Insurance Payers List

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Once you have contracted with payers, created e-Correspondents, and entered billing IDs for the Practice and each Provider who will receive payment for services, you will need to enter an insurance payer record and an associated provider record for each contracted payer.

To submit a HCFA claim/file for payment to an insurance payer (carrier), two records need to be maintained: the Insurance Payer record, which stores insurance payer information, and the Associated Provider record, which stores information about the provider(s) associated with the insurance payer. If a provider is not associated with a payer, you will be unable to generate a claim with this provider/payer combination.

Contents

[edit] Opening

To open the Insurance Payers List:

Go to the menu bar at the top of the Office Practicum screen and click Utilities --> Manage Codes --> Insurance Payers --> Insurance Payer - Provider Info.

[edit] Insurance Payer records

[edit] >Creating an Insurance Payer record

Initially, the payer list only contains a single entry for SELF-PAY ("SP"). This default payer should be assigned to any patient who is responsible for his own charges. In addition to people without insurance, this might include insured patients for whom you are not a participating provider and do not wish to send claims directly.

In most cases, however, you will probably want to participate with a variety of payers that are well represented in your area. For each payer, you must create an Insurance Payer record. To do so, follow these steps:

  1. Open the Insurance Payers List.
  2. Click the Image:Insurance Payers List Add Payer button.jpg button at the top of the window. The Insurance Payer Details form will open in a new window.
  3. Enter the following information about the new insurance payer in the Insurance Payer Details window:
    • OP code - A three-character alpha/numeric entry assigned by the user. This must be a unique code that will help you identify the payer.
      NOTE: When assigning this number, you can use any characters you like, but choose carefully, because 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 "UN1", "UN2"..., etc. for United Healthcare payers.
    • Short Name - A shorter (up to 15 characters) version of the payer's name that appears on many lookup lists.
      NOTE: 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 - Name of the payer to be printed on the HCFA form.
    • Address - Address of the payer to be printed on the HCFA form. This information should be entered as you would expect it to appear on the top of a HCFA for claim-mailing purposes, AND must include the city, state and zip code.
      NOTE: The address fields are optional if you are certain that only electronic claims will ever need to be sent for this payer.
    • Contact Name/Phone/Note - Optional reference fields to help you contact the payer for claim status, eligibility, etc.
  4. Make selections among the following billing parameters, ONLY IF you are NOT using Transaction Routing as is the standard recommendation:
    • Exclude this carrier from the Electronic Billing Transmittal process - To select, check (click) the box to the left.
      NOTE: Make this selection ONLY if claims for this payer cannot be sent electronically through your clearinghouse, AND you are NOT using Transaction Routing. By selecting this option, the system will mark this payer as needing to drop to paper in your office.
    • Check if charges are to be listed under Patient Responsibility - To select, check (click) the box to the left.
  5. Enter the National Payer ID, ONLY if this payer IS being sent electronically through your clearinghouse AND you are using Transaction Routing. If you are sending the claim electronically, entering this number is mandatory. It is optional ONLY if you selected Exclude this carrier... (see Step 4 above). This number appears on line 10 of a HCFA and is generally obtained from a patient insurance card for the selected payer.
    NOTE: Usually this is a 5-digit NAIC code, but some clearinghouses assign their own special value for certain payers, especially Medicaid/Medicare and Blue Cross affiliates. 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.
  6. Enter the Claim Payer ID ONLY if this payer IS being sent electronically through your clearinghouse. This number is either assigned by your clearinghouse, or is the same as the National Payer ID (see Step 5 above). 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 payor id lists.
  7. Enter the Real-time ID if you are signed up for real-time eligibility within Office Practicum. This number is either assigned by your clearinghouse, or is the same as the National Payor ID (see Step 5 above). Your office needs to verify if your clearinghouse assigns their own numbers to payers. Contact your clearinghouse for their specific payor ID lists.
  8. In the NPID Status field, click the Image:Down Arrow.jpg button and select one of the following:
    • Inactive - This option indicates that you will be including your tax ID and legacy number's on this payer's claims. This option will not send NPI information electronically and should therefore be selected ONLY when a payer CANNOT accept NPI numbers.
      NOTE: On print image and CMS-1500, both NPI and legacy Provider ID print. On ANSI 837, only Tax ID and legacy Provider ID are included in the claim file.
    • Primary - This option indicates that you are including your NPI numbers on this payer's claims as the primary identifier, and including your legacy numbers as your secondary identifier.
      NOTE: On print image and CMS-1500, both NPI and legacy Provider ID print. On ANSI 837, NPI is the primary identifier, and tax ID and legacy Provider ID (if available) are included as secondary IDs. As of fall 2007, this is typically the best choice.
    • Primary Only - Old ID excluded from CMS" - This option indicates that you are including your NPI numbers only on this payer's claims.
      NOTE: In all output formats, legacy Provider ID is suppressed.
    • Repeat Provider NPI in Box 33 - This option indicates that you are including your personal NPI numbers in all locations on this payers claims, even if your practice has its own NPI. This option is infrequently required and should only be used only when specifically requested by the payer.
      NOTE: In all output formats, the Rendering Provider's personal NPI is repeated in Box 33/billing provider loop.
  9. Select the Claim Type of the paper by clicking the Image:Down Arrow.jpg button and selecting from the drop-down menu.
    NOTE: Most commonly used types for this field are:
    • "CI - commercial payers"
    • "BL - Blue Cross/Blue Shield"
    • "MC - Medicaid"
    • "CH - Champus/Tricare"
    • "AM - automobile (for accidents)"
    • "WC - workers compensation"
    • "09 - Self-pay"
  10. "Fee schedule" Select the Fee Schedule associated with this payer's claims.
  11. In the Reimbursement field (new as of OP 8.1 Build 63) you can select the fee schedule by which you expect reimbursement from the insurance payers. For more information on entering fee schedules, click here.
  12. If the payer participates in the Vaccines for Children (VFC) program, select the VFC Eligibility value from the drop-down list. For most commercial payers, "5/NOT ELIGIBLE" is the correct choice. See VFC for more information.
  13. In the Use Taxonomy field, select "Do Not Show Providers Taxonomy Code on CMS 1500" if the specified payer does not want this entry on their claims.
  14. The Transaction Routing section in the lower half of the window is only for practices that are sending ANSI 837 claims. Generally, these are practices contracted for Full HIPAA Transaction services (e-Billing). See Transaction Routing, below, for details.
  15. Click the Save button to save changes and return to the Insurance Payers List.
  16. Click Exit to close.

[edit] Modifying insurance payer information

  1. Open the Insurance Payers List.
  2. Click to highlight the Insurance Payer in question.
  3. Click the Edit Highlighted button. The Insurance Payer Details form will open in a new window
  4. Edit the fields as appropriate.
  5. Click the Save button to save changes and return to the Insurance Payers List.
  6. Click Exit to close.

[edit] Blocked and Substituted Codes

Depending on insurance company requirements, your office may need to block a specific CPT code and substitute an alternate code to ensure processing of a claim. Once you have blocked a code and entered a substitute, the system will automatically replace the blocked code with its substitute.

[edit] Creating a list of blocked/substituted codes

  1. Go to the menu bar at the top of the Office Practicum screen and click Utilities --> Manage Codes --> Insurance Payers --> Blocked and Substituted Codes. The Blocked and Substituted Codes table will open, displaying a list of previously blocked and substituted CPT codes for all insurance carriers in the table in the lower portion of the window.
  2. Click the Add button in the task bar.
  3. Click on the Image:Lookup button.jpg button. The Insurance Carrier Lookup window will open.
  4. Click to highlight the desired Carrier in the Lookup window, then click the red arrow button to select and return to the Blocked and Substituted Codes table.
    NOTE: If you are blocking/substituting the same code for multiple payers, you must repeat this process for EACH payer. If you are blocking/substituting the same code for ALL payers, you can select the 'All Payer' payer record (as introduced with the 2009 CPT code update).
    NOTE: The OP three-character alpha/numeric code for 'All Payer' is [*]. However, if there are two rules entered for the same blocked code (one for all payer and another for the individual payer), the individual payer rule will trump the all payer rule.
  5. Enter the CPT you would like to block in the Blocked Code field. You can also click the CPT button, located in the same yellow box, and select a code from the CPT Code table.
  6. Enter the CPT you would like to substitute in the Substitute Code field. To enter a modifier, click the Image:Down Arrow.jpg beside the Modifier field and select a modifier from the drop-down list. You can also enter the modifier code by typing it directly in the field.
  7. Click the Image:Down Arrow.jpg beside the Activation Date field to select the date from a drop-down calendar. The Activation Date is set by default to the current date.
  8. Click the Save button to save and exit.

Note that you will not see the substitution until you into the superbill into the claims screen. At that time, you will be notified that the code has been substituted for that particular payer.

[edit] Helpful Hints

The Modifier Code enables a doctor to indicate that a procedure has been altered, but not changed in its definition or code. The modifier codes that are shipped with Office Practicum, listed on the Modifier Code drop-down list, represent the most commonly used codes. For additional information about the use and explanation of modifier codes, please refer to the American Medical Association's CPT resources catalog.

[edit] Attaching an NPI number to an insurance payer record

To comply with NPI Requirements for 2008 , the NPI status of each payer record in your system will have to be modified as follows:

  1. Follow Steps 1-3 in Modifying insurance payer information, above.
  2. Once you have opened the Insurance Payer Details form, click the Image:Down Arrow.jpg button to the right of the NPI Status field, and select the following:
    • Primary Only - Old ID excluded from CMS - This option indicates that you are including your NPI numbers only on this payer's claims.
      NOTE: In all output formats, legacy Provider IDs as entered on the associated provider records are suppressed.

[edit] Associated Provider records

[edit] >Creating an Associated Provider record for an insurance payer

Once a payer has been entered into OP, you then need to create an associated provider record for each of the providers credentialed with this payer. In order to generate a claim for a provider/payer combination, the provider(s) MUST be associated with the payer in the Insurance Payer List.

  1. Open the Insurance Payers List.
  2. Click to highlight the Insurance Payer in question.
  3. Click the small Image:Add.jpg button to the left of the Insurance Payer Name. The listing will expand, displaying associated providers for this payer.
  4. Click the Image:Add.jpg button in the small tool bar below the Associated Provider listings for this payer. The Insurance Carrier Provider Information window will open.
  5. Complete the following in the Insurance Carrier Provider Information window:
    • Provider's Initials - Select from the provider drop-down list
    • Provider ID (Line 24J) - Assigned by the payer; should appear in box 24 J (this is an identifier issued by the selected insurance payer and assigned directly to the provider; if the provider was not assigned an individual number by the payer, enter the practice tax id).
    • Type of Provider ID (to the left of Line 24J field) - The most commonly used types for this field are:
      • 24 - EIN/Federal Tax ID
      • G2 - assigned by a commercial carrier
      • 1B - Blue Cross/Blue Shield numbers
      • 1D - Medicaid number
      • 1H - Champus/Tricare ID
        NOTE: DO NOT enter a National Provider ID (NPI) in this field. NPIs should only be entered on the Provider Directory.
    • In the drop-down field to the far right, further identify the number entered in the Line 24J field as assigned to either a person or a corporation (e.g., if it is a personal pin number, select "Person"; if it is a tax ID, select "Corporation"). Click the Image:Down Arrow.jpg button and select from the drop-down menu accordingly.
    • Practice ID (Line 33B) - Number assigned by the payer for use in line 33B (this is an identifier issued by the selected insurance payer and assigned directly to the practice; if the practice was not assigned an individual number by the payer, enter the practice tax ID).
    • Type of Practice ID - Select the type of number entered in 33B for identification; most commonly used types for this field are:
      • 24 - EIN/Federal Tax ID
      • G2 - assigned by a commercial carrier
      • 1B - Blue Cross/Blue Shield numbers
      • 1D - Medicaid number
      • 1H - Champus/Tricare ID
        NOTE: Again, DO NOT enter the practice's National Provider ID (NPI) in this field. NPI's should only be entered in the Provider Directory.
    • In the drop-down field to the far right, further identify the number entered in the Line 33B field as assigned to a person or a corporation (e.g., if it is a personal pin number, select "Person"; if it is a tax ID, select "Corporation"). Click the Image:Down Arrow.jpg button and select from the drop-down menu accordingly.
    • Capitation ID (Optional) - If patients on this insurance plan must be enrolled with your practice before receiving services, enter the payer-assigned Office ID that would appear in their insurance records.
    • Locator Code (Optional) - Medicaid Locator Code; should be 3 numbers.
  6. Click Save to save changes and return to the Insurance Payers List window.

[edit] >Modifying an Associated Provider record

From time to time, your office may need to edit a provider pin or group number, as identified by a payer. To do so, follow these steps:

  1. Open the Insurance Payers List.
  2. Click to highlight the Insurance Payer in question.
  3. Click the small Image:Add.jpg button to the left of the Insurance Payer Name. The listing will expand, displaying associated providers for this payer.
  4. Click to highlight the associated provider record you wish to edit.
  5. Click the small Image:Edit.jpg (edit) button in the small tool bar below the Associated Provider listings for this payer. The Insurance Carrier Provider Information window will open.
  6. In the Insurance Carrier Provider Information window, edit the fields as appropriate.
  7. Click the Save button at the bottom of the form to save changes and return to the Insurance Payers List window.
  8. Repeat these steps as necessary for each associated provider for this payer.

[edit] Transaction Routing

NOTE: The Transaction Routing section of the Insurance Payer Details form is generally used by practices contracted for Full HIPAA Transaction services (e-Billing). As of Release 1780 Build 5 of Office Practicum, practices not contracted for these services are able to use this feature as well. However, as this feature is complex, we ask that all Office Practicum clients begin using Transaction Routing ONLY in cooperation with a Billing Trainer. If you have questions regarding this matter, please contact Office Practicum Support at (800) 218-9916.

[edit] Entering transaction routing details

If your practice has only one E-Correspondent (e.g., a clearinghouse that handles all your electronic transactions), you will only need to select a Default correspondent. By doing so, you will direct the system to use the selected correspondent for each transaction type on the E-Correspondent form. This is generally the best choice, as it minimizes the adjustments you will need to make if you change your primary correspondent in the future.

Practices with several E-Correspondents (e.g., practices that send some claims directly to certain payers, with the remainder being forwarded through a clearinghouse) may need to override the transaction routing defaults for the direct payers. In this case, the following three values must be entered for each type of transaction:

  • Correspondent - Choose a previously defined E-Correspondent from the drop-down list. Note that only correspondents who are capable of supporting the selected transaction type will appear in this list.
  • Interchange ID - This value is almost always blank, because the Interchange ID is part of the E-Correspondent record. However, in special situations where a payer is forwarding transactions to another payer (e.g., your 'home' BCBS plan forwards claims to another BCBS affiliate), you may need to enter an override value here.
  • Status - Almost always "Production", unless the payer requires you to submit some transaction in "Test" mode before going live.

The last three fields pertain to real-time requests for patient eligibility and benefits. This transaction requires a request made by a specific individual. If you are a solo provider, your name and ID(s) (or the practice name and ID(s), depending on the payer's requirements) should be entered in these fields. If your practice has several providers, you either need to enter the practice information (if the payer allows it) or pick a specific provider from whom all requests will seem to be coming.

Each payer may require slightly different information regarding the requesting provider, but here are general rules to follow:

  • Send eligibility as - If sending as the practice, enter the practice name in the first field and leave the second field blank. If sending as an individual, enter the last name in the first field, and the first name in the second field.
  • Primary ID - Choose an ID type (Service Provider ID means a unique ID provided by the payer; the rest are self-explanatory) and enter the ID number in the field to the right.
  • Secondary ID - Most payers only require a primary ID (and this will be the rule after universal adoption of NPIDs in 2007), but you may also need to enter a secondary ID for certain payers. Again, choose a type (these are all self-explanatory)and enter the ID number in the field to the right.

[edit] Troubleshooting/FAQs

[edit] Printing HCFAs

  • How Do I enter a locator code to print on NY Medicaid HCFA form?
    1. Click on Utilities in the main menu.
    2. Select Manage Codes --> Insurance Payers --> Insurance Payer - Provider Info
    3. In the Insurance Payers List form, locate the Medicaid insurance record.
    4. Click the Image:Add.jpg (plus) sign to the left of the OP Code for Medicaid to display the provider information.
    5. Click to highlight the provider name.
    6. Click the Image:Edit.jpg (edit) button to display the Insurance Carrier Provider Information form.
    7. At the bottom of the form, enter the 3-digit Medicaid locater code in the Locater Code box.
    8. Click the Save button at the bottom of the form.
    9. To print the Medicaid HCFA:
      1. Press F12 to open the Patient's Account.
      2. Choose the patient, if necessary.
      3. Click the Print button.
      4. From the HCFA drop-down button, choose NY Medicaid.
      5. Check the box next to the claim that you want to print.
      6. Put the NY Medicaid HCFA forms in the appropriate tray in your printer and click the Begin button to print.
  • How do I print a HCFA for a self-pay patient?
    • To print a HCFA for a self-pay patient whose insurance you don't accept, you must first create a self-pay insurance record for the patient. To do so:
      1. Begin the procedure for creating a new patient insurance record. Please see Creating a new insurance record.
      2. Instead of selecting an insurance payer in the Insurance Carrier Lookup form (Step 5), select SELF-PAY.
      3. Enter the Subsciber ID number and group numer of the insurance policy not accepted.
      4. You must then switch the charges from Patient balance to Insurance balance in order to print the HCFA.
  • Why do I get an error when printing a HCFA?
    • You may have received the following error when printing a HCFA form
      Error message: "DBISAM Engine Error # 11013 Access denied to table ‘HCFA_HEADER’"
    • To identify the source of the problem and rectify it, please:
      1. Ensure your OP system is on the latest release. To check for the latest release, please see Release Notes.
      2. Then check your OP system specs by clicking on Help at the top of the screen, and scrolling to the word About. The screen that appears will provide you with your version and release ("build") number.
      3. Ensure that your computer is NOT using terminal services.
      4. Ensure that the person using the computer has FULL privileges to read and write to the OP Folder.
      5. Log-out of Office Practicum.
      6. Go to C:\OP\data (the C drive on your computer).
      7. Locate the folder called OP.
      8. Double-click to open the sub-folder called Data.
      9. Delete everything in the data folder.
      10. Log back into Office Practicum.
    • The steps above should rectify the problem. If you still receive the same error message when printing a HCFA, please contact a representative at Connexin Software, Inc.
  • Why won't the insurance address print on top of the HCFA?
    • When the client creates a claim file using Map v1 or Map v2, the insurance address on top of the HCFA will NOT print out. They haven't sent any claims yet. This happened because the insurance carrier address information was put in after the charges where submitted to the queue.
    • To make this happen,
      1. Clear the Queue.
      2. Transfer the claims back into the queue.
      3. The claims will now printed properly, with the carriers address at the top.
  • Can I batch print HCFA's for a payer(s) that is supposed to be submitted electronically?
    • If you are having problems submitting electronic claims for a specific payer and want to drop these claims to paper, follow these steps:
      1. On the main menu bar at the top of the Office Practicum screen, click Utilities > Manage Codes > Insurance Payers > Insurance Payers - Provider Info.
      2. Click to highlight the payer, then click Edit Highlighted.
      3. In the Transaction Routing section of the screen, located toward the bottom of the payer screen, change the claim transmission (837) correspondent field to Standard HCFA by clicking the down arrow and selecting from the drop-down list.
      4. The default routing for the specified payer will be set to Standard HCFA. You can now transfer the specified claims back to the transmittal queue and OP will recognize that these claims need to print on paper.
    • If you need to drop ALL claims to paper for ALL payers, you can simply reassign the default correspondent from your clearinghouse to Standard HCFA as follows:
      1. On the main menu bar at the top of the Office Practicum screen, click Utilities > Manage Codes > e-Correspondents.
      2. Locate the Standard HCFA correspondent and click on it to select it.
      3. Next, click on the Transaction Routing tab.
      4. Check mark both the Default and Supported columns for the Claim Transmission (837) line.
      5. The default routing for all claim transmission will be set to Standard HCFA. You can now transfer the specified claims back to the transmittal queue and OP will recognize that these claims need to print on paper.
  • What do I do after I batch print my HCFAs?
    • After you batch print HCFAs:
      1. Close the print screen.
      2. Click the Clear from queue button. This will remove the printed claims from the queue.
      3. Each claim will be marked as 'HCFA printed' in the individual Patient's Account. (Refer to the log on the claims screen for record of this action).
    • Once these excluded claims are removed from the queue,
      1. Proceed to process electronic claims.
      2. Once electronic claims are sent to your clearinghouse, click Update status and clear to enter the clearing house confirmation number (batch id) and remove these claims from the queue.
      3. Again, each claim will be marked as sent to the clearinghouse (with the batch id) in the individual patient account.

[edit] Managing and editing HFCAs

  • How do I adjust the margins on my HCFA?
    • If your HCFA is printing out of the margins on a standard HCFA form,
      1. Go to File (on the menu drop down).
      2. Select Printer Setup.
      3. Click on HCFA or RB HCFA and unselect Use Printer Defaults.
      4. Adjust the margin fields for top or left based on your needs.
      5. Click on Save then Exit.
      6. Print a HCFA to determine if your problem is corrected.
      7. If not corrected, repeat the steps above and increase/decrease the margin field as appropriate.
      8. Continue to do this until your HCFA is printing within the margins.
  • How Do I Select HCFA Field Items to Appear In Add/Edit Charges Screen?
    1. Press F12 to access the Patient's Account.
    2. Select Charges.
    3. Click Add/Edit Charges.
    4. In the Middle, Right side of the screen, under the LookUp CPT button, Click on the Utility Icon (little box that looks like a sideways bar code).
    5. A vertical menu will open.
    6. Check each field item that you wish to see when entering charges.
  • How do I show only Provider NPI numbers on the HCFA form or 837 file?
    • Typically the HCFA form requires both the Provider NPI number AND the practice NPI number. However, some Insurance Payers are requesting that ONLY Provider ID numbers appear in BOTH fields on the HCFA form. If your Insurance Payer requests that ONLY Provider NPI numbers appear on the HCFA you must follow the steps below (dependent on your version):
      1. Click on Utilities.
      2. Scroll down to Manage Codes > Insurance Payers > Insurance Payer - Provider Info.
      3. From the Insurance Payers List that appears, click on the name of the Insurance Payer in question.
      4. Click on the button titled Edit Highlighted.
      5. The Insurance Payer Details screen will open. On this screen, you will need to locate either the field called NPI Status or the fields called Rendering Loop and Billing Loop.
      6. If your OP version has the NPI Status field, select the last choice in the drop-down Repeat Provider NPI. If your OP version has the Rendering Loop and Billing Loop select the Provider NPI Only option for each field. These selections will place the Provider NPI number on the HCFA in BOTH fields, in place of the Practice NPI number.
        NOTE: If you have legacy numbers and/or qualifiers on the associated provider records, these fields will need to be cleared out for NPI compliance (where a payer states that claims will reject due to the presence of a legacy number reference).
        • For the 24J and 33B, clear out the current number and click on the space bar (you will not be able to save the record if the field is completely blank - so enter a space in the field and OP will allow the save);
        • For the qualifier and entity type fields, highlight the current entry and backspace to clear the fields; click on Save.
    • If you do NOT have the choice Repeat Provider NPI in that drop-down, you need to run a quick Update of Office Practicum.
    • If you do not know how to run the OP Upgrade program, please contact a representative at Connexin Software, Inc to assist you with running the Update.

[edit] Editing Information

  • To access and edit the Insurance Payer-Provider Info, go to the main menu bar at the top of the Office Practicum screen and click Utilities > Manage Codes > Insurance Payers > Insurance Payer-Provider Info.
  • How do I edit the Provider pin, group number or qualifiers for an Insurance Payer?
    1. Go to Insurance Payer-Provider Info.
    2. Select the specified Insurance Payer from the list and click the plus sign to the left of the record to open the associated provider list.
    3. Select the Provider that needs to be edited from the list of Providers given.
    4. With the correct Provider selected, click the Image:Edit.jpg (edit) button below the list of Providers. This will open the Insurance Carrier Provider Information window
    5. In Line 24J enter the pin number for the provider in the first box.
      • Optional by payer: identify this number by selecting the appropriate Type from the pull down menu and select person or corporation as appropriate. Qualifier selected will print on the hcfa preceding the pin# entered in step 8 above.
    6. In Line 33b, enter the pin number (or group number) for the corporation in the first box.
      • Optional by payer: identify this number by selecting the appropriate Type from the pull down menu and select person or corporation as appropriate. Qualifier selected will print on the hcfa preceding the pin# entered in step 10 above.
    7. Click on Save to save the changes and, if needed, make the same changes to the other providers in the practice.
  • How do I make an associated provider inactive?
    1. Go to Insurance Payer-Provider Info.
    2. Select the Insurance Payer in question.
    3. Click the Image:Add.jpg (plus) sign to the left of the Insurance Payer.
    4. Select the Provider necessary.
    5. Click the Image:Edit.jpg (edit) button underneath of the provider list.
    6. In the Insurance Carrier Provider Information page look for a check box in the bottom of the box.
    7. Check the box that says Check if Status is Inactive for this provider.
  • How do I enter an interchange ID?
    1. Go to Insurance Payer-Provider Info.
    2. Select the specified payer.
    3. Click on Edit Highlighted.
    4. Scroll down to the Transaction Routing section of this screen (in OP 8 and above, click on the Claims/Routing tab).
    5. To the right of the Claim Transmission line, click on the drop-down box to select the appropriate clearinghouse in the correspondent field.
      NOTE: This field cannot be listed as "default".
    6. Next, enter the Interchange ID for the specified payer in the appropriate field.
      NOTE: The Interchange ID is provided by the specified payer.
    7. Click on Save and Exit.
  • Why is the Tax ID not posting on the claims?
    • If Tax ID is already in the Provider Directory, and still not showing up, go to:
      1. Go to Insurance Payer-Provider Info.
      2. Highlight and click on the Insurance Payer.
      3. Click on Edit Highlighted.
      4. If you are using OP 8 and above, click on the Claims/Routing tab.
      5. Go to NPI status and click on triangle button scrolling down to click on either PRIMARY, PRIMARY ONLY, or REPEAT. Make sure Inactive is not chosen. For more information, please see NPID Status.
      6. Click the Save button.

  • How do I remove the insurance name and address from claims?
    • To have the insurance name and address not appear on the HCFA form, follow these steps:
      1. Go to Insurance Payer-Provider Info.
      2. Highlight and click on the Insurance Payer.
      3. Click on Edit Highlighted.
      4. Remove the full name, address, city, state and zip code.
      5. When finished, click the Save button at the bottom of the screen.
  • How do I process an EOB/ERA payment from a primary payer if the patient has secondary insurance?
    • Manual Payment Entry from EOB:
      • When entering the payment from the primary carrier:
        1. Enter the amount paid; DO NOT enter an adjustment amount, even if an adjustment is listed on the primary's EOB, as the secondary carrier may choose to make an additional payment against this "adjusted" amount.
          NOTE: If your office does process the adjustment as identified by the primary payer, you can still proceed to transfer the claim to secondary - see step 2.
        2. Once you have entered the payment amount from the primary, click on the xsfer Balance to 2nd ins button located to the right of the Insurance Payment field. This will switch the insurance fields on the HCFA, allowing you to print a HCFA - with the secondary insurance payer listed at the top of the form, and the primary now appearing in the 'Other Insurance' field.
          NOTE 1: This option is available EVEN IF the cpt is paid in full and/or you selected to enter an adjustment amount based on the primary adjudication.
          NOTE 2: If your office is on 8.1 Build 139 or higher, be advised that the insurance payment, insurance adjustment and patient balance field are directly linked so to transfer an amount to the secondary payer, you would need to make manual entries in the insurance adjustment and patient balance fields as appropriate. If done, there will be a remaining unpaid insurance amount on the line item and then you will be able to select xfr to secondary as the next action to take.
        3. You should now print this HCFA for submission to the secondary carrier, and mail it with a copy of the EOB received from the primary carrier.
    • Automatic Payment Entry from Adjudication Table:
      • When approving the payment from the primary carrier:
        1. Delete entries in the insurance adjustment fields and/or patient responsibility fields, according to your standard procedure for submitting claims to secondary payers. As these amounts are deleted, OP will list the unpaid balance and automatically set the claim to transfer to the secondary payer as the next action to take.
        2. Click on approve and post (as is standard procedure for posting adjudications) and OP will post the amount paid and any adjustment amounts still listed on the adjudication (if not deleted by the user as listed above). OP will automatically switch the insurance fields on the HCFA, allowing you to print a HCFA - with the secondary insurance payer listed at the top of the HCFA, and the primary now appearing in the 'Other Insurance' field.
        3. You should now print this HCFA for submission to the secondary carrier, and mail it with a copy of the EOB/ERA received from the primary carrier. Generally, you should be able to obtain a copy of the corresponding EOB (for this ERA) on your clearinghouse or payer website.
  • How can I keep track of accounts that have been forwarded to my collection agency?
    • To maintain a list of accounts forwarded to your collection agency:
      1. Create an insurance payer record called 'In Collection'.
      2. The next time an account is turned over to a collection agency, press F12 to open the Patient's Account.
      3. Click the plus button in the tool bar to add a new insurance record.
      4. Assign the patient to the 'In Collection' payer, as you would any other payer (e.g., BCBS, United Healthcare, etc).
      5. You will now be able to run payer reports on accounts that have been placed in collection.
    • Remember to also put a patient note and stop code on the account, so that the front desk will know that the patient is in collection and cannot be scheduled for an appointment, if this is your office policy.
  • How do I remove primary or secondary insurance from a patient account?
    • Access the Insurance Record for the specified patient by pressing F3. To clear the primary insurance and set the account to selfpay:
      1. Click on the Image:Edit.jpg (edit) button on top of window.
      2. A popup box may appear stating that the insurance id is in use and cannot be edited or deleted.
        Optional: Click on the Policy Status drop down box and select Inactive.
      3. Click on the Clear button in the lower left half of the screen.
      4. The system will prompt you to confirm: Clear this patient's primary insurance and set as selfpay?.
      5. Click on Yes.
      6. Click on the Image:Check.jpg (check mark) to save changes.
        NOTE: This will need to be done for accounts where a selfpay insurance record was setup in error.
    • The steps are the same to remove the secondary insurance.
  • How do I add a modifier to the drop-down lists on the add/edit charges or superbill screen?
    • The list of modifiers is pre-set and cannot currently be updated to add a new modifier to this existing list. However, if the modifier you need for your claims is not on the field drop-down list, you can manually enter it in the modifier field:
      1. Got to either the add/edit charges screen or the Superbill screen.
      2. You should see a modifier column. If the modifier column is not visible,
        1. Click on the box to the extreme left of the column header line. (This box has several horizontal lines.)
        2. Check (make visible) or uncheck (make invisible) the columns that appear on your screen.
      3. Select the specific CPT.
      4. Either click on the drop-down to select from the pre-set list of modifiers or manually enter your own into this field. #Click on the Image:Check.jpg (check mark) to save prior to exiting the screen.
  • How do I record monies due/paid to our Collection Agency as a result of patient payments?
    • Some offices employ a Collection Agency to assist with overdue accounts. If your agency invoices you for a % of payments received from these overdue accounts, you can record these payments as follows:
      1. When the patient payment is received, enter the amount of the money that the office is due in the payment field (eg. total received less the amount due to the collection agency).
      2. Enter the amount due to the collection agency in the adjustment field.
      3. Select the adjustment type as Collection Agency fee. (For instructions on adding this adjustment type to OP, please see Adding adjustment codes).
      4. Enter the amount (received from the patient) that you are responsible for remitting to the Collection Agency as a patient credit.
      5. In the note field of the credit, enter the details of this transaction. (Eg. Payment for dos xx/xx/xx; 50% of payment due to Collection Agency).
      6. Once payment is sent to the Collection Agency, enter a credit refund with the details of the payment remit back to the Agency. (eg. ck #xxx issued to 'Name of Collection Agency').
  • What do I do if the insurance provider ID type I need is not available in the drop-down menu?
    • For Versions 7.1777 and beyond, if an insurance company requests an unusual provider type code that is not already listed in OP, you can add a new type code by following these steps:
      1. On the main menu bar at the top of the Office Practicum screen, click: Utilities > Manage Codes > HIPAA Code Table.
      2. Click Provider ID Type.
      3. Click the Image:Add.jpg (plus) sign to add a new provider ID type and enter all information.
      4. Click the Image:Check.jpg (check mark) button to save.
      5. This option will now be available in the insurance carrier provider info window.
  • How do I process an eob from a secondary payer?
  • How can I make an Insurance Payer inactive?
    • If you no longer take an insurance, you may inactivate the Insurance Payer. This should only be used when you are certain that you will not need to use the insurance payer any longer.
      • If you are not sure whether to delete the insurance payer,
        1. Click on F9 eBill.
        2. Click on the Claims tab.
        3. Click on Open Claims on the lower tab.
        4. Click the drop down menu to select the Payer.
        5. Look at the number of claims that you have open for this insurance. If there are a significant number of claims, consider waiting to inactivate the insurance payer.
      • To inactivate the payer,
        1. Go to the menu bar at the top of the Office Practicum screen and click Utilities > Manage Codes > Insurance Payers > Insurance Payer - Provider Info.
        2. Highlight the Insurance Payer that is no longer in use.
        3. Click Edit Highlighted.
        4. Click on the radial button in front of Inactive.
        5. Click Save.

[edit] Miscellaneous

  • What do I do if a payer does not support realtime eligibility?
    • If you determine that a specific payer CANNOT be validated as they are not listed in guide or your clearinghouse confirmed that the payer does not support this feature, you should edit the corresponding payer record to note this.
      1. Go to the transaction routing section of the payer record.
      2. Change the entry in the eligibility & benefits field to Standard Hcfa or Selfpay.
      3. OP will then recognize that electronic validation requests cannot be made for this payer. When you clicks on validate on a patient insurance record for this payer, OP will prompt Real time eligibility is not available for this payer. Would you like to mark this policy as 'manually verified?' You can then select yes, no or cancel as appropriate.
  • What qualifier do I use for an insurance assigned provider ID number?'
    • If you input an insurance assigned provider ID number In the shaded area in line 24J, then you must use the corresponding qualifier. Qualifier G2 works for some commercial insurances and 1B works for Blue Cross Blue Shield, but you should contact your clearinghouse and insurance companies to be sure.
  • Why is Insurance validation not working for a specific payer?
    • If Insurance Validation for a specific payer is not working, please refer to the Eligibility Transaction Guide that was provided by your clearinghouse. It could be that the Primary ID (refer to the send eligibility as fields on the payer record) or Payer ID# (refer to the Real-time ID field on the payer record) you have listed to check eligibility is incorrect, or that a secondary id is necessary for successful validation. Please refer to the guide, correct it and try to validate again. If the you do not have this guide, you can obtain the most current guide directly from your clearinghouse.
    • If you determine that a specific payer CANNOT be validated as they are not listed in the guide or your clearinghouse confirmed that the payer does not support this feature, refer to the solution: What do I do if a payer does not support realtime eligibility?

[edit] See also

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