General Billing Data Tab
The General Billing Data tab in the Edit Payers window contains general set up information about the payer's billing requirements. On this tab, you specify the billing method, which designates the format used to bill the payer.
Payer Group: If the payer is part of a payer group, select it from the Payer group drop-down list. Payer groups are used if you work with several payers who are essentially the same insurance company. For example, you may work with several Blue Cross Blue Shield payers and claims are all processed by one Blue Cross Blue Shield company. In this case, you can assign each Blue Cross Blue Shield to a payer group called Blue. This facilitates applying payment when you receive a check from Blue Cross Blue Shield that provides payment for claims to multiple Blue Cross Blue Shield payers. You can set up additional payer groups using the Settings menu (Payers-->Groups). Once the payer group has been created, it is ready to use in the General Billing Data tab, in the Payer Groups field.
Billing Info and EMR Settings
- Paper Billing Name and EDI Billing Name: These fields are automatically set when you enter a Payer name when setting up a new payer. If, however, you accidentally enter the incorrect Payer name or you rename an existing payer, you will need to make manual corrections in these fields.
- Billing Method and Post Primary Billing Method: Specify how you submit claims to the payer using the Billing Medium drop-down list. Specify the method the payer requires when it is not the primary payer in the Post Primary Billing Method drop-down list.
- Billing Medium and Post Primary Billing Medium: Specify how you submit claims to the payer using the Billing Medium drop-down list. If you submit claims electronically via a file, select Electronic. If you print your claims and mail them, select Paper. Specify the medium the payer requires when it is not the primary payer in the Post Primary Billing Medium drop-down list.
- Bill Frequency: This field is only available for UB-04 claims. Typically, UB-04 claims are billed monthly. To be able to bill UB-04 claims on a more frequent basis, set Bill Frequency to Unlimited.
- Trading Partner: If you are submitting electronic claims, select the Trading Partner (this is the clearinghouse that you send electronic claims to, such as Waystar). Click here for detailed information on Trading Partner Setup.
Note: Trading partners must be set up before you can select one on the Demographics tab on the Edit Payers dialog box. Clinicient's Technical Support sets up trading partners. Contact Clinicient if you do not see the trading partner you wish to use. If you select BCBS Georgia as the trading partner, a logon/logoff file is created and included with EDI Medicare Part A claim submissions.
- Claim Type: Select the type of claim the payer accepts: Medicare-A, Medicare-B, Medicaid, Champus, Champ VA, Group Health Plan, FECA Black Lung, or Blue Cross/Blue Shield. If the payer does not accept one of these claim types, select Other or Unknown.
- Claim Variant: This field is reserved for certain payers with certain unique requirements. Do not make a selection here unless you are asked to do so by Clinicient.
- Billing Rule Set: Assign an existing billing rule set to the payer.
- ICD10 Effective Date: The date that ICD-10 diagnosis codes become effective for the selected payer. Note: The ICD-10 Effective Date must begin on the first day of the specified month or the system display a warning.
- Clinic View Settings: Select this option if you use electronic signatures. If this check box is checked, the therapist's signature line on clinical documentation will include elements of an electronic signature, including a date and time stamp as illustrated:
- Group Provider ID: Enter the provider ID assigned to your company by the payer. Note: not all payers assign unique provider IDs. We recommend you check with the payer to determine whether a group provider ID has been assigned and is required on claims.
- Group Provider PT ID, Group Provider OT ID, and Group Provider ST ID: If required by the payer, enter the payers physical therapist (PT), occupational therapist (OT), and speech therapist (ST) identification numbers.
- EDI Payer ID: If the payer accepts electronic claims, enter its EDI payer identification number. You will need this number to assist you with matching payer names in your system to payer names in the clearinghouse system. If the payer does not accept electronic claims, Clinicient recommends making note of that in the Demographics tab in the Notes section.
- ERA Payer ID: Used to identify electronic remittance files for use with ERA processing. The system will prompt you to assign the ERA Payer ID during ERA payment processing. See the ERA User Guide for more information.
- COBA ID #: If you have a Medigap COBA number, enter it in the COBA # text box.
In previous versions of Billing, the Medigap COBA number was stored in the EDI Payer ID entry box. The EDI Payer ID entry box is now used solely to identify the clearinghouse for payers you bill electronically.
- Medicaid CarrierCode: Some Medicaid payers require that the EDI Payer ID of the primary payer be replaced with a Medicaid Carrier Code in electronic claims submitted to Medicaid for which Medicaid is the secondary payer. In those instances, type the Medicaid Carrier Code in this field for the primary payer.
Note: In order to function properly, the Claim Type value on the General Billing Data tab for the Medicaid payer must be Medicaid.
Caregiver Credentialing and Billing Flags
In certain installations, these settings are unavailable because they should only be changed by Clinicient Support. For payers that require credentials of therapists, you can specify which therapists are credentialed with which payers. This reduces claim denials due to the lack of credentialing with a payer. To use the credentialing capability, you need to designate which payers require credentialing and which therapists are credentialed with which payers. Refer to Insurance Credentialing Setup for more information.
- Requires Credentials for Caregivers: If the payer requires credentialing, check this check box. Once you check this check box, the Credentialed Providers box displays on the bottom of the dialog box. You must specify which therapists are credentialed with the payer in this box (described below). You can also view credentialed caregivers in the Provider Credentialing section.
- Provides Caregiver Credential #: Select this check box if the payer requires a credential number to be on the claim. Prior to deselecting this check box, it is important to also clear the Provides Caregiver Credential # check box and remove all staff under the Provider Credentialing section.
- Authorization Required: Select this option if the payer requires authorization prior to treatment. This setting is used by the system to flag claims as Not Ready (and prevents them from being sent) when there is not a valid authorization in the case.
- Authorization Required - Post Primary: Select this option if a payer requires authorization even if it is a secondary or tertiary payer. This setting is used by the system to flag claims as Not Ready when there is not a valid authorization in the case.
- Use CMS Rounding rules: Select this check box if the payer allows the use of CMS rounding rules.
- Use CCI Rule Set: Applies the Correct Coding Initiative (CCI) rules to the payer.
This area is only available if you check the Requires Credentials for Caregivers check box. To add the name of a caregiver who is credentialed with the payer, click the Add button at the bottom of the Credentialed Providers box and then select a caregiver in the blank line that displays in the box. You can also specify credentialed caregivers on the Credentialing tab. Refer to Insurance Credentialing Setup for more information.
Claims / Statements
In certain installations, these settings are unavailable because they should only be changed by Clinicient Support.
- Print Authorization Number: Check to include the authorization number on the claim if present.
- Never Send Statement to Patient: Check this option if a statement is never sent to the patient. An example of when this might happen is if someone else—such as an attorney—is paying the claim.
- Print Claim on Statement ONLY when Claim is Patient Responsibility: If this box is CHECKED, only charges sitting out to patient responsibility will be reflected on the patient statement. This means items out to insurance nor items just paid by the patient will be listed. If this box is unchecked, the patient statement will include items still out to insurance and all patient payments posted since the last time the statement was printed (or from the Other Date if this option is chosen).
- Order charges by Service Date, Charge Amount Descending: This specifies the order charges appear on a claim. If this check box is checked, charges are ordered from the most expensive to the least expensive for each service date. If this check box is not checked, charges are ordered by CPT code.
- Zip + 4 Required in Paper Claim Billing Provider Address: Select this option to include the full Zip + 4 Zip Code in the payer's address.
- Print Chart Notes With Paper Claims: If this check box is checked, you can choose to print chart notes at the same time as when you print claims. This is useful for payers that require chart notes to be submitted with claims such as Worker's Compensation or Motor Vehicle Accident.
- Apply bundling modifier for multiple visits on the same date: If this option is selected, then INSIGHT adds a bundling modifier, such as Modifier 59, to claims that have the same date of service for a particular patient.
- Use XE/XU modifiers as bundling modifier: If this option is selected, then INSIGHT adds modifiers XE or XU in place of the typical bundling modifiers.
- Include Attachment Control Number (PWK) segment in EDI files: If this option is selected, then INSIGHT adds the PWK control number to the applicable segment in EDI files that are created.
- Case Claim Number is Property Casualty Number (PCCN): Used on some property and casualty claims.
- Workers Comp - Use Employer as Subscriber: Required on some worker's compensation claims.
- MVA/PI Payer - show as Patient Owed on Statements: Select this option to allow obligations to accumulate to a third party while showing those obligations as the patient's responsibility on the patient statement for the purpose of submitting documentation to the third party for reimbursement. If this is selected, the patient ledger shows any PI/MVA payer obligation as the patient's responsibility.
Required Data Entry Fields
In certain installations, these settings are unavailable because they should only be changed by Clinicient Support. Place a check mark next to each item that the payer requires in order to process the claim. Any item that is checked here will cause a charge to be flagged as unapproved on the Charges tab if information is not provided for the item. For example, if you check Social Security Number any charges for the payer that are missing a social security number are flagged as having an error.
If you check the Plans of Care check box, therapists are alerted when a new Plan of Care or Progress Report is due, and service dates are validated to ensure that claims fall within a valid certification period. In most cases, you should only check this check box for Medicare payers. There are additional settings you need to ensure alerts are generated when Plans of Care and Progress Reports are due. See this article for detailed information on Medicare Plan of Care and Progress Report Tracking.