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PC-ACE user guide section 3
Last Modified: 1/4/2024
Location: FL, PR, USVI
Business: Part A, Part B
Medicare secondary institutional (Part A) claim
• Complete the fields as required on the Institutional claim form. See Section 2 for more information on the Institutional claim completion.
• Click on the Payer Info tab. Verify that the primary insurance is listed as the first payer and Medicare is listed as the second payer. If not correct, cancel the claim and correct the patient's insurance information on the Patient tab in Reference File Maintenance.
• Click on the Billing Line Items tab. Enter the line item charge amounts and total.
• Click on the Diagnosis/Procedure Code tab and type "Y" in the COB? field.
• Click on the Extended Payer tab and select the COB Info Primary sub-tab and complete the following fields:
• In the COB/MIA/MOA Amounts Field
• Type Code “D” and indicate the amount that was paid by the primary insurance.
• Type code "EAF" and indicate the amount that the patient still owes.
• Enter the claim adjudication date. This is the date the primary insurance processed the claim. (i.e. date of the primary explanation of benefits)
• In the Claim Level Adjustments (CAS) fields, enter adjustments. (Adjustments are anything that altered the payment from the primary, i.e. deductible, co-insurance, write offs, non-covered)
Note: CAS fields + the primary paid amount = the total charge.
• Click on the Patient Info & Codes tab. Enter a value code that describes the reason that Medicare is secondary. i.e. “12,” “13,” “41,” etc. Right click the Code field to access the valid options for the field. Information on the proper insurance type codes is provided in
MSP value codes and payer codes (fcso.com).
• When all of the information has been completed, click on Save. If errors exist on the claim, the Edit Validation Errors List window will appear. Double-click on the error message to jump to the error on the claim form.
• Make the corrections and click on Save or Error List to view any additional errors. The Save with Errors option is only available for claims that do not have fatal errors. Fatal errors are indicated on the Errors List with a red X. The Save with Fatal option is available when there are fatal errors. Claims with fatal errors cannot be sent to Medicare.
• Upon saving your claims, you will be returned to the Institutional/Professional Claims Entry screen. Here you may enter a new claim or click Cancel and Yes to go back to the Institutional/Professional Claims Menu.
• Repeat first eight steps to enter additional claims as needed. Click on Close to finish.
Medicare secondary professional (Part B) claim
• Complete the fields as required on the Professional claim form. See Section 2 for more information on the Professional claim completion
Note: Type a “Y” in the COB? field on the Patient Info & General screen to indicate the patient has Medicare as a secondary payer.
• Click on the Insured Information tab. Verify that the primary insurance is listed as the first payer and Medicare is listed as the second payer. If not correct, cancel the claim and correct the patient's insurance information on the Patient tab in Reference File Maintenance.
• Click on the Billing Line Items tab and enter the claim information.
Payment is broken down by service
• Click on the MSP/COB Line 1, 2, 3, etc tab and enter the following information found on the primary benefits statement:
• Service Line Adjudication (SVD) Information:
• P/S –Type "P" to indicate payment information is for the primary insurance.
• Proc – Type "HC" for all Healthcare Common Procedure Coding System (HCPCS) codes.
• Qual/Code – Enter the HCPCS (Procedure) code from the charge line.
• Modifiers – Enter if applicable
• Paid Amount – Enter what the primary insurance actually paid.
• Paid Units – Enter the units that were paid
• Line Adjustment (CAS)
• (Adjustments are anything that altered the payment from the primary, i.e. deductible, co-insurance, write offs, non-covered)
• Note: CAS fields + the primary paid amount = the total charge.
• This is where the difference between the charge and what was actually paid by the primary is entered.
• Group – Right click to select
• Reason – Right click to select. Find a Reason that best describes the reason the amount was not allowed. Be aware that these codes can have end-dates, and only select codes that are still active
• Amount – Amount of Adjustment
• Units – Units
• Adj/Payment Date – Date the primary payer adjudicated the claim
• Click on the Ext. Payer/Insured tab.
• Click on the COB Info (Primary) tab. Enter the appropriate information from the primary benefits statement:
• Paid - paid amount entered in the COB/MOA field with the code of "D"
• Zero payment indicator - right click to select
Note: The service line the cursor is on in the Line Item Details tab will determine the MSP/COB tab line. For example, if the cursor is on line 1, this tab will read as MSP/COB (Line 1). If the cursor is on line 2, the tab will read as MSP/COB (Line 2), and so on. Complete these steps for each line of service.
• Click on the Secondary Payer/Insured tab. Enter the insurance type code that best describes the reason why Medicare is Secondary. Right click on the Insurance Type Code field to retrieve the appropriate values for this field. Information on the proper insurance type codes is listed in Chapter 11 of the EDI Billing Guide.
• Make the corrections and click on Save or Error List to view any additional errors. The Save with Errors option is only available for claims that do not have fatal errors. Fatal errors are indicated on the Errors List with a red X. The Save with Fatal option is available when there are fatal errors. Claims with fatal errors cannot be sent to Medicare.
• Upon saving your claim you will be returned to the Institutional or Professional Claims Entry screen. Here you may enter additional claims or click Cancel and Yes to go back to the Claims Menu screen.
• Repeat first six steps to enter additional claims as needed. Click on Close when finished.
Payment is a flat payment
• Click on the Ext. Payer/Insured tab, and then COB Info (Primary) tab and enter the following information:
• Claim Level Adjustment (CAS)
• Adj/Payment Date
• Paid – paid amount entered in the COB/MOA field with the code of "D"
• Zero payment indicator – right click to select
• Click on the Secondary Payer/Insured tab. Enter the insurance type code that best describes the reason why Medicare is Secondary. Right click on the Insurance Type Code field to retrieve the appropriate values for this field. Information on the proper insurance type codes is listed in Chapter 11 of the EDI Billing Guide.
• When all the information has been completed, click on Save. If errors exist on the claim, the Edit Validation Errors List window will appear. Double-click on the error message to jump to the error on the claim form.
• Make the corrections and click on Save or Error List to view any additional errors. The Save with Errors option is only available for claims that do not have fatal errors. Fatal errors are indicated on the Errors List with a red X. The Save with Fatal option is available when there are fatal errors. Claims with fatal errors cannot be sent to Medicare.
• Upon saving your claim you will be returned to the Institutional or Professional Claims Entry screen. Here you may enter additional claims or click Cancel and Yes to go back to the Claims Menu screen.
• Repeat first nine steps to enter additional claims as needed. Click on Close when finished.
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.
