BIR Workflow

Bulk Bill reconciliation takes place between the vendor's PMS and Medicare. Tyro only controls the submission of claims via Easyclaim, at the time of service.

We hope the following assists with a vendor's scoping of how to build BIR.

What can be retrieved from Medicare

• Process status of a claim.
• Amount for a claim.
• Payment date/Payment run for a claim if it has been processed.

What can NOT be retrieved from Medicare

• When will a claim be paid if it has not been paid in a payment run.

Tyro's Observation

1. Medicare will process an arbitrary amount of claim transactions, group them in a payment run, and payout.
   • We do not know how medicare group these claim transactions.
   • We can only find out when medicare will pay once it has been paid via a payment run.
2. Some claims may take multiple days to be processed by medicare
3. We are unclear of the exact classification of the settlement date for a given claim.

Given the scenario below

• Provider did 10 claims for Day1 $10 each total of $100.
• Claim 1~10 gets put into ClaimBatchA001.
• On Day2, medicare reports Claim 1~8 processed with total $80 paid in PaymentRunA.
• On Day3, medicare reports Claim 9 processed with total $10 paid in PaymentRunB.
• On Day4, medicare reports Claim 10 rejected

We believe what may happen with vendors is on Day2, they try to match $80 payment from medicare with $100 expected for their nominated 'batch'.

• On Day3, they try to match $80 + $10 with $100 expected.

Since medicare does not do a payment run with the same transactions they have in a batch, the reconciliation does not match.

Recommended Approach

• Do not assume you can group a number of claim transaction and assume Medicare will pay for all transactions in the group in a single payment run.
• Reconcile each claim transaction individually

It probably should be like the following:

• On Day2, retrieve payment report for ClaimBatchA001 (this means check payment/process for each individual Claim 1~10, Medicare does not have concept of this ClaimBatchA001).
• Claim 1~8 as reconciled and paid.
• Report should show ClaimBatchA001 as $80/$100 paid. with $20 pending. Status: PENDING PAYMENT.
• On Day3, retrieve payment report for ClaimBatchA001. (this means check payment/process for Claim 9 and 10 only).
• Should mark Claim 9 as reconciled and paid.
• Report should show ClaimBatchA001 as $90/$100 paid, with $10 pending. Status: PENDING PAYMENT.
• On Day4, retrieve payment report for ClaimBatchA001. (this means check payment/process for Claim 10 only).
• Medicare has rejected Claim 10.
• Report should indicate ClaimBatchA001 as $90/$90 paid. $10 rejected. Status: EXCEPTION!