We are currently updating the OP Help Center content for the release of OP 14.19 or "OP 19". OP 19 is a member of the certified OP 14 family of products (official version is 14.19.1), which you may see in your software (such as in Help > About) and in the Help Center tabs labeled 14.19. You may also notice that the version number in content and videos may not match the version of your software, and some procedural content may not match the workflow in your software. We appreciate your patience and understanding as we make these enhancements.

Insurance Payer Record Field Descriptions

Version 14.19
Path: Billing tab > Payers > Select Payer > Edit button
Path: Billing tab > Payers > New button

Overview

The following field descriptions pertain to fields found in the Basic Information and Claims/Routing tabs of the Insurance Payer Details window. 

Basic Information Tab

FieldDescription
Short Code This must be a unique code that will help you identify the payer. When assigning this code, you can use any characters, but choose carefully. 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 appears on many lookup lists within OP. It is a user-defined field, and should be an abbreviation of the payer name that will be 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 information should be entered as you would expect it to appear on the top of a HCFA/CMS 1500 form for claim-mailing purposes. The address must include the city, state and zip code (include 9 digit zip when known). The address fields may be optional if you are certain that only electronic claims will ever need to be sent for this payer. However, you should verify this with your clearinghouse prior to batch submission for any payer.
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 is defaulted 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' will appear highlighted in grey in the Insurance Payers List.
  • Inactive: this payer is not being used by the practice at this time. Payers marked 'Inactive' will appear highlighted in red in the Insurance Payers List as long as the 'hide inactive' box is not checked.
Start Date/End DateSelect the date when your office initially contracted with this payer or stopped accepting this insurance, respectively.
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 list. For most commercial payers, select 5/NOT ELIGIBLE.
Pat resp typeClick this drop-down list to select a value applicable for the payer.
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, you will select Use global preference.
Include NDC on Vaccine ProductsSelect the checkbox to include NDC numbers when billing vaccines.
Auto ModifiersSelect to auto populate preventative exams with modifiers 25 or 33.
Always override VFCIf this box is not selected, the VFC eligibility for this payer will be applied to the patient Register for patients who have this insurance ranked as primary. Otherwise, VFC eligibility will be applied to the Register in all cases. This option would be appropriate where patients are VFC eligible even when Medicaid is their secondary insurance.
Show on PortalSelect this box if your office has an active patient portal, and you want this particular payer listed as a contracted payer as view-able by your patient base.
Charges - PATIENT RespThe selection of this checkbox indicates that all charges for this payer will be the responsibility of the patient.

Claims/Routing Tab

 Field NameDescription 
National Payor IDThis 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 typeMost 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 radio button next to Institutional.
Billing LoopThis field identifies what billing information will be sent on your claims. This information pertains to box 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 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 will be 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 will replace 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 will be placed in the Billing 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.
Render LoopThis field identifies what rendering provider information will be sent on your claims. This information pertains to box 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 will not be 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 will be 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, that value will replace 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 will 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 will cause the CLM12 segment to be blank on the 837. The field is defaulted to unchecked which means the CLM12 segment on an 837 for an EPSDT claim will have 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 will override the policy Group name.
Accepts ICD 10Check off the box 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.  

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 will be '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 will be 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 will be different from the default if, for example, a payer does not provide this service. In that case, select Standard HCFA, so the system will know not to send electronic eligibility requests.
Referrals & pre-auth (278)Used to select an alternative for uploading Referral and Pre-Authorization requests. This selection will be different from the default IF, for example, a payer does not provide this service. In that case, select Standard HCFA so OP will know 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 box 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.
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 Code for eligibilityThis field is used to identify the Service Type which will dictate 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 will be used for future system enhancements. Users should not expect this to function at this time.
Version 14.8
Utilities > Manage Practice > Insurance Payers

Overview

Below are the field descriptions for the Basic Information and Claims/Routing tabs of the Insurance Payer Details window.

Basic Information Field Name Description
Short Code This must be a unique code that will help you identify the payer. When assigning this code, you can use any characters, but choose carefully. 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 appears on many lookup lists within the program. This is a user-defined field, and should be an abbreviation of the payer name that will be 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 information should be entered as you would expect it to appear on the top of a HCFA/CMS 1500 form for claim-mailing purposes. The address must include the city, state and zip code (include 9 digit zip when known). The address fields may be optional if you are certain that only electronic claims will ever need to be sent for this payer. However, you should verify this with your clearinghouse prior to batch submission for any payer.
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 is defaulted 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' will appear highlighted in grey in the Insurance Payers List.
  • Inactive: this payer is not being used by the practice at this time. Payers marked 'Inactive' will appear highlighted in red in the Insurance Payers List as long as the 'hide inactive' box is not checked.
Start DateSelect the date when your office initially contracted with this payer.
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 list. For most commercial payers, select 5/NOT ELIGIBLE.
Pat resp typeClick this drop-down list to select a value applicable for the payer.
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, you will select Use global preference.
Include NDC on Vaccine ProductsSelect the checkbox to include NDC numbers when billing vaccines.
Auto ModifiersSelect to auto populate preventative exams with modifiers 25 or 33.
Always override VFCIf this box is not selected, the VFC eligibility for this payer will be applied to the patient Register for patients who have this insurance ranked as primary. Otherwise, VFC eligibility will be applied to the Register in all cases. This option would be appropriate where patients are VFC eligible even when Medicaid is their secondary insurance.
Show on PortalSelect this box if your office has an active patient portal, and you want this particular payer listed as a contracted payer as view-able by your patient base.
Charges - PATIENT RespThe selection of this checkbox indicates that all charges for this payer will be the responsibility of the patient.


Claims/Routing Field NameDescription 
National Payor IDIf you are sending claims for this payer electronically, entering this number is mandatory for 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 IDIf you are sending claims for this payer electronically, entering this number is mandatory for 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 typeMost 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 "09 - Self-pay".
Claim formatIf billing institutional claims for this payer (UB04's) select the radio button next to Institutional.
Billing LoopThis field identifies what billing information will be sent on your claims. This information pertains to box 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 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 will be 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 will replace 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 will be placed in the Billing 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.
Render LoopThis field identifies what rendering provider information will be sent on your claims. This information pertains to box 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 will not be 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 will be 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, that value will replace 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 will 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 will cause the CLM12 segment to be blank on the 837. The field is defaulted to unchecked which means the CLM12 segment on an 837 for an EPSDT claim will have 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 will override the policy Group name.
Accepts ICD 10Check off the box 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.
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 will be '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 will be 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 will be different from the default if, for example, a payer does not provide this service. In that case, select Standard HCFA, so the system will know not to send electronic eligibility requests.
Referrals & pre-auth (278)Used to select an alternative for uploading Referral and Pre-Authorization requests. This selection will be different from the default IF, for example, a payer does not provide this service. In that case, select Standard HCFA so OP will know 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 box 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.
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 Code for eligibilityThis field is used to identify the Service Type which will dictate 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 guarantorOnly used to identify if this is required by this payer in order to send properly formatted Eligibility & Benefits requests when the insured is someone other than the patient, yet the payer requires you to list the patient as the insured in order to receive a valid Eligibility & Benefit response.
Version 14.10
Utilities > Manage Practice > Insurance Payers

Overview

Field descriptions for the Basic Information and Claims/Routing tab.

Basic Information Field Name Description
Short Code This must be a unique code that will help you identify the payer. When assigning this code, you can use any characters, but choose carefully. 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 appears on many lookup lists within the program. This is a user-defined field, and should be an abbreviation of the payer name that will be 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 information should be entered as you would expect it to appear on the top of a HCFA/CMS 1500 form for claim-mailing purposes. The address must include the city, state and zip code (include 9 digit zip when known). The address fields may be optional if you are certain that only electronic claims will ever need to be sent for this payer. However, you should verify this with your clearinghouse prior to batch submission for any payer.
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 is defaulted 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' will appear highlighted in grey in the Insurance Payers List.
  • Inactive: this payer is not being used by the practice at this time. Payers marked 'Inactive' will appear highlighted in red in the Insurance Payers List as long as the 'hide inactive' box is not checked.
Start DateSelect the date when your office initially contracted with this payer.
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 list. For most commercial payers, select 5/NOT ELIGIBLE.
Pat resp typeClick this drop-down list to select a value applicable for the payer.
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, you will select Use global preference.
Include NDC on Vaccine ProductsSelect the checkbox to include NDC numbers when billing vaccines.
Auto ModifiersSelect to auto populate preventative exams with modifiers 25 or 33.
Always override VFCIf this box is not selected, the VFC eligibility for this payer will be applied to the patient Register for patients who have this insurance ranked as primary. Otherwise, VFC eligibility will be applied to the Register in all cases. This option would be appropriate where patients are VFC eligible even when Medicaid is their secondary insurance.
Show on PortalSelect this box if your office has an active patient portal, and you want this particular payer listed as a contracted payer as view-able by your patient base.
Charges - PATIENT RespThe selection of this checkbox indicates that all charges for this payer will be the responsibility of the patient.


Claims/Routing Field NameDescription 
National Payor IDIf you are sending claims for this payer electronically, entering this number is mandatory for 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 IDIf you are sending claims for this payer electronically, entering this number is mandatory for 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 typeMost 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 "09 - Self-pay".
Claim formatIf billing institutional claims for this payer (UB04's) select the radio button next to Institutional.
Billing LoopThis field identifies what billing information will be sent on your claims. This information pertains to box 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 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 will be 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 will replace 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 will be placed in the Billing 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.
Render LoopThis field identifies what rendering provider information will be sent on your claims. This information pertains to box 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 will not be 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 will be 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, that value will replace 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 will 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 will cause the CLM12 segment to be blank on the 837. The field is defaulted to unchecked which means the CLM12 segment on an 837 for an EPSDT claim will have 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 will override the policy Group name.
Accepts ICD 10Check off the box 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.  

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 will be '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 will be 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 will be different from the default if, for example, a payer does not provide this service. In that case, select Standard HCFA, so the system will know not to send electronic eligibility requests.
Referrals & pre-auth (278)Used to select an alternative for uploading Referral and Pre-Authorization requests. This selection will be different from the default IF, for example, a payer does not provide this service. In that case, select Standard HCFA so OP will know 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 box 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.
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 Code for eligibilityThis field is used to identify the Service Type which will dictate 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 guarantorOnly used to identify if this is required by this payer in order to send properly formatted Eligibility & Benefits requests when the insured is someone other than the patient, yet the payer requires you to list the patient as the insured in order to receive a valid Eligibility & Benefit response.
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 will be used for future system enhancements. Users should not expect this to function at this time.
Version 14.8
Utilities > Manage Practice > Insurance Payers

Overview

Below are the field descriptions for the Basic Information and Claims/Routing tabs of the Insurance Payer Details window.

Basic Information Field Name Description
Short Code This must be a unique code that will help you identify the payer. When assigning this code, you can use any characters, but choose carefully. 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 appears on many lookup lists within the program. This is a user-defined field, and should be an abbreviation of the payer name that will be 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 information should be entered as you would expect it to appear on the top of a HCFA/CMS 1500 form for claim-mailing purposes. The address must include the city, state and zip code (include 9 digit zip when known). The address fields may be optional if you are certain that only electronic claims will ever need to be sent for this payer. However, you should verify this with your clearinghouse prior to batch submission for any payer.
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 is defaulted 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' will appear highlighted in grey in the Insurance Payers List.
  • Inactive: this payer is not being used by the practice at this time. Payers marked 'Inactive' will appear highlighted in red in the Insurance Payers List as long as the 'hide inactive' box is not checked.
Start DateSelect the date when your office initially contracted with this payer.
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 list. For most commercial payers, select 5/NOT ELIGIBLE.
Pat resp typeClick this drop-down list to select a value applicable for the payer.
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, you will select Use global preference.
Include NDC on Vaccine ProductsSelect the checkbox to include NDC numbers when billing vaccines.
Auto ModifiersSelect to auto populate preventative exams with modifiers 25 or 33.
Always override VFCIf this box is not selected, the VFC eligibility for this payer will be applied to the patient Register for patients who have this insurance ranked as primary. Otherwise, VFC eligibility will be applied to the Register in all cases. This option would be appropriate where patients are VFC eligible even when Medicaid is their secondary insurance.
Show on PortalSelect this box if your office has an active patient portal, and you want this particular payer listed as a contracted payer as view-able by your patient base.
Charges - PATIENT RespThe selection of this checkbox indicates that all charges for this payer will be the responsibility of the patient.


Claims/Routing Field NameDescription 
National Payor IDIf you are sending claims for this payer electronically, entering this number is mandatory for 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 IDIf you are sending claims for this payer electronically, entering this number is mandatory for 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 typeMost 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 "09 - Self-pay".
Claim formatIf billing institutional claims for this payer (UB04's) select the radio button next to Institutional.
Billing LoopThis field identifies what billing information will be sent on your claims. This information pertains to box 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 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 will be 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 will replace 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 will be placed in the Billing 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.
Render LoopThis field identifies what rendering provider information will be sent on your claims. This information pertains to box 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 will not be 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 will be 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, that value will replace 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 will 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 will cause the CLM12 segment to be blank on the 837. The field is defaulted to unchecked which means the CLM12 segment on an 837 for an EPSDT claim will have 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 will override the policy Group name.
Accepts ICD 10Check off the box 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.
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 will be '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 will be 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 will be different from the default if, for example, a payer does not provide this service. In that case, select Standard HCFA, so the system will know not to send electronic eligibility requests.
Referrals & pre-auth (278)Used to select an alternative for uploading Referral and Pre-Authorization requests. This selection will be different from the default IF, for example, a payer does not provide this service. In that case, select Standard HCFA so OP will know 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 box 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.
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 Code for eligibilityThis field is used to identify the Service Type which will dictate 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 guarantorOnly used to identify if this is required by this payer in order to send properly formatted Eligibility & Benefits requests when the insured is someone other than the patient, yet the payer requires you to list the patient as the insured in order to receive a valid Eligibility & Benefit response.