MAILING ADDRESS-ZIP:

 PO BOX 410
ALBUQUERQUE//
NEW MEXICO//
87110//
AFTER CHANGES MADE
DATE: 03/17/2005

 

EMPLOYEE:  JONES, SANDRA

Select LOCATION to Edit:    SANTA MARIA HOSPITAL     PORTLAND
SANTA MARIA   

MAILING ADDRESS:
MAILING ADDRESS-CITY:
MAILING ADDRESS-STATE:
MAILING ADDRESS-ZIP

 PO BOX 2220
ALBUQUERQUE//
NEW MEXICO//
87110//

6.  Incomplete Coding Report - Inpatient [HIM]
RPMS Patient Information Management System (PIMS)
Application Under Admission, Discharge, and Transfer

Month/Year # Discharged # Code # Not-Coded # Exported # Errors
Mar 2004  3 1  2 0 0
Apr 2004  3 0  3 0 0
May 2004  1 0  1 0 0
Jul   2004  2 1  1 0 0
Aug 2004  3 1  2 0 0
Oct 2004  2 0  2 0 0
Dec 2004 11 1 10 0 0
Jan  2004  1  0  1 0 0
Feb 2004  3  0  3 0 0
   7  4 25 0 0
Admit & Discharge Dates
Apr 10, 2005 12:25:26		 Patient Name Chart # Srv Insurance
03/25/2004  03/25/2004 CIMS, DLN 100000 FAMLP IHS
03/25/2004  03/25/2004 SMITTS, DOUG 150000 GM IHS
04/12/2004  04/12/0224 BEN, AMA 160000 OB IHS
04/12/2004  04/12/2004 DEAN, ACOSTA 100000 OB MCD
04/30/2004  04/30/2004 YES, MARGE 102000 GM IHS
07/03/2004  05/13/2004 ROSS, MARCIE 100090 PED IHS
01/08/2004  07/06/2004 TIFF, EDGAR 100990 MENTL MCD

7. Incomplete Coding Report - Outpatient [HIM]
Patient Care Component (PCC) RPMS Application

This report has not been released in a national version of PCC as of the date of this policy. The screens are provided below but may vary slightly when the development is finalized.

SMS Apr 1, 2005 Page 1

     INCOMPLETE CODED VISITS
 Visit Dates: Mar 01, 2005, to Mar 01,2005

HRN PATIENT NAME VISIT DATE TIME TYPE CLINIC INSURANCE

TOTAL NUMBER OF VISITS FOUND:  6

             
SMH 7007 MONEY, JOHNE Mar 01, 2005 12:30 A 18 MEDICAID
SMH 999 JENS, MARCY Mar 01, 2005 13:15 A 20 IHS
SMH 57 WILLIS, MG Mar 01, 2005 12:00 A 01 MEDICARE
SMH 1 SANS, WES Mar 01, 2005 16:15 A 01 IHS
SMH 3 GUS, GF Mar 01, 2005 12:20 A 20 MEDICAID
SMH 9 PANS, DTA Mar 01, 2005 14:20 A 18 MEDICARE

End of report.  PRESS ENTER:

8.  Incomplete PCC Visits by Provider Report - Inpatient [HIM]
PIMS RPMS Application, ADT Portion

Provider's Incomplete

SUMMARY PAGE

Apr 10, 20005, 12:22:08

 

 Page 1 of 1
 
PROVIDER INCOMP CHARTS DELINQ CHARTS A SHEET OP RPT SUMM SIG
ADAM, ADAM 2 2 1 0 0 0
ANTONIO, JOE 2 2 0 0 0 0
BOAL, STEPHANIE 2 2 0 0 2 0
BORDERAVE, DALE 1 1 0 0 0 1
BRUCE, TENUM CONTR 2 2 0 0 1 1
DELECKI, JOHN 1 1 0 0 0 0
DELONG, THOMAS 1 1 0 0 0 0
DORRELL, DDS TIMOTHY 1 1 1 0 0 0
             
TOTALS 12 12 2 0 3 2

9. Incomplete PCC Visits by Provider Report - Outpatient [HIM]
Patient Care Component (PCC) RPMS application

The report has not been released in a normal version of PCC as of the date of this policy.  The screens are provided below but may vary slightly when the development is finalized.

Provider's Incomplete Ambulatory Charts


 

Apr 10, 20005, 12:22:08


SUMMARY PAGE

 Page 1 of 1
 
PROVIDER INCOMP CHARTS MISSING POV SIG E&M PRIM PROV
ADAM, ADAM 2 2 1 0 0
ANTONIO, JOE 2 2 0 0 0
BOAL, STEPHANIE 2 2 0 0 0
BORDENAVE, DALE 1 1 0 0 0
BRUCE, TENUM CONTRACT 2 2 0 0 0
DELECKI, JOHN 1 1 0 0 0
DELONG, THOMAS 1 1 0 0 0
DORRELL, DDS TIMOTHY 1 1 1 0 0
           
TOTALS 12 12 2 0 0

10.  PCC Incomplete Error Report [HIM]
Patient Care Component (PCC) RPMS Application

APR 1, 2005 Page:1
 

PCC Data Entry Module
***************************
*VISIT REVIEW ERROR REPORT*
****************************

Report of Errors for VISIT Date Range: JAN 01,2004, through APR 15, 2005

Location of Encounter:  JONES HEALTH CENTER
-----------------------------------------------------------------------------------------------------------------------
VISITS WITH A ZERO DEPENDENT ENTRY COUNT---------POTENTIAL DELEGATIONS
-----------------------------------------------------------------------------------------------------------------------
HRN FAC:[JH]
DATE: [JAN 8, 2004@12:00]
SERVICE CATEGORY: [A]		 HRN:[55-8555]

TYPE: [I]		 NAME: [ACKSTAYN, AMY LYNN]
LOCATION: [JONES HEALTH CENTER]
CLINIC: [NONE]
 
HRN FAC:[JH]
DATE: [FEB 9, 2005@14:00]
SERVICE CATEGORY: [A]		 HRN:[66-19996]

TYPE: [I]		 NAME: [BOCK, BEVERLY]
LOCATION: [JONES HEALTH CENTER]
CLINIC: [NONE]
-----------------------------------------------------------------------------------------------------------------------
THE FOLLOWING VISITS DO NOT HAVE EITHER A PRIMARY PROVIDER OR PURPOSE OF VISIT
-----------------------------------------------------------------------------------------------------------------------
HRN FAC:[JH]
DATE: [JAN 12, 2004@14:00]
SERVICE CATEGORY: [A]		 HRN:[06-19999]

TYPE: [I]		 NAME: [ACKSTAYN,ETHEL]
LOCATION: [JONES HEALTH CENTER]
CLINIC: [ALCOHOL & SUBST ABUSE]

11.  Incomplete PCC Visits by Ancillary Department Report [HIM]
Patient Care Component (PCC) RPMS Application

The report displayed is for Lab visits only, but it is available for Radiology visits as well.

SMS

Apr 01, 2005

 Page 1 of 1
 

INCOMPLETE LAB VISITS
Visit Dates: Mar 01, 2005 to Mar 01, 2005
 
HRN PATIENT NAME DATE/TIME SC TYPE LOC LAB RX RAD

TOTAL NUMBER OF VISITS FOUND:  6

                 
SMH 7007 MONEY, JOHNE Mar 01, 2005 12:00 I I SMH  7  0 0
SMH 999 JENS, MARCY Mar 01, 2005 12:00 I I SMH 53 12 0
SMH 57 WILLS, MG Mar 01, 2005 12:00 I I SMH 61  0 0
SMH 1 SANS, WES Mar 01, 2005 12:00 I I SMH  1  0 0
SMH 3 GUS, GF Mar 01, 2005 12:00 I I SMH 52  0 0
SMH 9 PANS, DTA Mar 01, 2005 12:00 I I SMH  4  0 0

End of Report.  PRESS ENTER:

12. Patient Errors/Warnings Audit Detailed Report
[Business Office/Patient Registration]
Patient Registration RPMS

UNSPECIFIED SERVICE UNIT
PATIENT'S ERRORS/WARNINGS AUDIT
DETAILED REPORT
as of JAN 12, 2004@10:48:41
 
003 ERROR:  ASSIGNMENT OF BENEFITS EXPIRED (past 1 year)
CORRECTIVE ACTION:  The Assignment of Benefits date has exceeded 1 year. Obtain Assignment of Benefits and
                                           enter date on page 9.
-----------------------------------------------------------------------------------------------------------------------
NAME IHS# FACILITY DOB
BALEY, RAYMOND 8944 UNSPECIFIED SERVICE UNIT 02/05/1960
 
BEAR, MARY 1240 BIG HOSPITAL 01/11/1970
 
BLUE, SKY 22581 UNSPECIFIED SERVICE UNIT 10/01/1940
 
TRAYLOR, BOB 1571 UNSPECIFIED SERVICE UNIT 11/07/1968
 
NIXON, STEVE 21577 BIG HOSPITAL 07/24/1960
-----------------------------------------------------------------------------------------------------------------------

 

UNSPECIFIED SERVICE UNIT
PATIENT'S ERRORS/WARNINGS AUDIT
DETAILED REPORT
as of JAN 12, 2004@10:48:41
 
006 ERROR:  PATIENTS ADDRESS IS INCOMPLETE
CORRECTIVE ACTION:  Complete patient address fields including street, city, state and zip code on page 1.
 
-----------------------------------------------------------------------------------------------------------------------
NAME IHS# FACILITY DOB
TOYLAND 9371 UNSPECIFIED SERVICE UNIT 12/08/1970
 
BRATT, ROY 24050 BIG HOSPITAL 03/11/1980
 
CLEARY, DREW 58110 UNSPECIFIED SERVICE UNIT 09/10/1950
 
ROGER, TOM 31571 UNSPECIFIED SERVICE UNIT 01/07/1978
 
NIXON, STEVE 21577 BIG HOSPITAL 07/24/1960

13.  Benefit Coordinator Productivity Report
[Business Office/Benefits Coordinator]
Patient Registration RPMS Application

This report is not available in a nationally released version of Patient Registration RPMS as of the date of this policy. The screens may change when the development is finalized and released in the RPMS Patient Registration application V7.1 Patch 1.

-----------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------
BENEFITS COORDINATOR PRODUCTIVITY REPORT FOR ALL APPLICATION              Page 1
APR1, 2005
DATE OBTAINED CHART APPLICATION TYPE STATUS
03-01-2005 000112 MEDICARE APPLICATION PENDING
03-01-2005 012121 NM MEDICAID APPLICATION APPROVED
03-21-2005 234123 SSA APPLICATION RESUBMITTED
03-30-2005 121211 NM MEDICAID APPLICATION Follow-up Needed

Total Applications: 4

14. Exception Report - Patients Under 18With No Third-party Coverage
[Business Office/Benefits Coordinator]
Patient Registration RPMS Application

This report is not available in a nationally released version of  Patient Registration RPMS as of the date of this policy. The report will be released in the RPMS Patient Registration application V7.1 Patch 1.

SMITH; SANDRA  

 INDIAN HEALTH CENTER  

 Page 1

PATIENTS 18 YRS OLD AND UNDER
WITH NO THIRD-PARTY COVERAGE
Report date: APR 11,2005@08:21:36

NAME (CHART#) HOME PHONE GENDER LAST UPDATE
SMITH, JONES 505 999 985 M FEB 2, 2005

SMITH, JONES
PO BOX 1
GALLUP NM 87364
------------------------------
Total patients 18 yrs or under: 1

15. Exception Report -Patients Over 65 Years of Age
[Business Office/Benefits Coordinator]
Patient Registration RPMS Application

SMITH; SANDRA  

 INDIAN HEALTH CENTER  

 Page 1

PATIENTS 65 YRS OLD AND OLDER
Report date: APR 11,2005@08:21:36

NAME (CHART#) HOME PHONE MEDICARE (M)
RAILROAD (R)		 SOCIAL SECURITY NUMBER
SMITH, JONES 505 999 985 M = 555-55-5555 -A 555-55-5555

PO BOX 1
GALLUP NM 87364
(MCR) SMITH, JONES
------------------------------
Total patients 65 yrs or older: 1

Total patients 65 or older with Medicare: 1

Total patients 65 or older with Railroad Ret.: 0

16.  Brief Claims Listing (BRRP) Report [Business Office/Management]
Third-Party Billing RPMS Application

-----------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------
BRIEF LISTING of CLAIMS FLAGGED AS BILLABLE
APR 1, 2005

[For ALL BILLING SOURCES at SANTA MARIA HOSPITAL]
[With VISIT DATES from 03/01/2005 to 03/02/2005

Page 1
-----------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------
Location Visit Type Number of Claims
SANTA MARIA HOSPITAL

MENTAL HEALTH
INPATIENT
PHYSICAL THERAPY
OUTPATIENT
AMBULATORY SURGERY
PHARMACY
DENTAL
PROFESSIONAL COMPONENT

 13
  2
  1
91
  1
  1
  9
  4
-----
Total: 122          

17.  Bills Awaiting Export Report [Business Office/Management]
Third-Party Billing RPMS Application

-----------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------
BILLS AWAITING EXPORT for ALL BILLING SOURCES
APR 10, 2005

[With VISIT DATES from 03/01/2005 to 03/31/2005

Page 1
-----------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------
Insurer Number Bills Avg Days Awaiting Export Total Charges
RAILROAD RETIREMENT   1 6   331.00
MEDICARE 61 6 6,868.00
BC/BS/PPO   1 6    157.98
  ------
------
63		 ------
------		 ----------
----------
7,356.98

18.  Incomplete Claims Status Report [Business Office/Management
Third-party Billing RPMS Application

This report has not been released in a national version of RPMS Third Party Billing as of the date of the policy. The screens are provided below but may vary slightly when the development is finalized. The new features will he included in Third-party Billing V2.5 P8.

-----------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------
BRIEF LISTING of CLAIMS with an Incomplete Status FOR ALL BILLERS
APR 1, 2005

[For ALL BILLING SOURCES at SANTA MARIA HOSPITAL]
[With VISIT DATES from 03/01/2005 to 03/05/2005

Page 1
-----------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------

Biller:                    JONES, SANDRA
Visit Location:       SANTA MARIA HOSPITAL
Visit Type:             OUTPATIENT
Active Insurer:        MEDICAID

Patient HRN Claim Number Visit Date Clinic REASON
JONES, BABY BOY 8888 870318 03/04/2005 OPTOM RETURN TO PROV
SPOT, BABY BY 89000 869254 03/01/2005 GEN MISSING POV
ROST, MICKEY 99999 871343 03/04/2005 LAB LAB NOT FINAL
PITTS, JOHN 22222 868577 03/03/2005 GEN VERIFY ELIG
GUEST, MY 99333 869932 03/04/2005 DENTAL RETURN TO PROV
VICK, RUSTY 88111 868576 03/01/205 GEN MISSING POV
WISEMAN, LES 88881 868152 03/03/2005 MH CLAIM NOT CODED

 		 Totla:7        

19. Batch Statistical Report [Business Office/Management]
Accounts Receivable RPMS Application

The Batch Statistical Report (BSL) displays, for each collection point, how much has been posted.  It also displays what still needs to be posted from each batch.  The COLLECTION PROCESSED column indicates the amount posted, and the BALANCE column is the amount still to be posted.  The user is prompted for beginning and ending dates.

Batch Date Batch Total Collections
Processed		 Unallocated
True Total		 Refunded From Batch Balance


COLLECTION ID:  SM_MEDICAID
           
02/03/2005-1-P 842.00 842.00 0.00   0.00 0.00 0.00
02/04/2005-1-P 267564.47 267564.47 0.00   0.00 0.00 0.00
02/07/2005-1-P 432.00 432.00 0.00   0.00 0.00 0.00
02/07/2005-2-P 11532.45 11532.45 0.00   0.00 0.00 0.00
02/09/2005-1-P 3240.00 3240.00 0.00   0.00 0.00 0.00
02/11/2005-1-p 145121.82 145121.82 0.00   0.00 0.00 0.00
02/11/2005-2-P 3450.71 3450.71 0.00   0.00 0.00 0.00
02/15/2005-1-P 1664.01 1664.01 0.00   0.00 0.00 0.00
02/18/2005-1-P 9585.84 9585.84 0.00   0.00 0.00 0.00
02/18/2005-2-P 58933.17 58933.17 0.00   0.00 0.00 11.19
02/23/2005-1-P 56637.46 56637.46 0.00   0.00 0.00 0.00
           
SUBTOTAL 566585.93 566574.74 0.00   0.00 0.00 11.19

20.  Transaction Report (TAR) [Business Office/Management
Accounts Receivable RPMS Application

The Transaction Report (TAR) presents a listing of transactions for all billing sources. This report may be sorted by Location, Clinic/Visit Type, Transaction Date Range, Collection Batch, Collection Batch Item, Accounts Receivable Entry Clerk, and Provider.

WARNING:  CONFIDENTIAL PATIENT INFORMATION, PRIVACY ACT APPLIES

-----------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------
DETAIL Transaction Report for ALL BILLING SOURCE(S)
JUL 5, 2005@14:24

At SANTA MARIA HOSPITAL Visit Location Regardless of Billing Location
[With TRANSACTION DATES from 03/01/2005 to 03/31/2005

Page 1
-----------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------
Bill Number Pay-Amt PRV-CRD REFUND PAYMENT BILL AMT ADJ
Visit Location..........:
Collection batch......:
Collection Batch Item:
Visit Type...............:
A/R Account		 SANTA MARIA HOSPITAL
SMH_MEDICAID-08/06/2005-1
2
PROFESSIONAL COMPONENT
MEDICAID
             
719511A-SM 60.14 0.00 0.00 60.14 549.00 0.00
719512A-SM

 		 -60.14

 		 0.00

 		 0.00

 		 -60.14

 		 2,576.00

 		 1,517.46

 
A/R Acct Tot: 0.00 0.00 0.00 0.00 3,125.00 1,517.46
Visit Tot 0.00 0.00 0.00 0.00 3,125.00 1,517.46
Item Tot 0.00 0.00 0.00 0.00 3,125.00 1,517.46

Collection Batch Item:  7
Visit Type:  OUTPATIENT
A/R Account: MEDICAID

751713A-SM 101.21 0.00 0.00 101.21 432.00 -101.21

21.  Zero Pay/Adjustment Correspondence Report
[Business Office Management]
Accounts Receivable RPMS Application

This report is currently available in RPMS Accounts Receivable, but the facility must have a process in place to batch all individual Zero Payment and Adjustment correspondence documents into the RPMS A/R batch module.

DATE:
APR 1, 2005 13:34		 BATCH STATISTICS FOR
SANTA MARIA HOSPITAL
1-MAR-2005 TO 5-MAR-2005

PAGE 1

                              UNALLOCATED
BATCH DATE
-SEQ-BS-		 BATCH TOTAL COLLECTIONS
PROCESSED		 TRUE TOTAL REFUNDED
FROM BATCH		 BAL

    COLLECTION ID: SMHO_MEDICAID

BATCH DATE
-SEQ-BS-		 BATCH TOTAL COLLECTIONS
PROCESSED		 TRUE TOTAL REFUNDED
FROM BATCH		 BAL
03/02/2005-1-P 10152.00 0.00 0.00 0.00 0.00 10152.00
03/02/2005-2-P 823.00 0.00 0.00 0.00 0.00 823.00
03/03/2005-1-P 1906.89 0.00 0.00 0.00 0.00 1906.89
03/03/2005-2-P 129715.59 0.00 0.00 0.00 0.00 129715.59
03/03/2005-1-P 16670.31
-----------		 0.00
------		 0.00
------		 0.00
------		 0.00
-------		 16670.31
-----------
SUBTOTAL

159267.79

 0.00 0.00 0.00 0.00 159267.79

   COLLECTION ID:SMHO_MEDICARE

             
03/01/2005-1-P 1716.40 0.00 0.00 0.00 0.00 1716.40
03/02/2005-1-P 2212.99
-----------		 0.00
-------		 0.00
-------		 0.00
------		 0.00
-------		 2212.99
----------
SUBTOTAL 19829.39 0.00 0.00 0.00 0.00 19829.39

   COLLECTION ID: SMHO_PI

             
03/02/2005-1-P 259.15 0.00 0.00 0.00 0.00 259.15
03/02/2005-2-P 3709.60 0.00 0.00 0.00 0.00 3709.60
03/03/2005-1-P 867.21 0.00 0.00 0.00 0.00 867.21
03/03/2005-2-P 3549.93 0.00 0.00 0.00 0.00 3549.93
03/03/2005-3-P 1169.66 0.00 0.00 0.00 0.00 1169.66
03/03/2005-4-P 42.87
-------		 0.00
------		 0.00
------		 0.00
-----		 0.00
------		 542.87
---------
SUBTOTAL: 10098.42
-------		 0.00
-----		 0.00
------		 0.00
-----		 0.00
------		 10098.42
---------
TOTAL: 189195.60 0.00 0.00 0.00 0.00 189195.60

22. Period Summary Report (PSR) [Business Office/Management
Accounts Receivable RPMS Application

The Period Summary Report (PSR) represents a summary of transaction activity for all hilling sources for a specified date range, including total billed, payment, and adjustment amounts.

The PSR may be sorted by A/R Account, Clinic Type, Visit Type, Discharge Service, Allowance Category, Billing Entity, and Insurer Type.

WARNING:  CONFIDENTIAL PATIENT INFORMATION, PRIVACY ACT APPLIES

-----------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------
Period Summary Report by A/R ACCOUNT
JUL 5,2005 @14:34


At SANTA MARIA HOSPITAL Visit Location (s) Regardless of Billing Loc
[With TRANSACTION DATES from 03/01/2005 to 03/31/2005]

 

Page 1
A/R ACCOUNT Billed Amt Payment Adjustment Refund
MEDICARE 233,000.48
--------------		 40,600.46
-------------		 13,200.48
-----------		 0.00
------
***VISIT
Loc Total		 233,000.48
---------------		 40,600.46
-------------		 13,200.48
-----------		 0.00
-----

*****REPORT
TOTAL		 233,000.48 40,600.46 13,200.48 0.00

23.  Age Summary Report (ASM) [Business Office/Management]
RPMS Accounts Receivable Application

AGE SUMMARY REPORT

The Age Summary Report (ASM) provides summary information on all open balance bills by insurer or Clinic. The report summarizes the outstanding bill totals by age category.

***CONFIDENTIAL PATIENT INFORMATION***

DATE:
05/29/2001
 		 ASM REPORT BY INSURER BASED ON DATE BILLED LAKE COUNTY TRIBAL HEALTH
 

PAGE 1
 
CURRENT 31-60 61-90 91-120 120+ BALANCE

24. ASYNC Report [Business Office/Management]
RPMS Accounts Receivable Application


WARNING:  Confidential Patient Information, Privacy Act Applies
-----------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------
SUMMARY A/R Bill and Transaction Synchronization Report
MARCH 10,2005 

Page 1
A/R BILL DOS A/R ACCOUNT BILL BAL TRANSACTION
HISTORY BAL		 DIFFERENCE

Visit Location:  DEMO HEALTH CENTER

17147B-DHC
 		 11/23/2004
 		 BCBS OF NEW MEX
 		 36.56
------		 73.12
-------		 -36.56
-------
Visit Location Total (Bill cnt: 1)   36.56
------		 73.12
------		 -36.56
------
***REPORT TOTAL (Bill cnt: 1)   36.56 73.12 -36.56
 

25.  Bills Listing Report [Business Office/Management]
Accounts Receivable RPMS Application

The Bills Listing Report (BLS) provides detailed information on bills uploaded from the Third Party Billing application to the Accounts Receivable application. The report may be sorted by Date Range, Clinic/visit type, Billing Entity and Provider.

WARNING:  Confidential Patient Information, Privacy Act Applies

-----------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------
DETAIL Bills Listing Report
JUL 5, 2005 @15:13

For MEDICAID BILLING SOURCE(S) at SANTA MARIA HOSPITAL Visit Location Regardless of Billing Location
[With VISIT DATES from 03/01/2005 to 03/15/2005]

Page 1
Patient Bill Number DOS Amount Billed Balance

Visit Location:  SANTA MARIA HOSPITAL
Visit Type:        INPATIENT
A/R Account:    MEDICAID
 
         
ROSS, JOHN BOY

A/R Account		 866333A-SM

Count   1		 MAR 15, 2005

Total:
3,024.00

3,024.00		 0.00

0.00

A/R Account:  MEDICAID AZ
BAA, CAYDEN 870070A-SM MAR 04, 2005 7,710.00 150.00
BASTANO, BABY 800000A-SM MAR 04, 2005 7,71.000 150.00
BLACKEYE, MEARS 867777A-SM MAR 01, 2005 3,084.00 60.00
CAADEN, DESIREE 866666A-SM MAR 09, 2005 3,084.00 60.00
CHIMENY, BABY BO 899999A-SM MAR 01, 2005 1,542.00 30.00
COORS, JANNA 833333A-SM MAR 09, 2005 10,794.00 210.00
COORS, JASON 809999A-SM MAR 14, 2005 3,084.00 60.00
GROUSE, MICKEY 800500A-SM MAR 04, 2005 3,084.00 60.00
JONES, ARLISS 889229A-SM MAR 06, 2005 7,710.00 150.00
JONES, DENNY 874444A-SM MAR 13, 2005 3,084.00 60.00
JONES, MITRE 871111A-SM MAR 07, 2005 3,084.00 60.00

26.  Bill Negative Balance List [Business Office Management]
Accounts Receivable RPMS Application

1-MAY-2005 NEGATIVE BALANCE Page 1

 
IEN BILL# PATIENT DOS BILLED TO BALANCE
2010201 200-SMH DUCK, DAFFY 02-05-2005 NM MEDICAID -52.01
2001111 2900-SMH MOUSE, MICKEY 01-09-2004 MEDICARE -2.00
3910001 450-SMH JONES, SMITH 03-05-1999 BC/BS OK -3.05

END OF REPORT