Community Health Centers (CHC) Setup Process

• Bureau of Primary Health Care (BPHC) Definitions
  
• Patient Setup - Patient Registration and Change Patient Data
  
• Tables Setup
  
• Reports Setup
  
• UDS Billing
  
• UDS Reports

• Defining a Patient
  According to the BPHC Manual, 2008 Revision, Patients are individuals who have at least one encounter during the yearThe term patient is not limited to recipients of medical or dental services the term is used universally to describe all persons provided UDS-countable encounters.
  
  
• Defining a Grantee
  According to the BPHC Manual, 2008 Revision, A grantee is the direct recipient of one or more BPHC grants.
  
  
• Defining a Full-Time Equivalent (FTE)
  According to the BPHC Manual, 2008 Revision, A full-time equivalent (FTE) of 1.0 means that the person worked full-time for one year. Each agency defines the number of hours for full-time work. For example, if a physician is hired full-time and works 36 hours per week, she is a 1.0 FTE. The full-time equivalent is based on employment contracts for clinicians and exempt employees. FTE is calculated based on paid hours for non-exempt employees. FTEs are adjusted for part-time work or for part-year employment. In an organization that has a 40 hour work week (2080 hours/year), a person who works 20 hours per week (i.e., 50% time) is reported as 0.5 FTE. In some organizations different positions have different time expectations. Positions with different time expectations, especially clinicians, should be calculated on whatever they have as a base for that positionFTE is also based on the number of months the employee works. An employee who works full time for four months out of the year would be reported as 0.33 FTE (4 months/12 months).
  
  
• Defining an Encounter
  The definition of an Encounter is critical to accurate UDS reporting. According to the BPHC Manual, 2008 Revision, Encounters are defined as documented, face-to-face contacts between a patient and a provider who exercises independent professional judgment in the provision of services to the patient. To be included as an encounter, services rendered must be documented in a chart in the possession of the grantee.
  
  While this may sound simple in concept, it becomes somewhat complex in application, as a patient may see more than one provider for a variety of services on the same day. A patient may have multiple types of encounters performed within the health center in one day but only one encounter within each Category. The Categories are: Medical Care, Dental, Other Professional, Enabling, Mental and Substance Abuse.
  
  If a patient sees more than one provider for the same encounter type (Service Delivery Location), within one Category, the encounter will only be counted once.
  
  
• Defining a Universal Report
  According to the BPHC Manual, 2008 Revision, The Universal Report is completed by all grantees. This report provides data on services, staffing, and financing across all programs. The Universal Report is the source of unduplicated data on BPHC programs. The Universal Report provides a comprehensive picture of all activities within the scope of BPHC-supported projects. In this report grantees should report on the total unduplicated number of patients and activities within the scope of projects supported by any and all BPHC primary care programs covered by the UDS. The Universal Report includes all individuals who have at least one encounter during the year within the scope of activities supported by any BPHC grant covered by the UDS. In any given category (e.g. medical, dental, enabling, etc.) on Tables 3A, 3B, 4 and 6A of the Universal Report, each patient is counted once and only once, even if s/he received more than one type of service or receives services supported by more than one BPHC grant.
  
  
• Defining a Grant Report
  According to the BPHC Manual, 2008 Revision, The Grant Reports are completed by a sub-set of grantees who receive multiple BPHC grants. These reports repeat all or part of the elements of five of the Universal Report tables. They provide comparable data for that portion of their program that falls within the scope of a project funded under a particular grant. For Grant Reports, grantees provide data on the patients and activities within that part of their program which is funded under a particular grant or was supported by the SBHC program. Because a patient can receive services through more than one type of BPHC grant, and not all grants are reported separately, totals from the Grant Reports cannot be aggregated to generate totals in the Universal Report. For each Grant Report, patients include individuals who have at least one encounter during the year within the scope of a project activities supported by the specific BPHC grant. A patient counted in any cell on a Grant Report is also included in the same cell on the Universal Report.

• Patient Name and Address Information
  On the Patient Name and Address Information screen, complete the Birth Date, Race, and Language fields. This information is used to compile the data for Tables 3A and 3B. For information on completing this screen, see Patient Name and Address Information.
  
  
• Billing Information
  On the Billing Information screen, select the sliding fee schedule that is normally applied to charges for this patient. (This will be overridden if you use a case that has a sliding fee schedule attached to it in Case Management.) For information on completing this screen, see Billing Information.
  
  
• Insurance Policy Information
  You must select the correct insurance carrier and that carrier must be set up correctly to ensure accurate reporting. A patient can have multiple carriers throughout the reporting period. For Table 4, the patients primary (principal) health insurance, covering primary medical care as of the last visit during the reporting period, is reported. According to the BPHC Manual, 2008 Revision, Principal insurance is defined as the insurance plan/program that the grantee would bill first for services rendered. For Table 9, the insurance that was responsible for each date of service is used.
  
  If a patient does not have any insurance and is considered self-pay, do not enter any insurance information on the account. If a patient has insurance at some point during the reporting period, but then becomes self-pay, CGM webPRACTICE automatically reclassifies the charges based on the termination date of the insurance policy. For information on completing this screen, see Insurance Policy Information.
  
  
• Family Income Data DMS Record
  Click DMS in the Action Column to access the Family Income Data screen. This captures which grant(s) each individual patient belongs to. This information is held historically so that each time you review the family income data, a new record can be added with the updated information.
  
  If you register a family member to an already existing account, this information is copied to that family member. After the information is copied, you can edit it to suit the individual family member, if necessary. Each individual family member can belong to different grant programs. The income portion of the Family Income Data screen is always the same for each member of the family, since this is considered to be the income for the entire family.
  
  Although grantees are not required to collect this information more frequently than once during the year, you can update it as frequently as you are made aware of any changes. If this screen is updated during the year, the reports will use the most current information stored. If this information is not entered, it is reported as unknown in Table 4. For information on completing this screen, see Family Income Data.
  
  
• Case Management
  Cases can be utilized to segregate certain types of charges. When you create a Case, you are required to enter a Case Type. This is a user-defined table within CGM webPRACTICE. If you set up a Case Type and a Sliding Fee Schedule with the same name, CGM webPRACTICE applies that Sliding Fee Schedule to any charges posted for Cases entered with that same Case Type.
  
  Example: If you have a Sliding Fee Schedule named ABC and a Case Type named ABC, then when posting charges for Cases that have ABC type, CGM webPRACTICE looks to this Sliding Fee Schedule to determine the discount amount, rather than the normal fee schedule set up in the patients Billing Information screen. For information on completing the Case Management screen, see Case Management.
  
  
• Add Financial Account for Patient
  Sometimes for billing purposes (if the guarantor is different) the need arises to set up a separate account for a patient. You can do this in CGM webPRACTICE by setting up a Financial Account. For UDS reporting purposes, CGM webPRACTICE knows that if an account has multiple financial accounts, it is still the same person and is only counted as one patient according to the BPHC criteria.

• Maintain Adjustment Codes
  If you will be writing off balances as bad-debt select the Bad Debt Write Off check box on all appropriate adjustment codes. Any amount written-off with this adjustment will be included on the Table 9D UDS Report. For information on completing this screen, see Maintain Adjustment Codes.
  
  
• Maintain Capitation Schedule and Enter Capitated Procedure Codes
  Enter capitated insurance plans in the Capitation Schedule Table. This table also includes whether specific codes are 'carved-out' or paid on a 'fee-for-service' basis. For information on completing these screens see, Maintain Capitation Schedule and Enter Capitated Procedure Codes.
  
  
  
• Maintain Doctor Codes
  A valid provider must be used for the visit to be counted as an encounter. For an encounter to be counted for a provider, the provider must be assigned a UDS Provider Type. If you have other personnel that are not defined as a provider, leave the UDS Provider Type field blank. The doctor entered in the Per Dr (Performing Doctor) field in the Procedure Entry Function is the provider that the encounter is credited to.
  
  The providers UDS FTE Equivalent status must also be assigned. For information on completing this screen, see Maintain Doctor Codes.
  
  
• UDS Provider Details (Tables, Doctor Code Table)
  The UDS Provider Details table only includes personnel that are considered providers. The provider that is given credit for the encounter is based on how each clinic weights their providers. The standard weighting used in CGM webPRACTICE is the order shown on the UDS Provider Details screen. If these weights need to be applied differently, this can be discussed during the Implementation process.
  
  
• Maintain Fee Schedules and Maintain Income Based Fees
  Sliding Fee Scale
  Most CHCs apply a sliding fee scale discount to self-pay patients or towards balances that have been reclassified as self-pay. CGM webPRACTICE automatically discounts charges based on the applicable sliding fee scale and the income level of the patient.
  
  When charges are entered for a patient, CGM webPRACTICE checks the patients income level held in the Family Income Data screen and discounts the services based on the sliding fee schedule.
  
  A clinic may have more than one sliding fee schedule. The Types of Service provided may determine which sliding fee schedule is utilized. In the patients Billing Information screen, in the Fee Schedule field, you can select which sliding fee scale is normally applied to charges for this patient. Is this true? Doesnt it just affect if you want to charge Alternate Fees? (There are instances however, that you may need to apply a different type of discount. To accomplish this, see the Case Management information under the Patient section of this document.)
  
  For information on completing this screen, see Maintain Fee Schedules.
  
  Set up the fees for the sliding fee schedule. For information on completing this screen, see Maintain Income Based Fees.
  
  
• Maintain Insurance Carrier Codes
  • If the insurance carrier is a State Child Health Insurance Program (S-CHIP) carrier, you must include the word CHIP somewhere in the Insurance Carrier Name field for that carrier.
  • Make sure you assign the correct Insurance Form Type in the Insurance Form field.
  • Make sure to select the appropriate check box to indicate if this is a Managed Care Plan, PCCM (Primary Care Case Management) Program or a Public Insurance.

 For information on completing this screen, see Maintain Insurance Carriers.

• Maintain Location Codes
  A location in CGM webPRACTICE is also known as a site in the CHC community. You can Suppress Encounters for specific locations. This might be applicable if a provider is primarily conducting outreach and/or group education sessions and not providing direct services. If these services are entered into the billing system, the Loc code entered in the Procedure Entry Function would suppress the transaction from counting as an encounter. You can also override this in the Procedure Entry Function. For information on completing this screen, see Maintain Location Codes.
  
  
• Maintain Procedure Codes
  You can prevent specific procedures from being counted as an encounter by selecting the UDS Suppress check box. You can override this in the Procedure Entry Function.
  
  You can also charge a minimum fee (flat fee) by procedure code. For example, if your practice charges a flat fee of $20.00 for 99213, type 20.00 in the Nominal Fee/Cost $ field. This field works within an order hierarchy with three other fields (Nominal Fee $ in Type of Service Table, Medical Fee $ in the Family Income Data DMS Record, and Medical Fee $ in UDS Integration). Determining which fees take precedence is discussed during Implementation, as they can vary by clinic.
  
  For information on completing this screen, see Maintain Procedure Codes.
  
  
• Maintain Type of Service Codes
  You can Suppress Encounters for specific types of service. The general types of service are:
  • 1 - Medical Care
  • 2 - Surgery
  • 3 - Consultations
  • 4 - Radiology
  • 5 - Laboratory Services
  • 6 - Radiation Therapy
  • 7 - Anesthesiologist
  • 8 - Assistant Surgeon
  • 9 - Other Medical Services
  
  You can expand on these categories and still print the correct category on the claim form by entering the correct Type of Service code in the appropriate Alternate Type of Service field. For example, you could set up a separate Type of Service Code for immunizations. Then you would assign the correct general type of service code in the HCFA Alternate Type of Service field and select the Suppress Encounters check box. All procedures attached to this Type of Service would then not count as encounters, unless specifically overridden during procedure entry.
  
  You can also charge a minimum fee (flat fee) by type of service. For example, if your practice charges a flat fee of $10.00 for Immunizations, type 10.00 in the Nominal Fee $ field. This field works within an order hierarchy with three other fields (Nominal Fee/Cost $ in Procedure Code Table, Medical Fee $ in the Family Income Data DMS Record, and Medical Fee $ in UDS Integration). Determining which fees take precedence is discussed during Implementation as they can vary by clinic.
  
  According to the BPHC manual, encounter criteria are not met when the only services provided are lab tests, x-rays, immunizations, TB tests and/or prescription refills. Therefore, if an immunization is entered into CGM webPRACTICE by itself, it would not be counted as an encounter. For information on completing this screen, see Maintain Type of Service Codes.
  
  

• UDS Integration
  You can discount balances owing on patients that have insurance. For information on completing this screen, see UDS Integration.
  
  

• Procedure Entry Function (Transactions)
  The encounter types are determined by the UDS Provider Type selected in the Doctor Code Table for the doctor entered in the Per Dr field on the Procedure Entry Function detail screen.
  
  If a Sliding Fee Schedule applies, when charges are entered for a patient, CGM webPRACTICE checks the patients income level held in the Family Income Data screen and discounts the services based on the sliding fee schedule.
  
  NE Modifier:
  If a visit should not be counted as an encounter, post the procedure using the NE (Not an Encounter) modifier. Using this modifier overrides all other encounter settings in all of the other tables. The NE modifier does not print on claim forms.
  
  IE Modifier:
  If a visit should be counted as an encounter, post the procedure using the IE (Is an Encounter) modifier. Using this modifier overrides all other encounter settings in all of the other tables. The IE modifier does not print on claim forms.
  
  
• Contracted Rates
  Medicaid normally has special rules depending on your state. Typically, on a Medicaid patient, the contracted rate and not the individual charges are billed to the insurance carrier. CGM webPRACTICE has the ability to either write-off the charges billed, and replace them with a single charge (sometimes referred to as a T code - generally T1015), or write-up or down to the contracted amount. What normally appears on the claim form is the single line item for the date of service for the contracted amount.
  
  NOTE: If charges are being written-off and replaced with a single code, this can inflate the productivity figures. The T code should be put in a separate category (Type of Visit), to easily distinguish and separate it from the normal productivity.
  
  Other clinic specific requirements will be discussed during Implementation.

• Compile UDS Reports (Reports > UDS Reports)
  
  The UDS Reports are the reports needed for the Universal Report and the individual Grant Reports. The Compile UDS Reports function provides all the necessary options for selecting the report criteria and indicating which report(s) you need to prepare.
  
  For the Universal Report, all individuals receiving at least one encounter for services within the scope of the four programs covered by UDS are included.
  
  The Grant Reports include only individuals who received at least one encounter for the program selected. Patients will be reported only once for each report filed, however, if the same patient is served in more than one program, they will then be reported on the Grant Report for each program that served them.
  
  For information on completing this screen, see Compile UDS Reports.
  
  The UDS reports compile in the background so you can continue working in other functions. A message displays when the reports are compiled and ready to print. You must refresh the screen by clicking another menu or function before this message will display.
  
  
• Print UDS Reports
  Select check box(es) next to the report(s) you want to print and click Save. The report automatically prints to screen and you can print it to your printer from there. For additional information, see Print UDS Reports.
  
  
• Auditing UDS Reports
  A sample report for Table 6A is displayed below. The number of Encounters and the number of Users (Patients) are displayed in blue type. You can click any of the blue-type results to view the detail for those results. This methodology allows you to take snapshots of your data for any date or range of dates and validate your data. You can run these reports as often as needed.