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Add an Insurance Payer

Version 20.5
Path: Billing tab > Payers button

Overview

Insurance Payers may be added to OP by users with the appropriate permission. The sections below contain information on entering information into each section of the Insurance Payer Details window. The fields described may also be edited in this window. When entries or edits are complete, click the Save button to save the payer. If a new payer was added, be sure to also connect providers to Insurance Payers.

User Permission: Users must have permission: Billing_Payers_Modify to add an insurance payer.

WarningSELF-PAY must remain in the payer list. OP automatically assigns patients to the SELF-PAY payer if they do not have insurance or their insurance is not ranked.

Expand each section below to learn how to add an insurance payer. 

Basic Information Tab

This tab contains the Insurance Payer's address, contact, and basic setup information.

  1. Navigate to the Insurance Payers List using the path above.
  2. Click the New button. The Insurance Payer Details window opens to the Basic Information tab.

  1. Complete the following:

Basic Information Field
Description
Short Code This must be a unique code that helps you identify the payer. When assigning this code, you can use any characters. This value cannot be changed once the new record has been saved. Most practices create a mnemonic code, using characters that closely resemble the payer. For example, BC1, BC2, etc. for Blue Cross payers, and UHC1, UHC2, etc. for United Healthcare payers.
Short Name This is a shorter (up to 15 characters) version of the payer's name that is displayed on many lookup lists within OP. It is a user-defined field, and should be an abbreviation of the payer name that is easily recognized by staff when selecting an insurance for a patient. For example, Blue Cross/Blue Shield of Florida could be entered as BCBS FL.
Full Name/ Address This is the name and address of the payer as you would expect it to be displayed on the top of a HCFA/CMS 1500 form for claim-mailing purposes. City, State and Zip code (9 digits, no dash) are required. The Full Name field must not include any special characters, such as :, -, or /. The presence of special characters may cause 837 claim files to be rejected by your clearinghouse. If a directive such as, "Attn: Claims Dept." is necessary, add that information to the Address line prior to the physical address. 
Contact Name/Phone/NoteOptional reference fields to help you contact the payer for claim status, eligibility, etc.
Active StatusWhen entering a new payer record, the payer status defaults to Active. Select the appropriate radio button:
  • Active for all: All providers are credentialed with this payer and have been associated to the payer.
  • Active for some: Not all providers are credentialed with this payer and only those who are credentialed have been associated to the payer. Payers marked Active for some are highlighted in grey in the Insurance Payers List. 

Note:  If your OP version is prior to OP 20.5, creation of block and substitute rules is disabled for the payer when Active for some is selected. OP AWARE rules in version 20.5 and higher can be created.


  • Inactive: This payer is not being used by the practice at this time. Payers marked Inactive are highlighted in red in the Insurance Payers List as long as the hide inactive box is not selected.
Start Date/End DateSelect the date when your office initially contracted with this payer or stopped accepting this insurance.
Fee ScheduleSelect the chargeable fee schedule associated with this payer's claims.
VFC EligibilityIf the payer participates in the Vaccines for Children (VFC) program, select the appropriate VFC Eligibility value from the drop-down menu. For most commercial payers, select 5/NOT ELIGIBLE.
Pat resp typeClick this drop-down menu to select a value applicable for the payer.
Show on PortalSelect this checkbox if your office has an active patient portal, and you want this particular payer listed as a contracted payer as viewable by your patient base. Note: This is not applicable to the OP Patient Portal, powered by InteliChart.
Charges - PATIENT RespSelect this checkbox to indicate that all charges for this payer are the responsibility of the patient.

Note: To edit a payer's Short Code Name, plan on doing so outside of normal business hours as it may take several hours to complete.

  1. From the Insurance Payers List, select the payer to edit.
  2. Click the Change/Merge Code button. 
  3. In the Change/Merge Carrier Codes window under New Code type in the new Short Code for the payer. There is a six character limit in this box.
  4. Click Continue. 
  5. Review the changes and click the Save button at the bottom of the window.

Payer Coding Rules Tab

The rules defined in this tab are applied:

  • When the Post All or Post Selected button is pressed. Therefore, the additions to superbills via Payer Coding Rules are not displayed when the charges are in superbill form. The rules are only displayed when the superbills charges have been converted to a claim.
  • After OP AWARE rules created for this payer are applied. For more information on creating OP AWARE rules for an insurance payer, click here.
  1. Click the Payer Coding Rules tab.

  1. Complete the following:

Payer Coding Rules FieldDescription
Immunization administration- coding rule overrideThis selection is based on this payer's known requirements and is used to override your system preference for a particular payer once the Superbill has been converted to a claim. If the payer adheres to your system preference, you do not need to make a selection in this field. Select Use global preference.
  • 90460/1, Pairwise antigens: Each vaccine billed will have its own set of administration codes, 90460 and 90461 (when applicable), as appropriate per the number of antigens in said vaccine.
  • 90460/1, Total antigens: 90460 and 90461 (when applicable) will each appear once on the claim with the total number of units as appropriate for the total of the vaccines on the claim. 
  • 90460/1, Pairwise doses: Each vaccine billed will have its own set of administration codes, 90460 and 90461 (when applicable), as appropriate per the doses in said vaccine.
  • 90460/1, Total Doses: 90460 and 90461 (when applicable) will each appear once on the claim with the total number of units as appropriate for the total of the vaccines on the claim.
  • 9047x, Force non-counseled: The non-counseled immunization administration codes will be applied.
  • None (withhold): Immunization administration codes will not be added to claims with vaccines.
Include NDC on vaccine productsSelect this checkbox if when billing vaccines for this payer, the NDC# should be included on the claim.
Unit type for included NDCs on vaccine productsSelect the unit type if including the NDC on vaccine products. The default value set here is milliliter, but should be changed, if necessary.
Auto-populate Z23 on vaccine productsThis checkbox is selected by default to auto-populate diagnosis code Z23 on claims and apply it to vaccine products. If this is not appropriate for the selected payer, deselect the checkbox.
Auto modifier -25 on well visitsSelect this checkbox if when you bill vaccines with a preventive visit for this payer, you include a 25 modifier on the preventive visit CPT.
Auto modifier -25 on E&M with proceduresThis checkbox is selected by default to automatically add a -25 modifier to sick visits with procedures. Procedures are defined as:
  • CPT Codes 0xxxx through 6xxxx
  • CPT Codes 92550-92588
  • CPT Codes 99173-99177
  • CPT Codes: 961xx
  • CPT Code 94760

If this is not appropriate for the selected payer, deselect the checkbox.

Auto modifier -33 on preventiveSelect this checkbox if when you bill preventive visits to this payer, you include the 33 modifier on the preventive services CPT code(s).
Modifier for telehealth services

(If applicable) Select the payer-required Modifier for Telehealth services. The default selection is 95 but should be changed as needed, according to the payer's specific guidelines.

Auto-populate service location when no facility specified
Select this checkbox to automatically populate Box 32 when nothing else is populated on the claim. By default, this checkbox is not selected.
Auto-populate PCP as referring provider
Select this checkbox if the payer requires the patient's PCP to be the referring provider in Box 17 on claims. The payer preference will override the selection made in Locations. By default, this checkbox is not selected.
Override POS, non-telehealthSelect the default Place of Service for non-telehealth visits.
Override POS, telehealth

(If applicable) Select the Place of Service that should override POS for telehealth services. The selection made here overrides the implied POS, 02 Telehealth, for visits where the Telehealth information has been populated in Visit Info.

Claims/Routing Tab

This tab contains information for how claims for the Insurance Payer should be transmitted to ensure timely receipt and processing. It also includes how different types of transactions, such as eligibility and claim status, are received into OP.

  1. Click the Claims/Routing tab.

  1. Complete the following:

Claims/Routing Field
Description
National Payor ID
This number is mandatory for electronic claim submission. This number is usually a 5-digit NAIC code, but some clearinghouses assign their own special value for certain payers. If you are using a clearinghouse to reach the payer, always check the clearinghouse's official Payer List for the value to put in this field.
Claim Payor IDThis number is mandatory for electronic claim submission. This number is either assigned by your clearinghouse, or it is the same as the National Payor ID. Your office must verify if your clearinghouse assigns their own numbers to certain payers. Contact your clearinghouse for their specific Payer ID lists.
Real-time IDEnter only if you are set up for real-time eligibility within Office Practicum. This number is either assigned by your clearinghouse, or is the same as the National Payer ID. Your office must verify if your clearinghouse assigns their own numbers to certain payers, especially Medicaid and Blue Cross. Contact your clearinghouse for their specific payer Real Time ID lists.
Claim type The Claim Type is necessary in order to report the correct insurance qualifier on claims. A missing or incorrect Claim Type may cause claim rejections. The most commonly used payer types are: Cl - commercial payers, BL - Blue Cross/Blue Shield, MC - Medicaid, CH - Champus/Tricare, AM - automobile (for accidents), WC - workers compensation, and Self-pay.
Claim formatIf billing institutional claims for this payer (UB04's), select the Institutional radio button.
Billing LoopThis field identifies what billing information is sent on your claims. This information pertains to field 33 on a standard HCFA/CMS 1500 form. You can select one of the following: Practice NPI Only, Practice NPI plus Payer Assigned ID, Practice Payer Assigned ID only, Provider NPI Only, Provider NPI plus Payer Assigned ID, or Provider Payer Assigned Only. Your selection should be based on your knowledge of the particular payer's requirements for electronic and/or paper claim submission.  If you are selecting Practice NPI only in this field, you must visit Group NPI Setup to determine what fields to populate with your Practice/Group NPI to ensure it is correctly rendered on claims.
if EPDST (As it relates to the Billing Loop): The system default for EPSDT claims is set to Same as NON-EPSDT which means that the selection is identical to the selection made in the Billing Loop as listed above. This field pertains only to those offices that participate with Medicaid plans and are required to adhere to EPSDT guidelines. If a selection is made from this drop-down, that value replaces the Billing Loop selection. For example, if a payer's Billing Loop is set to Practice NPI Only, and the if EPSDT field is set to Provider NPI only, the Provider NPI is placed in the Billing Loop of claims. To change the default, click the drop-down menu to the right of the text If EPSDT and select an alternate option.
Render LoopThis field identifies what rendering provider information is sent on your claims. This information pertains to field 24 on a standard HCFA/CMS 1500 form. You can select one of the following: Provider NPI Only, Provider NPI plus Payer Assigned ID, Provider Payer Assigned ID only, Provider NPI plus Tax ID , Provider NPI plus Tax ID plus Payer Assigned ID, Provider Payer Assigned plus Tax ID, or Suppress (which means that you are not sending/printing rendering provider information on your claims for this payer). Your selection should be based on YOUR knowledge of the particular payer's requirements for electronic and/or paper claim submission
if EPSDT (As it relates to the Render Loop): The system default for EPSDT claims is set to Same as NON-EPSDT which means that the selection is identical to the selection made in the Render Loop as listed above. This field pertains only to those offices that participate with Medicaids and are required to adhere to EPSDT guidelines. If a selection is made from this drop-down menu, that value replaces the Render Loop selection. For example, if a payer's Render Loop is set to Provider NPI Only, and the if EPSDT field is set to Provider NPI + tax ID, the Provider NPI + tax ID is be placed in the Render Loop of claims. To change the default, click on the drop-down to the right of the text If EPSDT and select an alternate option as appropriate.
CLM12 ExcludeSelecting this checkbox causes the CLM12 segment to be blank on the 837. The field is defaulted to deselected, which means the CLM12 segment on an 837 for an EPSDT claim has an 03 value indicating a Special Federal Funding. According to the 5010 standard, the CLM12 is situational and the value of 03 only applies to most Medicaid payers. 
EPSDT GroupThis field pertains only to those offices that participate with medicaid and are required to adhere to EPSDT guidelines. An entry in this field overrides the policy Group name.
Accepts ICD 10Select the checkbox if this payer accepts ICD-10 codes. Set date when the payer starts accepting ICD-10. As a reminder, ICD-10 replaced ICD-9 coding on October 1, 2015.
Suppress NPID on service location

Select the checkbox to Suppress NPID on service location when the NPI of the location on the claim (either Practice or Facility location) is the same as the Billing Provider NPI on claims for the payer.  

Note: In the boxes to the right of the loop fields, click to select if your payer requires TAXONOMY information to be sent along with the information previously identified in the corresponding loop. In the box above the field EPSDT Group, click to select if your payer requires TAXONOMY information to be printed on the standard HCFA/CMS 1500 form. For more information on Taxonomy Fields in OP, visit Taxonomy Fields.

Claims/Routing Tab: Transaction Routing

If your office is contracted for Full HIPAA Transaction services (e-Billing), you must complete the Transaction Routing section of the Claims/Routing tab. Transaction Routing is used only for practices that are sending ANSI 837 claim files. Meaning, if the majority of your payers claims are submitted electronically to a clearinghouse, then the default is defined as such. The following section allows you the opportunity to override system defaults for a particular payer.

  1. Edit the following Transaction Routing fields, only if you are overriding the system default for the specified transmission.

Transaction Routing Field
Description
Claims Transmission (primary)
Used to select an alternative for claim submission to primary payers. If paper claim submission is preferred by the payer, use the drop-down to select Standard HCFA.
Claims Transmission (secondary)Used to select an alternative for claim submission to secondary payers. Most often, this selection is Standard HCFA because most payers require paper claims to accompany primary payer EOBs in order to process secondary claims.
Claim Adjudication (835)Used to select an alternative for downloading Electronic Remittance Advice. This selection is different from the default if, for example, a payer does not provide this service.
Claim status (276/277)Used to select an alternative for downloading claim acknowledgment and status information.
Eligibility & benefits (270/271)Used to select an alternative for downloading Eligibility and Benefits information. This selection is different from the default if, for example, a payer does not provide this service. In that case, select Standard HCFA, so the system knows not to send electronic eligibility requests.
Referrals & pre-auth (278)Used to select an alternative for uploading Referral and Pre-Authorization requests. This selection is different from the default IF, for example, a payer does not provide this service. In that case, select Standard HCFA so OP knows NOT to send these electronic requests.
Send Eligibility AsEnter the name of the provider or practice under which your office is recognized by this payer in order to send properly formatted Eligibility & Benefit requests. If entering a practice name, use only the field directly to the right of the Send Eligibility As field. If entering a provider name, enter the last name of the provider followed by their credentialed initials (MD, for example) in the field directly to the right of the Send Eligibility As field and enter the first name of the provider in the field to the right of the field where the last name was entered.
Primary ID (for eligibility)This field pertains to the type of ID number under which your office is recognized by this payer in order to send properly formatted Eligibility & Benefits requests. To the right of this selection, enter the corresponding ID number.

See the TIP below for information on copying the entries from one payer to another.
Secondary ID (if necessary)This field pertains to a secondary type of ID number under which your office is recognized by this payer in order to send properly formatted Eligibility & Benefits requests. To the right of this selection, enter that ID number. Most often, a secondary ID is not required by payers for Eligibility & Benefits requests, so these secondary ID fields may remain blank.
Service Type for eligibilityThis field is used to identify the Service Type which dictates the Medical Benefits and Copay information produced by the clearinghouse upon insurance validation.
  • 30: Health Benefit Plan Coverage: Returns general insurance information, but the co-pay may be inaccurate for primary care. 
  • 98: Professional Physician Visit-Office: Returns insurance information specific to physician office, often delivers the best co-pay information. This is typically the code for all payers. 
  • 96: Professional (Physician): Similar to 98, but is typically only used when the information returned by 98 is not accurate.
Always send dependent eligibility as guarantorSelect this checkbox to send the patient's information as if they were the guarantor for the insurance policy. This is especially common for Cigna insurance policies where each patient has their own unique identification number suffix and the relationship to subscriber is SELF.
Policy ID not required when checking eligibilityThis checkbox should remain BLANK. This is not yet a functional piece of eligibility setup. It is a foundation piece that is used for future system enhancements. Users should not expect this to function at this time.

Tip: Once the Primary ID for Eligibility field entries have been entered for one Payer, they can easily be copied and applied to other Insurance Payers:

  1. Close the Insurance Payer Details window.
  2. In the Insurance Payers List window, sort the payer list so that the payer you will be copying from is listed above the payer you are copying to. Because the Insurance Payers List is listed alphabetically, you can click the column header for the Payer Short Name column to change the listing from ascending to descending order in order to get the correct payer listed first.
  3. Select the Payer whose Eligibility ID information you want to copy.
  4. Click to select the Payer(s) who the Eligibility ID information will be copied to. If the payers are listed one after another, use Shift on the keyboard to select all payers. If they are separated by other payers in the list, use CTRL on the keyboard and select each payer.
  5. Click the Elig button. A confirmation pop-up box is displayed. 
  6. Click the OK button. 
  7. Review and click the OK button in the Information window that is displayed.

Version 20.4
Path: Billing tab > Payers button

Overview

Insurance Payers may be added to OP by users with the appropriate permission. The sections below contain information on entering information into each section of the Insurance Payer Details window. The fields described may also be edited in this window. When entries or edits are complete, click the Save button to save the payer. If a new payer was added, be sure to also connect providers to Insurance Payers.

User Permission: Users must have permission: Billing_Payers_Modify to add an insurance payer.

WarningSELF-PAY must remain in the payer list. OP automatically assigns patients to the SELF-PAY payer if they do not have insurance or their insurance is not ranked.

Expand each section below to learn how to add an insurance payer. 

Basic Information Tab

  1. Navigate to the Insurance Payers List using the path above.
  2. Click the New button. The Insurance Payer Details window opens to the Basic Information tab.

  1. Complete the following:

Basic Information Field
Description
Short Code This must be a unique code that helps you identify the payer. When assigning this code, you can use any characters. This value cannot be changed once the new record has been saved. Most practices create a mnemonic code, using characters that closely resemble the payer. For example, BC1, BC2, etc. for Blue Cross payers, and UHC1, UHC2, etc. for United Healthcare payers.
Short Name This is a shorter (up to 15 characters) version of the payer's name that is displayed on many lookup lists within OP. It is a user-defined field, and should be an abbreviation of the payer name that is easily recognized by staff when selecting an insurance for a patient. For example, Blue Cross/Blue Shield of Florida could be entered as BCBS FL.
Full Name/ Address This is the name and address of the payer as you would expect it to be displayed on the top of a HCFA/CMS 1500 form for claim-mailing purposes. City, State and Zip code (9 digits, no dash) are required. The Full Name field must not include any special characters, such as :, -, or /. The presence of special characters may cause 837 claim files to be rejected by your clearinghouse. If a directive such as, "Attn: Claims Dept." is necessary, add that information to the Address line prior to the physical address. 
Contact Name/Phone/NoteOptional reference fields to help you contact the payer for claim status, eligibility, etc.
Active StatusWhen entering a new payer record, the payer status defaults to Active. Select the appropriate radio button:
  • Active for all: All providers are credentialed with this payer and have been associated to the payer.
  • Active for some: Not all providers are credentialed with this payer and only those who are credentialed have been associated to the payer. Payers marked Active for some are highlighted in grey in the Insurance Payers List. 

Note:  If your OP version is prior to OP 20.5, creation of block and substitute rules is disabled for the payer when Active for some is selected. OP AWARE rules in version 20.5 and higher can be created.


  • Inactive: This payer is not being used by the practice at this time. Payers marked Inactive are highlighted in red in the Insurance Payers List as long as the hide inactive box is not selected.
Start Date/End DateSelect the date when your office initially contracted with this payer or stopped accepting this insurance.
Fee ScheduleSelect the chargeable fee schedule associated with this payer's claims.
VFC EligibilityIf the payer participates in the Vaccines for Children (VFC) program, select the appropriate VFC Eligibility value from the drop-down menu. For most commercial payers, select 5/NOT ELIGIBLE.
Pat resp typeClick this drop-down menu to select a value applicable for the payer.
Show on PortalSelect this checkbox if your office has an active patient portal, and you want this particular payer listed as a contracted payer as viewable by your patient base. Note: This is not applicable to the OP Patient Portal, powered by InteliChart.
Charges - PATIENT RespSelect this checkbox to indicate that all charges for this payer are the responsibility of the patient.

Note: To edit a payer's Short Code Name, plan on doing so outside of normal business hours as it may take several hours to complete.

  1. From the Insurance Payers List, select the payer to edit.
  2. Click the Change/Merge Code button. 
  3. In the Change/Merge Carrier Codes window under New Code type in the new Short Code for the payer. There is a six character limit in this box.
  4. Click Continue. 
  5. Review the changes and click the Save button at the bottom of the window.

Payer Coding Rules Tab

  1. Click the Payer Coding Rules tab.

  1. Complete the following:

Payer Coding Rules FieldDescription
Immunization administration- coding rule overrideThis selection is based on this payer's known requirements and is used to override your system preference for a particular payer once the Superbill has been converted to a claim. If the payer adheres to your system preference, you do not need to make a selection in this field. Select Use global preference.
  • 90460/1, Pairwise antigens: Each vaccine billed will have its own set of administration codes, 90460 and 90461 (when applicable), as appropriate per the number of antigens in said vaccine.
  • 90460/1, Total antigens: 90460 and 90461 (when applicable) will each appear once on the claim with the total number of units as appropriate for the total of the vaccines on the claim. 
  • 90460/1, Pairwise doses: Each vaccine billed will have its own set of administration codes, 90460 and 90461 (when applicable), as appropriate per the doses in said vaccine.
  • 90460/1, Total Doses: 90460 and 90461 (when applicable) will each appear once on the claim with the total number of units as appropriate for the total of the vaccines on the claim.
  • 9047x, Force non-counseled: The non-counseled immunization administration codes will be applied.
  • None (withhold): Immunization administration codes will not be added to claims with vaccines.
Include NDC on vaccine productsSelect this checkbox if when billing vaccines for this payer, the NDC# should be included on the claim.
Unit type for included NDCs on vaccine productsSelect the unit type if including the NDC on vaccine products. The default value set here is milliliter, but should be changed, if necessary.
Auto-populate Z23 on vaccine productsThis checkbox is selected by default to auto-populate diagnosis code Z23 on claims and apply it to vaccine products. If this is not appropriate for the selected payer, deselect the checkbox.
Auto modifier -25 on well visitsSelect this checkbox if when you bill vaccines with a preventive visit for this payer, you include a 25 modifier on the preventive visit CPT.
Auto modifier -25 on E&M with proceduresThis checkbox is selected by default to automatically add a -25 modifier to sick visits with procedures. Procedures are defined as:
  • CPT Codes 0xxxx through 6xxxx
  • CPT Codes 92550-92588
  • CPT Codes 99173-99177
  • CPT Codes: 961xx
  • CPT Code 94760

If this is not appropriate for the selected payer, deselect the checkbox.

Auto modifier -33 on preventiveSelect this checkbox if when you bill preventive visits to this payer, you include the 33 modifier on the preventive services CPT code(s).
Modifier for telehealth services

(If applicable) Select the payer-required Modifier for Telehealth services. The default selection is 95 but should be changed as needed, according to the payer's specific guidelines.

Auto-populate service location when no facility specified
Select this checkbox to automatically populate Box 32 when nothing else is populated on the claim. By default, this checkbox is not selected.
Auto-populate PCP as referring provider
Select this checkbox if the payer requires the patient's PCP to be the referring provider in Box 17 on claims. The payer preference will override the selection made in Locations. By default, this checkbox is not selected.
Override POS, non-telehealthSelect the default Place of Service for non-telehealth visits.
Override POS, telehealth

(If applicable) Select the Place of Service that should override POS for telehealth services. The selection made here overrides the implied POS, 02 Telehealth, for visits where the Telehealth information has been populated in Visit Info.

Claims/Routing Tab

  1. Click the Claims/Routing tab.

  1. Complete the following:

Claims/Routing Field
Description
National Payor ID
This number is mandatory for electronic claim submission. This number is usually a 5-digit NAIC code, but some clearinghouses assign their own special value for certain payers. If you are using a clearinghouse to reach the payer, always check the clearinghouse's official Payer List for the value to put in this field.
Claim Payor IDThis number is mandatory for electronic claim submission. This number is either assigned by your clearinghouse, or it is the same as the National Payor ID. Your office must verify if your clearinghouse assigns their own numbers to certain payers. Contact your clearinghouse for their specific Payer ID lists.
Real-time IDEnter only if you are set up for real-time eligibility within Office Practicum. This number is either assigned by your clearinghouse, or is the same as the National Payer ID. Your office must verify if your clearinghouse assigns their own numbers to certain payers, especially Medicaid and Blue Cross. Contact your clearinghouse for their specific payer Real Time ID lists.
Claim type The Claim Type is necessary in order to report the correct insurance qualifier on claims. A missing or incorrect Claim Type may cause claim rejections. The most commonly used payer types are: Cl - commercial payers, BL - Blue Cross/Blue Shield, MC - Medicaid, CH - Champus/Tricare, AM - automobile (for accidents), WC - workers compensation, and Self-pay.
Claim formatIf billing institutional claims for this payer (UB04's), select the Institutional radio button.
Billing LoopThis field identifies what billing information is sent on your claims. This information pertains to field 33 on a standard HCFA/CMS 1500 form. You can select one of the following: Practice NPI Only, Practice NPI plus Payer Assigned ID, Practice Payer Assigned ID only, Provider NPI Only, Provider NPI plus Payer Assigned ID, or Provider Payer Assigned Only. Your selection should be based on your knowledge of the particular payer's requirements for electronic and/or paper claim submission.  If you are selecting Practice NPI only in this field, you must visit Group NPI Setup to determine what fields to populate with your Practice/Group NPI to ensure it is correctly rendered on claims.
if EPDST (As it relates to the Billing Loop): The system default for EPSDT claims is set to Same as NON-EPSDT which means that the selection is identical to the selection made in the Billing Loop as listed above. This field pertains only to those offices that participate with Medicaid plans and are required to adhere to EPSDT guidelines. If a selection is made from this drop-down, that value replaces the Billing Loop selection. For example, if a payer's Billing Loop is set to Practice NPI Only, and the if EPSDT field is set to Provider NPI only, the Provider NPI is placed in the Billing Loop of claims. To change the default, click the drop-down menu to the right of the text If EPSDT and select an alternate option.
Render LoopThis field identifies what rendering provider information is sent on your claims. This information pertains to field 24 on a standard HCFA/CMS 1500 form. You can select one of the following: Provider NPI Only, Provider NPI plus Payer Assigned ID, Provider Payer Assigned ID only, Provider NPI plus Tax ID , Provider NPI plus Tax ID plus Payer Assigned ID, Provider Payer Assigned plus Tax ID, or Suppress (which means that you are not sending/printing rendering provider information on your claims for this payer). Your selection should be based on YOUR knowledge of the particular payer's requirements for electronic and/or paper claim submission
if EPSDT (As it relates to the Render Loop): The system default for EPSDT claims is set to Same as NON-EPSDT which means that the selection is identical to the selection made in the Render Loop as listed above. This field pertains only to those offices that participate with Medicaids and are required to adhere to EPSDT guidelines. If a selection is made from this drop-down menu, that value replaces the Render Loop selection. For example, if a payer's Render Loop is set to Provider NPI Only, and the if EPSDT field is set to Provider NPI + tax ID, the Provider NPI + tax ID is be placed in the Render Loop of claims. To change the default, click on the drop-down to the right of the text If EPSDT and select an alternate option as appropriate.
CLM12 ExcludeSelecting this checkbox causes the CLM12 segment to be blank on the 837. The field is defaulted to deselected, which means the CLM12 segment on an 837 for an EPSDT claim has an 03 value indicating a Special Federal Funding. According to the 5010 standard, the CLM12 is situational and the value of 03 only applies to most Medicaid payers. 
EPSDT GroupThis field pertains only to those offices that participate with medicaid and are required to adhere to EPSDT guidelines. An entry in this field overrides the policy Group name.
Accepts ICD 10Select the checkbox if this payer accepts ICD-10 codes. Set date when the payer starts accepting ICD-10. As a reminder, ICD-10 replaced ICD-9 coding on October 1, 2015.
Suppress NPID on service location

Select the checkbox to Suppress NPID on service location when the NPI of the location on the claim (either Practice or Facility location) is the same as the Billing Provider NPI on claims for the payer.  

Note: In the boxes to the right of the loop fields, click to select if your payer requires TAXONOMY information to be sent along with the information previously identified in the corresponding loop. In the box above the field EPSDT Group, click to select if your payer requires TAXONOMY information to be printed on the standard HCFA/CMS 1500 form. For more information on Taxonomy Fields in OP, visit Taxonomy Fields.

Claims/Routing Tab: Transaction Routing

If your office is contracted for Full HIPAA Transaction services (e-Billing), you must complete the Transaction Routing section of the Claims/Routing tab. Transaction Routing is used only for practices that are sending ANSI 837 claim files. Meaning, if the majority of your payers claims are submitted electronically to a clearinghouse, then the default is defined as such. The following section allows you the opportunity to override system defaults for a particular payer.

  1. Edit the following Transaction Routing fields, only if you are overriding the system default for the specified transmission.

Transaction Routing Field
Description
Claims Transmission (primary)
Used to select an alternative for claim submission to primary payers. If paper claim submission is preferred by the payer, use the drop-down to select Standard HCFA.
Claims Transmission (secondary)Used to select an alternative for claim submission to secondary payers. Most often, this selection is Standard HCFA because most payers require paper claims to accompany primary payer EOBs in order to process secondary claims.
Claim Adjudication (835)Used to select an alternative for downloading Electronic Remittance Advice. This selection is different from the default if, for example, a payer does not provide this service.
Claim status (276/277)Used to select an alternative for downloading claim acknowledgment and status information.
Eligibility & benefits (270/271)Used to select an alternative for downloading Eligibility and Benefits information. This selection is different from the default if, for example, a payer does not provide this service. In that case, select Standard HCFA, so the system knows not to send electronic eligibility requests.
Referrals & pre-auth (278)Used to select an alternative for uploading Referral and Pre-Authorization requests. This selection is different from the default IF, for example, a payer does not provide this service. In that case, select Standard HCFA so OP knows NOT to send these electronic requests.
Send Eligibility AsEnter the name of the provider or practice under which your office is recognized by this payer in order to send properly formatted Eligibility & Benefit requests. If entering a practice name, use only the field directly to the right of the Send Eligibility As field. If entering a provider name, enter the last name of the provider followed by their credentialed initials (MD, for example) in the field directly to the right of the Send Eligibility As field and enter the first name of the provider in the field to the right of the field where the last name was entered.
Primary ID (for eligibility)This field pertains to the type of ID number under which your office is recognized by this payer in order to send properly formatted Eligibility & Benefits requests. To the right of this selection, enter the corresponding ID number.

See the TIP below for information on copying the entries from one payer to another.
Secondary ID (if necessary)This field pertains to a secondary type of ID number under which your office is recognized by this payer in order to send properly formatted Eligibility & Benefits requests. To the right of this selection, enter that ID number. Most often, a secondary ID is not required by payers for Eligibility & Benefits requests, so these secondary ID fields may remain blank.
Service Type for eligibilityThis field is used to identify the Service Type which dictates the Medical Benefits and Copay information produced by the clearinghouse upon insurance validation.
  • 30: Health Benefit Plan Coverage: Returns general insurance information, but the co-pay may be inaccurate for primary care. 
  • 98: Professional Physician Visit-Office: Returns insurance information specific to physician office, often delivers the best co-pay information. This is typically the code for all payers. 
  • 96: Professional (Physician): Similar to 98, but is typically only used when the information returned by 98 is not accurate.
Always send dependent eligibility as guarantorSelect this checkbox to send the patient's information as if they were the guarantor for the insurance policy. This is especially common for Cigna insurance policies where each patient has their own unique identification number suffix and the relationship to subscriber is SELF.
Policy ID not required when checking eligibilityThis checkbox should remain BLANK. This is not yet a functional piece of eligibility setup. It is a foundation piece that is used for future system enhancements. Users should not expect this to function at this time.

Tip: Once the Primary ID for Eligibility field entries have been entered for one Payer, they can easily be copied and applied to other Insurance Payers:

  1. Close the Insurance Payer Details window.
  2. In the Insurance Payers List window, sort the payer list so that the payer you will be copying from is listed above the payer you are copying to. Because the Insurance Payers List is listed alphabetically, you can click the column header for the Payer Short Name column to change the listing from ascending to descending order in order to get the correct payer listed first.
  3. Select the Payer whose Eligibility ID information you want to copy.
  4. Click to select the Payer(s) who the Eligibility ID information will be copied to. If the payers are listed one after another, use Shift on the keyboard to select all payers. If they are separated by other payers in the list, use CTRL on the keyboard and select each payer.
  5. Click the Elig button. A confirmation pop-up box is displayed. 
  6. Click the OK button. 
  7. Review and click the OK button in the Information window that is displayed.