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Add an Insurance Payer

Version 14.19
Path: Billing tab > Payers button

Overview

Follow the steps below to add additional insurance payers. If, after reviewing the information in this article, more thorough explanation of the Insurance Payer Fields is needed, visit Insurance Payer Field Descriptions.

Note: SELF-PAY should remain in the table. OP will automatically assign patients to the SELF-PAY payer if they do not have insurance or their insurance is not ranked.

Basic Information

NoteIn order to have the ability to add an Insurance Payers, users need the permission Billing_Payers_Modify. If the New and Edit buttons are not visible on the Insurance Payers List window, the necessary permission must be obtained from a Practice Administrator.
  1. Navigate to the Insurance Payers List using the path above.
  2. Click the New button. The Insurance Payer Details window opens.
  3. Enter the following information on the Basic Information tab: 

  • Enter a Short code (unique six-character alpha/numeric entry).
  • Enter the Short Name (up to 15 characters).
  • Enter the Full Name and Address.
Note: The Full Name of the Payer 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. 
  • Enter Contact Name/Phone/Note (optional).
  • Select Active status.
  • Active for all: This is the default setting for all insurances and indicates that all providers are active with the insurance. It is acceptable to leave this setting even if all providers are not credentialed as the association of provider to payer occurs in another window.    
  • Active for some: When selected, the insurance payer will appear highlighted in gray in the Insurance Payer List. If selected, creation of block and substitute rules will be disabled for the payer.  
  • Set the Start date and End date.
  • Select the VFC eligibility.
  • Select the Pat Resp Type.
  • Select the Fee schedule.
  • Select the Immunization Administration Coding Rule to override system default, if necessary. This is dependent upon this individual payer's requirements regarding immunization administration coding. If the payer's requirement is the same as what you have previously set in Global Preferences, select Use global preference. Otherwise, your options for this administration rule are:
  • 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.
  • Select the Include NDC on vaccine products checkbox if when billing vaccines for this payer, the NDC# should be included on the claim.
  • Select the Add -25 modifier on well visits checkbox if when you bill vaccines with a preventive visit for this payer, you include a 25 modifier on the preventive visit CPT.
  • Select the Add -33 modifier on well visits checkbox if when you bill preventive visits to this payer, you include the 33 modifier on the preventive services CPT code(s).
  • Select the Always override VFC checkbox if VFC eligibility should be applied to the patient's record regardless of Insurance ranking.
  • Select the Show on patient portal checkbox if your office has an active portal and you would like to show this as an accepted insurance.
  • Select the Charges - PATIENT Resp checkbox if all charges billed to this insurance are the responsibility to the patient.

Claims/Routing

  1. Enter the following information on the Claims/Routing tab:

  • Enter the National Payer ID. Your selected clearinghouse vendor should provide you with a list of payers that are supported and their respective Payer ID numbers.
  • Enter the Claim Payer ID. Your selected clearinghouse vendor should provide you with a list of payers that are supported and their respective Payer ID numbers.
  • Enter the Real-time ID. This is required for offices contracted for eligibility and benefits services. This number may be different than the National or Claim Payer ID number and should also be supplied by your clearinghouse. If you have changed clearinghouses, it is likely the Real-time ID will be different. 
  • Select the Claim Type as appropriate for the payer. 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. 
  • Select the Claim Format. If you are doing Institutional billing (UB04's), select the Institutional radio button.
  • Select the Billing Loop (equivalent to box 33 of CMS-1500 form).
Warning: 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. 
  • Select the EPSDT loop (to override Billing Loop, if applicable).
  • Select the Render Loop (equivalent to box 24J of CMS-1500 form).
  • Select the EPSDT loop (to override Render Loop, if applicable).
Note:  In the boxes to the right of the loop fields, you can 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, you can 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.
  • Select the CLM12 Exclude (Claim Special Program Code) if applicable.
  • Enter the EPSDT (Early and Periodic Screening, Diagnostic and Treatment) Group number if applicable for your payer.
  • Check off the box next to Accepts ICD-10 and enter the As of date for payers accepting ICD-10 codes (typically 10/1/2015).
  • 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.  

Claims/Routing: 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. The system default for transaction routing is initially set up as part of Practice Management, where defaults are set to the most common method of transmission. In other words, if the majority of your payers claims are submitted electronically to a particular entity (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.
  • Claims Transmission (Primary)
  • Claims Transmission (Secondary)
Note:  If secondary claims should be submitted to the payer on a paper claim form, select  Standard HCFA from the dropdown list.
  • Claim Adjudication (835)
  • Eligibility & Benefits (270/271)
  • Referrals & PreAuth (278)
  1. Complete the Eligibility fields only if you are contracted for Eligibility & Benefits Services:
  • Enter Send Eligibility As name/entity.
  • Select and enter Primary ID for eligibility: Enter either a Provider's Individual NPI or Practice Group NPI depending on your contract with the clearinghouse.
Note: 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 by doing the following:
  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 may 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 will be copied.
  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 confirm box opens asking you to confirm the action that is about to be taken.
  6. Click OK
  7. Review and click OK in the Information window that displays.
  • Select and enter Secondary ID (if necessary).
  • Select the checkbox to Always send dependent eligibility as guarantor (if applicable).
Warning: The Policy ID not required when checking eligibility checkbox is not yet a functional piece of eligibility setup. It is a foundation piece that will be used for future system enhancements. Users should not expect this to function at this time. This checkbox should remain blank.


Note for Medicaid/Commercial HMOs: Most Medicaid plans do not return PCP assignment. This is a plan decision and is not an OP or clearinghouse issue. 
  1. Select the Service Type for eligibility code. This often determine the correct copay fields.
  • 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.
  1. Click the Save button to save changes and return to the Insurance Payers List.
  2. Connect the credentialed providers to the insurance using the steps in Connect Providers to Insurance Payers.

Editing the Short Code Name

  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.
Note:  Do not perform this process during normal business hours. It may take several hours to complete.
  1. Click Continue. 
  2. Review the changes and click the Save button at the bottom of the window.
Version 14.10
Utilities > Manage Practice > Insurance Payers

Overview

Follow the steps below to add additional insurance payers. If, after reviewing the information in this article, more thorough explanation of the Insurance Payer Fields is needed, visit Insurance Payer Field Descriptions.

Note: SELF-PAY should remain in the table. OP will automatically assign patients to SELF-PAY if they do not have insurance or their insurance is not ranked.

Basic Information

  1. Open the Insurance Payers List using the path above.
  2. Click the Add Payer button at the top of the window. The Insurance Payer Details window will open.
  3. Enter the following information about the new insurance payer on the Basic Information tab of the Insurance Payer Details window: 

  • Enter a Short code (unique six-character alpha/numeric entry).
  • Enter the Short Name (up to 15 characters).
  • Enter the Full Name and Address.
Note: The Full Name of the Payer 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.
  • Enter Contact Name/Phone/Note (optional).
  • Select Active status.
  • Active for all: This is the default setting for all insurances and indicates that all providers are active with the insurance. It is acceptable to leave this setting even if all providers are not credentialed as the association of provider to payer occurs in another window.    
  • Active for some: When selected, the insurance payer will appear highlighted in gray in the Insurance Payer List. If selected, creation of block and substitute rules will be disabled for the payer.  
  • Set the Start date and End date.
  • Select VFC eligibility.
  • Select the Pat Resp Type.
  • Select Fee schedule.
  • Select Immunization Administration Coding Rule to override system default, if necessary. This is dependent upon this individual payer's requirements regarding immunization administration coding. If the payer's requirement is the same as what you have previously set in System Preferences, select Use global preference. Otherwise, your options for this administration rule are:
  • 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.
  • Select the Include NDC on vaccine products checkbox if when billing vaccines for this payer, the NDC# should be included on the claim.
  • Select the Auto -25 modifier on well visits checkbox if when you bill vaccines with a preventive visit for this payer, you include a 25 modifier on the preventive visit CPT.
  • Select the Auto -33 modifier on preventive checkbox if when you bill preventive visits to this payer, you include the 33 modifier on the preventive services CPT code(s).
  • Select the Always override VFC checkbox if VFC eligibility should be applied to the patient's record regardless of Insurance ranking.
  • Select the Show on patient portal checkbox if your office has an active portal and you would like to show this as an accepted insurance.
  • Select the Charges - PATIENT Resp checkbox if all charges billed to this insurance are the responsibility to the patient.

Claims/Routing

  1. Enter the following on the Claims/Routing tab.

  • Enter the National Payer ID. Your selected clearinghouse vendor should provide you with a list of payers that are supported and their respective Payer ID numbers.
  • Enter the Claim Payer ID. Your selected clearinghouse vendor should provide you with a list of payers that are supported and their respective Payer ID numbers.
  • Enter the Real-time ID. This is required for offices contracted for eligibility and benefits services. This number may be different than the National or Claim Payer ID number and should also be supplied by your clearinghouse. If you have changed clearinghouses, it is likely the Real-time ID will be different. 
  • Select the Claim Type as appropriate for the payer. 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. 
  • Select the Claim Format. If you are doing institutional billing (UB04's), select the Institutional radio button.
  • Select the Billing Loop (equivalent to box 33 of CMS-1500 form).
Warning: 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.
  • Select the EPSDT loop (to override Billing Loop, if applicable).
  • Select the Render Loop (equivalent to box 24J of CMS-1500 form).
  • Select the EPSDT loop (to override Render Loop, if applicable).
Note:  In the boxes to the right of the loop fields, you can 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, you can 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.
  • Select the CLM12 Exclude (Claim Special Program Code) if applicable.
  • Enter the EPSDT (Early and Periodic Screening, Diagnostic and Treatment) Group number if applicable for your payer.
  • Check off the box next to Accepts ICD-10 and enter the As of date for payers accepting ICD-10 codes (typically 10/1/2015).
  • 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.  

Claims/Routing: Transaction Routing

Transaction Routing: If your office is contracted for Full HIPAA Transaction services (e-Billing), you must complete the Transaction Routing section of this screen. Transaction Routing is used ONLY for practices that are sending ANSI 837 claim files. The system default for transaction routing is initially set up as part of Practice Management, where defaults are set to the most common method of transmission. In other words, if the majority of your payers claims are submitted electronically to a particular entity (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.
  • Claims Transmission (Primary)
  • Claims Transmission (Secondary)
Note:  If secondary claims should be submitted to the payer on a paper claim form, select  Standard HCFA from the dropdown list.
  • Claim Adjudication (835)
  • Eligibility & Benefits (270/271)
  • Referrals & PreAuth (278)
  1. Complete the Eligibility fields only if you are contracted for Eligibility & Benefits Services:
  • Enter Send Eligibility As name/entity.
  • Select and enter Primary ID for eligibility: Enter either a Provider's Individual NPI or Practice Group NPI depending on your contract with the clearinghouse.
Note: 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 by doing the following:
  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 may 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 will be copied.
  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 confirm box opens asking you to confirm the action that is about to be taken.
  6. Click OK
  7. Review and click OK in the Information window that displays.
  • Select and enter Secondary ID (if necessary).
  • Select the checkbox to Always send dependent eligibility as guarantor (if applicable).
Warning: The Policy ID not required when checking eligibility checkbox is not yet a functional piece of eligibility setup. It is a foundation piece that will be used for future system enhancements. Users should not expect this to function at this time. This checkbox should remain blank.


Note for Medicaid/Commercial HMOs: Most Medicaid plans do not return PCP assignment. This is a plan decision and is not an OP or clearinghouse issue. 
  1. Select the Service Type code. Service Type codes often determine the correct copay fields.
  • 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.
  1. Click the Save button to save changes and return to the Insurance Payers List.
  2. Connect the credentialed providers to the insurance using the steps in Connect Providers to Insurance Payers.

Editing the Short Code Name

  1. From the Insurance Payers List, select the payer to edit.
  2. Click the Change/Merge Code button. 

  1. 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.
Note:  Do not perform this process during normal business hours. It may take several hours to complete.
  1. Click Continue. 

  1. Review changes and click the Save button at the bottom of the window.
Version 14.8
Utilities > Manage Practice > Insurance Payers

Overview

Follow the steps below to add additional insurance payers. If, after reviewing the information in this article, more thorough explanation of the Insurance Payer Fields is needed, visit Insurance Payer Field Descriptions.

Note: SELF-PAY should remain in the table. OP will automatically assign patients to the SELF-PAY if they do not have insurance or their insurance is not ranked.

Adding an Insurance Payer

  1. Open the Insurance Payers List using the path above.
  2. Click the Add Payer button at the top of the window. The Insurance Payer Details window will open.
  3. Enter the following information about the new insurance payer on the Basic Information tab of the Insurance Payer Details window: 

  • Enter a Short code (unique six-character alpha/numeric entry)
  • Enter the Short Name (up to 15 characters)
  • Enter the Full Name and Address
Note: The Full Name of the payer 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. 
  • Enter Contact Name/Phone/Note (optional)
  • Select Active status
  • Active for all: This is the default setting for all insurances and indicates that all providers are active with the insurance. It is acceptable to leave this setting even if all providers are not credentialed as the association of provider to payer occurs in another window.    
  • Active for some: When selected, the insurance payer will appear in a grey bar in the Insurance Payer List. If selected, creation of block and substitute rules will be disabled for the payer.  
  • Set the Start date and End date
  • Select VFC eligibility
  • Select the Pat Resp Type
  • Select Fee schedule
  • Select Immunization Administration Coding Rule to override system default, if necessary.
  • Select "Include NDC on vaccine products" if, when billing vaccines for this payer, the NDC# should be included on the claim.
  • Select "Add -25 modifier on well visits" if, when you bill vaccines with a preventative visit for this payer, you include a 25 modifier on the preventative visit CPT.
  • Select "Add -33 modifier on well visits" if, when you bill preventative visits to this payer, you include the 33 modifier.
  • Select Always override VFC
  • Select "Show on patient portal" if your office has an active portal and you would like to show this as an accepted insurance.
  • Select "Charges - PATIENT Resp" if all charges billed to this insurance are the responsibility to the patient.
  1. Enter the following on the Claims/Routing tab:

  • Enter the National Payer ID. Your selected clearinghouse vendor should provide you with a list of payers that are supported and their respective Payer ID numbers.
  • Enter the Claim Payer ID. Your selected clearinghouse vendor should provide you with a list of payers that are supported and their respective Payer ID numbers.
  • Enter the Real-time ID. This is required for offices contracted for eligibility and benefits services. This number may be different than the National or Claim Payer ID number and should also be supplied by your clearinghouse. If you have changed clearinghouses, it is likely the Real-time ID will be different. 
  • Select the Claim Type as appropriate for the payer. 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. 
  • Select the Claim Format. If you are doing institutional billing (UB04's), select the Institutional radio button.
  • Select the Billing Loop (equivalent to box 33 of CMS-1500 form)
  • Select the EPSDT loop (to override Billing Loop, if applicable)
  • Select the Render Loop (equivalent to box 24J of CMS-1500 form)
  • Select the EPSDT loop (to override Render Loop, if applicable)
Note:  In the boxes to the right of the loop fields, you can 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, you can 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 14, visit Taxonomy Fields.
  • Select the CLM12(*Claim Special Program Code)*Exclude if applicable.
  • Enter the EPSDT (Early and Periodic Screening, Diagnostic and Treatment) Group number if applicable for your payer.
  • Check off the box next to Accepts ICD-10 and enter the As of date for payers accepting ICD-10 codes (typically 10/1/2015).

Transaction Routing: If your office is contracted for Full HIPAA Transaction services (e-Billing), you must complete the Transaction Routing section of this screen. Transaction Routing is used ONLY for practices that are sending ANSI 837 claim files. The system default for transaction routing is initially set up as part of Practice Management, where defaults are set to the most common method of transmission. In other words, if the majority of your payers claims are submitted electronically to a particular entity (eg. 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.
  • Claims Transmission (Primary)
  • Claims Transmission (Secondary)
Note:  In previous versions this setting was restricted to Standard HCFA only because Office Practicum did not support secondaries electronically. In OP 14, if the payer has indicated that it accepts secondary claims electronically, set field to  Default value. This allows you to create secondary claims with the primary payer’s adjudication details embedded in them and to send these secondary claims to the same clearinghouse used by the primary claims.
  • Claim Adjudication (835)
  • Eligibility & Benefits (270/271)
  • Referrals & PreAuth (278)
  1. Complete the Eligibility fields ONLY if you are contracted for Eligibility & Benefits Services:
  • Enter Send Eligibility As name/entity
  • Select and Enter Primary ID (for eligibility) - enter either provider's Individual or practice Group NPI
  • Select and Enter Secondary ID (if necessary)
  • Select 'Always send dependent eligibility as guarantor' (if applicable)
Note for Medicaid/Commercial HMOs: Most Medicaid plans do not return PCP assignment. This is a plan decision and is not an OP or clearinghouse issue. 
  1. Select the Service Type code. Service Type codes often determine the correct copay fields.
  • 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.
  1. Click the Save button to save changes and return to the Insurance Payers List.
  2. Connect the credentialed providers to the insurance using the steps in Connect Providers to Insurance Payers.
  3. Click Exit button to close.

Editing the Short Code Name

  1. Select the payer to edit.
  2. To edit the Short code, click the Change/Merge Code button. 

  1. 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.
Note:  Do not perform this process during normal business hours. It may take several hours to complete.
  1. Click the Continue button. 

  1. Review changes and click the Save button at the bottom of the window.