Last
updated 7/12/2007
Insurances Module
This chapter
covers the following area of this module...
- Name and Address
- Provider Numbers Links and
Notes
- Billing Information
- Electronic
Claims Submission
Information
Each section
on the data entry screen is discussed. If you need help click the Help
me!
button to get on-screen help! Unless we imported insurance records for
you, the software comes loaded
with only a few common carriers for demonstration. There is a record
for your local Medicare (MED1),
Blue
Shield (BLU1), Federal Employment Program (FEP), Aetna (AET1) and
United Healthcare
(UNI1). Complete these records before adding others!
Name
and Address
- Name is the full name of the company and
should not go beyond the field size.
-
Code identifies this carrier and
will be calculated when you create a new record. This
calculation will ignore the first word “The” and create the code. Your
first Blue Shield
would have the code BLU1. The Hartford, however,
would
have the code HAR1. You
can
change the code by clicking into the field and
reading
a warning message!
- The Reference Qualifier (previously
called "Source Of Pay") is used to identify the insurance and the type
of provider number used to submit claims.
There are three
separate sets of address fields for each record. These are the Claim Address, Contact Address, and Other Address.
- Addr
1 contains the MOST specific portion of the
address, such as a PO Box, which is absolutely needed for mail to reach
the company. POB (which stands for P.O. Box) appears as
the default for every new record and should NOT be changed to PO Box or
anything else if used.
- Addr 2 contains the least
specific part of the
address, especially when a POB (most specific) is used in addition to a
street
address (least specific). If a POB is used this part of the
address
is NOT NEEDED!
- The Zipcode is for the...zip code. If no City
and State fills in, complete the fields. Doing so creates a new
record in the Zipcodes Module.
- Contact Name is
for the name of the person to contact at this address. Checking off the
box next to the field adds this contact information below the full
address for this section
The remainder of the fields
will be the same for each record. Each of the non-fax phone numbers
fields have an Ext field for
extension or extra information...
- Phone is for the general
phone number.
- There is separate field for the Eligibility phone
number.
- The Precert
phone number is a separate entry.
- The Fax is for the fax number of this carrier.
If you have your modem connected you can dial the phone number by
clicking the associated phone icon (Mac OS9 and Windows only).
- In Email and Web site enter the pertinent
carrier's information. If your computer is web enabled, click the web
icon
opens your web browser to the URL for that carrier.
Provider
Number Links and Notes
PracticeMaker® supports
unlimited providers in the office.
Each provider can have up to 27 different insurance numbers, including Blue Shield, Champus, Medicaid, Medicare, UPIN and many more. With the advent of
HIPPA, and the National Provider Identifier (NPI, select 26), these
other provider numbers may one day be obsolete.
- In Link to Provider No
select which of the 27
provider numbers will be used for this insurance.
- If instructed to do so by technical support, select a Provider ID Qualifier that is
different from the Reference Qualifier
in the top section.
- In Consultant Link select which provider number
field will be used to link a referring provider to a claim. For
example, with Medicare this field should be UPIN, but
with Medicaid it would be Medicaid.
- For Group is for the group
provider number under which the entire practice needs to bill. The
group
ID entered here is used on both paper and electronic claims. On the
HCFA/CMS
1500 this appears in Box 33 in the Grp# section. The individual
provider's
number will appear on each line charge (Box 24K) on the individual line
item
sent electronically.
- The scrolling text field below these fields is for
additional information.
- In Special Formatting Requirements enter any
special information that you want to pop-up during insurance selection
in the Coverages Module.
Billing
Information
- Assignment determines if
you accept assignment on
insurance’s claims (No or Yes).
- When Auto-Bill is selected Yes, an
insurance claim will be generated AFTER the primary insurance has paid
its share AND and this insurance has been selected as the next Balance
Due From source.
This is specifically to be used for Medicare patients when you want to
automatically
bill the secondary. This automatic printing will occur only
ONCE.
Thereafter its need to be done manually.
- Referrals flags this insurance carrier as
requiring a referral for each visit.
- TOS Type needs to be selected from the pop-up
list. Each procedure code can be assigned THREE different Type Of
Service codes (TOS, TOS2 and TOS3). Since many insurance carriers, like
Medicaid, want you
to use THEIR TOS codes. PracticeMaker® gives you three choices.
Once the
ANSI X12 transaction set is standard (HIPAA) only one TOS will
be
needed.
- The Fee Schedule is selected to
determine which of 15 possible fee schedules will be used for this
carrier. It is NOT necessary to use multiple fee schedules. If
you do use multiple schedules, fee schedule A(1) has been
pre-selected to be for patients (or “self-pay”). If you do not
use multiple fee schedules then all claims will go to the patient side
of the invoice. We therefore recommend that if you will be
billing insurance, and will have just one fee schedule, use fee
schedule P(4) for private pay!
- List Sort determines how this carrier usually
sorts its EOBs. The selected sort order will used used when
PracticeMaker® creates
a report.
- Ins Type should be
selected from the pop-up
list. The most important choices are MP for Medicare
Primary, MG for Medigap and SP For Supplemental.
Medicare
will only give complimentary crossover to “true” medigap policies.
- Form
assigns a claim form
the insurance form that
this carrier's claims will be printed on.
- In CMS
1500 Printing Specifications are some checkboxes to determine
what elements are not printed for this insurance.
- Affiliate just flags this
insurance as a member
of a larger organization. It is used internally only for special
reporting. Select the parent company from the list of
abbreviations. To add new affiliates do so in the PickList User
database. The Affiliate Memo
field is used to describe the selection.
- Crossover flags the insurance as
definitely
having complimentary crossover and not requiring certain electronic
claims “edits”.
- Cycle selects how often this carrier's unpaid
claims will be either re-printed OR sent again electronic (either in
the next “batch” processing). The default is ONE (1) month! Every time
you "age" your accounts this "cycle" feature is used to decide which
claims get billed and which are
ignored.
- Del Age determines how many years you MUST hold
an invoice before you can delete it. The
default is THREE (3) years!
- Max LIs is the maximum number of line charges you
can have on a claim for this carrier. The software will beep you
when you approach this limit!
- POS Type needs to be selected from the pop-up
list. In the PickList Module you can change the value in
this list. Once the ANSI X12 transaction set is
standard (HIPAA) only one POS will be needed.
- Allow Schedule has a list of currently available
codes that links insurance company reimbursements under one schedule.
For example, Medicare of PA and Medicare Railroad both pay the same for
each procedure. Therefore, the "MCR" allowance schedule I created would
be used or both.
- The fields W'Hold%,
W'Hold Adj, and Deduct
are fields used practices that have special withhold arrangements with
the carrier.
- Capitated flags this carrier as being a capitated
carrier. This will help in the future for special reporting.
PracticeMaker® will calculate an automatic adjustment for any
insurance
services on an invoice and post it to an invoice.
Electronic
Claims Submission
Information
- ECS# if Pri identifies
which electronic claims
“address” this carrier's claims can be sent to when the carrier is the
primary insurance on a claim. Medicare is always #1, Blue
Shield #2 and your clearinghouse is #98, regardless of which one
you use.
- ECS if Sec tells
PracticeMaker® to send the
claim electronic when this carrier is NOT the primary insurance.
Some carriers will not accept secondary claims via ECS.
- EClaims Name is
the name transmitted when you send claims electronically. For
example, in Pennsylvania Highmark Blue Shield wants all insurance names
submitted to them to have "Highmark" as the insurance
name. The Iplexus clearinghouse will use this name to group claims for
transmission and not the NAIC Code.
- Claim Filing Indicator (previous called Product
line) needs to be properly selected to each insurance. Most times
the description is very close to the description of the Reference Qualifier.
- NAIC is the National Association of Insurance
Commissioners code assigned to this insurance company. This code is
REQUIRED if you intend to submit commercial claims via EClaims and is a
5 digit number.
- MG Code is the code assigned to an insurance
carrier if it is an approved “medigap policy” with Medicare.
These insurances receive electronic information from Medicare about how
they processed a claim.
- Group Required tells the system that a
group number is required for EClaims processing and MUST be entered
when you create an insurance record for a patient. This is the default for
each new record.
Legacy Fields
The following fields are not used with the current ANSI X12
transmission standard.
- NAIC Suffix may be required
for EClaims
processing.
- Claim Office is filled when
required for a
commercial claim carrier.
- Batch ID may be required for
EClaims processing.
- Document Indicator is assigned
to a claim when it
is first created IF it is required and IF sent
electronically.
