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MACSIS
Documentation: Claims Status Report

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 Board received the file from the provider but has not yet submitted that data to the MACSIS Project. Boards are required to do certain levels of duplicate checking about claims before they are sent on to MACSIS.
  • Each Board is assigned a day and time per week when their submitted files will be handled by MACSIS. If the file was received by the Board after their scheduled processing, there may be a week's delay before the data will be available inside MACSIS.
  • The submitted file was not readable or in the required form and was rejected by the Board or MACSIS processing.
  • A "significant" number of claims in a batch were judged to be "critical errors" when posting into MACSIS -- in such situations the entire Batch is returned to the Board for review and rehabilitation. In such cases the Provider should be notified by the Board.

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)).

DEFINITIONS:

  1. UPI: Unique Provider Identifier

    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.

  2. Board

    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.

  3. Batch ID

    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.

  4. CS: Claims Status

    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).

  5. PS: Processing Status

    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:

    • AF = Been Adjusted (likely reversed), Been Through Adjudication, but not yet "Check-Posted. These claims will not appear on a ERA or ARA as the Vendor lacks a Positive Total Balance
    • AH = Been Adjusted (most likely reversed) and has been placed on HOLD.
    • AP = Been Adjusted (most likely reversed) and is now Paid.
    • AU = Been Adjusted (most likely reversed) and is now Unposted (awaiting APUPD Handling).
    • DF = Denied and Final.
    • DH = Denied and On-Hold
    • DP = Denied and Paid.
    • DU = Denied and Unposted (Awaiting APUPD Handling).
    • PF = Payable and Final (Awaiting positive Vendor Balance to finish handling).
    • PH = Payable and On-Hold.
    • PP = Payable and Paid (Should appear on ERA and ARA Files).
    • PU = Payable and Unposted (Awaiting APUPD Handling).

  6. Number of Claims

    The number of claims in the Batch under each of the Status categories displayed.

  7. Quantity

    A summary of the "quantity" or units of service of the included claims as provided in the Professional Claims Detail Record (JUTILDM0).

  8. Billed Amount

    Cost of service as submitted in the NSF file from the Provider.

  9. Allowed Amount

    Approved unit cost derived from the Diamond PROCP record.

  10. Co-Pay Amount

    Client sliding fee for payment or flat fee payment.

  11. Other Carrier Amount

    Third-party insurance payments.

  12. Withholding

    Deducted payments for grant funding or non-fee-for-service equivalencies.

  13. Net Amount

    Total amount due Provider.

COMMENTS:

  • Please be sure to understand that the processing statuses containing "Posted to AP" as shown here refer solely events inside of the MACSIS Diamond 725 Product. These statuses do NOT include adjudication and payment processes taking place at the Ohio Department of Jobs and Family Services nor do they indicate that the claims were "paid" by check or voucher as disbursed via the Board's County Auditor.

    In MACSIS language, neither Loop 1 nor Loop 2 events are reflected in the material presented here.

  • Plans are to produce this Claims Status Report the weekend following the true (Calendar) month's end and will be retained for only three months. Prior reporting is not available at this time.

  • The SAS © program used in the report is available upon request.