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Knowledge Base > Setup > Payer Setup > CMS-1500 Settings

Change CMS-1500 Settings

The CMS-1500 tab is used to format Professional Claims for Physical Therapists in Independent Practice (PTIPs). Most payers follow standard settings, such as National Provider Identifier (NPI), for CMS-1500 and UB-04 settings. However, there are some payers who require legacy identifiers (such as Unique Physician Identification Numbers (UPINs) and payer-specific provider numbers) as well as other non-standard settings. Understanding your credentialing status and specific payer requirements is crucial in setting up billing forms correctly. Most payers provide instructions on their website and their claims representatives should be able to provide the proper settings for both paper and electronic requirements.

CMS-1500 tab

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CMS-1500 Default Settings

The default settings are used by payers who follow the standardized CMS-1500 settings. However, be sure to review selections for each setting in the NPI column and make any necessary changes. The Legacy ID column is only used if the payer requires legacy identification. Changes to the default Electronic Data Interchange (EDI) Settings and Formatting sections are typically only made if the payer has specific non-standard requirements.

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Edit CMS-1500 Settings
  1. In the Edit menu, click Payers, click , or press F11. The Edit Payers dialog box appears.
  2. For a new payer, click New Payer. For an existing payer, select the payer from the Payer list. Refer to Add or Edit Basic Payer Information to learn about adding new payers.
  3. Click the CMS-1500 tab.
  4. Verify selections for the following areas of the CMS-1500 tab and make any necessary changes:
  5. To save your additions or changes, click Save.
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Payer CMS-1500 Settings

The following defines fields in the CMS-1500 payer settings and provides instructions to enter information in fields used to populate the CMS-1500 form and the Electronic Data Interchange (EDI) file. Each field has a set of options and is labeled with the corresponding location on the CMS-1500 form and EDI file. Before you are ready to bill claims, you must select an option for each of these fields, then follow the instructions to enter the information for that option. Clinicient recommends checking with your payers to ensure proper settings.

CMS-1500 tab

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Common Settings

The settings under NPI on the CMS-1500 tab are for payers that use the current National Provider Identifier (NPI) reporting. The settings under Legacy ID on the CMS-1500 tab are for payers following legacy reporting requirements.

CMS-1500 tab Common Settings section

Title Functionality
Referring Provider ID

To enter the referring provider identification numbers, click , select a referrer, then enter the values in the respective fields. See this article for detailed information on Enter Referral Contact Information.
Rendering Provider ID To enter the rendering provider identification numbers click , select a caregiver, then enter the values in the respective fields. See this article for detailed information on Add Staff Members.
Service Facility ID

Use the following steps to enter the service facility identification numbers:

  1. From the Settings menu, select Company and Clinic Info or click . The Company Info and Clinic Management dialog displays.
  2. If you have multiple clinics, select a clinic from the Clinic list, then enter the values in the respective fields of the Clinic Billing Info section.

See Clinic Billing Information for more detailed information.

Set this field if the payer requires a qualifier or prefix in box 32b.
Billing
Provider ID

Use the following steps to enter the billing provider identification numbers:

  1. From the Settings menu, click Company and Clinic Info or click . The Company Info and Clinic Management dialog box appears.
  2. If you have multiple clinics, then select a clinic from the Clinic list.

  3. In the Clinic Provider Numbers section, click the Add button to enter the Insurance Plan and corresponding Provider #.

See this article for detailed information on Clinic Billing Information.

Set this field if the payer requires a qualifier or prefix in box 33b.

  • If the payer requires caregiver NPIs in this field, see the information above under Rendering Provider ID (Caregiver).
  • If the payer requires a company (group) NPI, use the following procedure:
    1. Click Edit Payers.
    2. Click the Payer arrow to display a list of payers.
    3. Select a payer from the list.
    4. Click the General Billing Data tab.
    5. Enter the parent company's provider number in the
    6. Group Provider ID field in the Company ID #s area.
  • If the payer requires clinic payer provider #,
    1. From the Settings menu, select Company and Clinic Info or click . The Company Info and Clinic Management dialog displays.
    2. Click the Clinic arrow to display a list of clinics.
    3. Select a clinic from the list.
    4. In the Clinic Provider Numbers table, click Add to add a new row.
    5. Click the Insurance Plans field and click the arrow to display a list of insurance plans.
    6. Select an insurance plan from the list.
    7. Enter the insurance plan provider number in the Provider # field.
Accept assignment of payments from payer Select this check box to indicate that the treatment facility will accept payment for the claim on behalf of the patient.
Name/
Address (Paper)

Select the address that the payer requires in the Name and Address fields on the CMS-1500 form. Choices are as follows:

  • Clinic Billing Address
  • Company
  • Referring MD
  • Clinic Billing Address
  • Region
  • Caregiver Name + Company Address
  • Other Billing Provider
  • Incident to Company
  • Incident to Physician
  • Pay To Address
  • Clinic Physical Address

To enter the billing provider name and address, click Settings from the menu bar and select Company & Clinic Info. See Clinic Billing Information for further details.
Name/
Address (EDI)

Select the address that the payer requires in the Name and Address fields in the EDI file. Choices are as follows:

  • Clinic Billing Address
  • Company
  • Referring MD
  • Clinic Billing Address
  • Region
  • Caregiver Name + Company Address
  • Other Billing Provider
  • Incident to Company
  • Incident to Physician
  • Pay To Address
  • Clinic Physical Address

To enter the billing provider name and address, perform the following steps.

  1. Click Settings from the menu bar and select Company & Clinic Info or click . The Company Info and Clinic Management dialog displays.
  2. If you have multiple clinics, select a clinic from the Clinic list, then enter the values in the respective fields of the Clinic Billing Info section.

See Clinic Billing Information for further details.
Pay To (EDI)

Select the address that the payer requires in the Pay To field in the EDI file. Choices are as follows:

  • None
  • Pay To Address
  • Clinic Billing Address
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Charge Modifiers

Use the Charge Modifier area of the Edit Payer dialog set charge modifier preferences.

CMS-1500 tab Charge Modifiers section

Title Functionality
Include modifiers in print and EDI output

Modifiers are recorded with each charge. They can be added:

  • By the therapist when preparing documentation
  • Automatically, based on billing rules
  • By the Billing group when editing or adding charges

If this option is checked, modifiers are included in the claim.

Add discipline modifiers (GP, GO, GN)

Discipline modifiers are automatically added to a charge when this check box is selected. They indicate the discipline for the charge:

  • GP = Physical Therapy
  • GO = Occupational Therapy
  • GN = Speech Therapy

Typically Medicare requires discipline modifiers. However, Clinicient recommends checking with payers to ensure proper settings.
Always add this modifier Used in rare circumstances on some payers. Entering a modifier in that field will apply the modifier to all codes for that payer.
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Additional Claim Information

Use the Additional Claim Information area of the Edit Payer dialog to customize claim notes.

CMS-1500 tab Additional Claim Information section

  1. Click Define to display the Claim Notes dialog.
  2. Select the Referring MD UPIN check box to include the referring physician's UPIN. To enter the Referring Provider Identification numbers, click , select a referrer from the Name list, then enter the values in the respective fields. See Enter Referral Contact Information for detailed instructions.
  3. Select the Last Plan of Care Date check box to include the patient's last Plan of Care date. The Plan of Care date is included in the patient's case information. See Medicare Requirements for detailed information.
  4. Select the Quarterly Medicaid Codes check box if the payer requires this information. This setting is a unique requirement for specific state Medicaid programs.
  5. If you select both Referring MD UPIN and Last Plan of Care Date check boxes, use the Print First arrow to display a list from which you select which claim information to include first.
  6. If you select the Last Plan of Care Date check box and the payer requires a caption in front of the date, enter the caption title in the Last Plan of Care Date Caption field. Examples are "Date last seen", "Date last saw MD", and "DLSMD".
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Place of Service

Use the Place of Service area of the Edit Payer dialog to add and edit place of service codes.

CMS-1500 tab Place of Service section

  1. Click Define to display the Place of Service dialog.
  2. Click Add to add a new row to the Place of Service table.
  3. Click the Place of Service field in the new row. Then click the arrow to display a list of service locations.
  4. Select a service location. The system responds by displaying a two-digit code that indicates the place of service in the field. The Place of Service you define here populates each claim in EDI loop 2300 CLM05 or Paper block 24b for the selected payer.
  5. If a payer requires a unique two-digit code instead of the standard Place of Service code defined above, enter it in the Print on HCFA field. This typically is not required.
  6. Click Close to save your changes and return to the Edit Payer dialog.
  7. Optionally select the Include Patient Address in Block 32 when Place of Service is Home (12) check box when services are performed at the patient's home. This inserts the patient's address in box 32 of the CMS-1500 form.

Add Place of Service for 1500 Form (Box 32)

If therapists treat patients off-site (such as at the patient's home) and are required to use a specific address in Box 32 on the 1500 form, then you need to set up the place of service (POS) in the Client Editor at the time the patient registers and before the first visit is scheduled.

Note: You must have Place of Service turn on in order to see all the fields below. Contact support if you do not see Place of Service on the Case Information tab of the Client Editor.

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Paper Setting

Use the Paper Settings area of the CMS-1500 tab to preset the needed information in the corresponding field in the 1500 claim form.

CMS-1500 tab Paper Settings section

Title Functionality
Other Plan? 11d
Other Plan Use if the payer requires that you report additional insurance coverage. When you make this selection, the system automatically populates blocks 9 a-d with the other insurance information entered in the Client Editor under the Sase Information tab.
Always Blank Use to leave block 11d blank.
Plan Name
11c

Plan Name

 Use to populate block 11c with the insurance plan name.
Group ID Use to populate block 11c with the patient's insurance Group ID.
Always Blank Use if you wish to leave block 11c blank for the selected payer.
Outside Lab
20
No Typical setting.
Blank Typical setting.
Yes Use when some charges are for an outside lab.
Tax ID
25
Caregiver SSN

Used when each caregiver is contracted directly with the payer and insurance payments are made directly to the caregiver. If the payer requires the Caregiver SSN:

  1. Click the button,
  2. Select a caregiver and enter the caregiver's social security number in the SSN text box.
Company Tax ID #
  • Use when the payer requires the Company Tax ID#:
    1. Click Settings from the menu bar and select Company & Clinic Info or click . The Company Info and Clinic Management dialog displays.
    2. If you have multiple clinics, select a clinic from the Clinic list, then enter the values in the respective fields of the Clinic Billing Info section.
  • See Clinic Billing Information for detailed information.
    		•
    Referring MD Feder

    Use if the payer requires the Referring MD Federal Employer ID #:

    1. Click .
    2. Select a referrer.
    3. Enter the values in the respective fields.

    See Enter Referral Contact Information for detailed information.
    Caregiver-Payer Pr

    Use if the payer requires Caregiver-Payer Provider #:

    1. Click the button,
    2. Select a caregiver
    3. Enter the values in the respective fields.

    See Add Staff Members for detailed information.
    Clinic Tax ID #

    Use if the payer has clinics that require separate tax ID IDs:

    1. Click Settings from the menu bar and select Company & Clinic Info or click . The Company Info and Clinic Management dialog displays.
    2. If you have multiple clinics, select a clinic from the Clinic list, then enter the values in the respective fields of the Clinic Billing Info section.

    See Clinic Billing Information for detailed information.
    Signature
    31
    Leave Blank Use to leave block 31 blank. This setting is not typically used.
    Caregiver Name

    Use when the payer requires caregiver name in this field.

    1. Click .
    2. Select a caregiver.
    3. Enter the caregiver's signature, including credentials, in the Signature Line field.

    Do this for the therapist and/or assistant, depending on how your organization uses the cosign capability. See Add Staff Members and Set Up Documentation Cosigning for detailed information.
    Other Use to create a custom label in block 31. When selected, an Other Label field displays that you use to specify the custom label.
    Remarks/Claim Codes
    10d    		 Enter up to 21 characters to appear as a remark on the form.
    Print ICD10 DX Indicator As 10 Select this check box to print "10" in the DX field on paper claims as is required by Medicaid plans. This setting is per-payer and can be selected according to the payer requirements.
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    New 1500 Settings

    Use the New 1500 Settings area of the CMS-1500 tab to set blocks as specified by the payer. The fields currently default to leave blank. Clinicient recommends that you do not change these settings until a payer indicates they want something specific printed in the block.

    CMS-1500 tab New 1500 Settings section

    Block Qualifier Description
    9c Leave blank
    11b Leave blank
    15 Leave blank
    30 Leave blank
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    EDI settings

    Use the EDI Settings area of the CMS-1500 tab to set advanced, non-standard payer requirements. Please contact Clinicient technical support if you need to make modifications to the settings in this section.

    CMS-1500 tab EDI Settings section

    Title Functionality
    BCBS Billing Provider REF Qualifier This only applies to Blue Cross Blue Shield claims. In most cases. it should be set to 1B. In isolated cases (for example, for Idaho Blue Cross Blue Shield), it should be set to 1A.
    CMS Rendering Provider Loop

    Specify whether the therapist provider loop goes with:

    • 2310B - Overall for Claim
    • 2420A - With Treatment
    • Both
    • Neither
    • Billing Provider PRV Bl
    Add Rendering Provider REF segment to 2010AA Loop Select this check box to add the clinic tax ID number to the billing provider loop.
    Include Secondary/Tertiary COB Segments When Primary

    If this option is checked, coordination of benefits (COB) information about the secondary and tertiary payers is included.
    Use EI qualifier for Legacy ID when Legacy ID = Federal Tax ID Check this check box if required by the payer. This is typically only used in unique cases.
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    Formatting

    The settings in this section are advanced and often only used for non-standard requirements. Please contact Clinicient technical support if you need to make modifications to the settings in this section.

    CMS-1500 tab Formatting section

    Title Functionality
    Output Charges Click the Output Charges arrow to display a list of output charge formatting choices. Select Line-By-Line if the payer requires each charge for a CPT code to be submitted on a separate line. Select Summary if the charges for each CPT code are added together and submitted as one item.
    Output one unit per line This check box is not typically selected. If selected, each unit of a charge is submitted on a separate line. For example, four units of therapeutic exercise in one appointment would be reported on four separate lines, one unit on each line.
    Output charges w/ time rounded This check box is not typically selected. If selected, charges are rounded up to the next whole unit.
    Output page totals for multi-page claims Select this check box to have totals for each page of a claim to be included at the end of each page. If this option isn't selected, totals are provided at the end of the claim.
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    Override ID Qualifiers

    Use the Override ID Qualifiers area of the CMS-1500 tab to override the qualifiers provided by the system. These Legacy ID Qualifier overrides will also be incorporated in EDI claim files in the appropriate loops and segments. The settings in this section support some unusual requirements from payers, primarily required qualifiers for legacy identifiers.

    CMS-1500 tab Override ID Qualifiers section

    Block Qualifier Description ID
    17a Referring Provider Legacy ID 0B
    1B
    1C
    1D
    1H
    E1
    G2
    24i Rendering Provider Legacy ID 0B
    1B
    1C
    1D
    1H
    E1
    G2  
    32b Facility Legacy ID 0B
    1B
    1C
    1D
    1H
    E1
    G2
    33B Billing Provider Legacy ID 0B
    1B
    1C
    1D
    1H
    E1
    G2
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