Please review and complete the following items in your system account to ensure proper setup and seamless and efficient billing in your system.
NOTE: Throughout the system, you will see this CMS icon. These fields populate on the electronic claim form and are required to bill insurance.
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Setup Tasks
PERMISSIONS REQUIRED: You must have Administrative Permissions.
- Make sure all fields are completed under Organization > Settings. See Set Up Your Organization's Profile for more information. Take note of items below:
- Correct Address
- State with 2 letter abbreviation
- Zip code must have 5 +4 digit
- Organization NPI (Type 2)
- Add Service Types. See Add & Edit Service Types for more information.
- If you have multiple Type 2 NPI numbers, add locations to Use Location-Specific Group Settings.
- Payer Setup under Billing >Insurers:
- Add your payers
- Setup EDI File Settings under each payer
- Setup Staff
- Add & Edit Staff Members (you will enter their type 1 NPI number here)
- Assign AMA CPT Licenses to any provider using CPT codes
- Assign Billing Provider on Invoice- this article will explain the workflow for billing with type 1 NPI number.
- Client Setup
- Ensure the following items are added under Client > Details
- First and Last Name
- Client ID number. See Generate or Edit Client ID Number for more information.
- Home/Mobile Number
- Address (State is 2 letter abbreviation only)
- Date of Birth
- Legal Sex (must match what is on file with the insurance company.
- Ensure the following items are added under the Bill to and Insurance Tab (left side menu). See Add Insurance to Client Profile for more information.
- Effective Date- if unknown please use the earliest date you will bill.
- Insurer- Insurance Company
- Insured ID- Enter the Client's ID number from their insurance card. This is also commonly called the Policy Number.
- Plan Name-not required, but will appear on your Client's Insurance card. If no name appears they don't have one
- Policy of FECA Number - The FECA number is used in cases of Federal Workman's comp claims. Generally this box will be left blank. To satisfy Medicare requirements, type NONE.
- Group Number - Not all Client's will have a Group number, but if they do, it will appear on their card.
- Accept Assignment - To Accept Assignment means you are accepting the Payers contract rate. If you are In-Network with the Insurance, you must mark Yes.
- Authorize Payment to Provider - This means you want the payment sent directly to you. Check Yes
- Client Authorized Release of Information Necessary to Process Claims - Choosing Yes means that the Client has authorized you to release any medical information necessary to process this Claim. This includes diagnosis, procedure, and notes if requested by Insurance. Must be marked YES to submit a claim.
- Ensure the following items are added under Client > Details
Enrollment Tasks
PERMISSIONS REQUIRED: You must have Administrative Permissions.
- Complete the enrollment survey found under Organization tab. See Get Started: Claims with Ensora Clearinghouse for more information.
- Click Organization
- Click Claims Service
- Read over Information in the main content section of the page
- Click Request Electronic Insurance Claims Service
- Read over Terms and Conditions and select: Accept and Continue
- Enroll with Payers who require Enrollment
- Enrollment is required to receive ERAs even if EDI enrollment is not required
- Work with your Enrollment Rep to complete necessary tasks for enrollment. See FAQ: Enrollment Process for more information.
- An Apex Enrollment Rep will reach out to you in 2-5 business days, you will receive a welcome packet via email that needs to be returned as soon as possible. After it is returned, your assigned Enrollment Rep will email you further instructions.
Automation Settings (optional)
PERMISSIONS REQUIRED: You must have Administrative Permissions.
- You can enable Billing Automation for Claims Submission, Invoice Creation, Invoice Processing and ERA Processing. See Billing Automation Overview for more information.
- Click Organization
- Click Claims Service
- Click Automation Settings Tab
- Click the toggle to enable each automation as needed
- Billing Automation: Invoice Creation- When enabled, all existing unbilled Appointments in kept status (past, present and future) will automatically have Invoices created once this setting is enabled.
- You can exclude invoices from automatic creation by configuring exclusion rules.
- Once enabled, the Exclusion Rules window opens
- Select Conditions in the dropdowns for fields When (condition) Equals (condition)
- Click +Add Condition to add as many conditions as needed.
- Click +Add Rule to add as many rules as needed
- Click Save for each rule.
- You can exclude invoices from automatic creation by configuring exclusion rules.
- Billing Automation - Invoice Processing- When enabled, all existing Invoices (past, present and future) that have not been added to Claims Awaiting Submission will be automatically added to Claims Awaiting Submission once this setting is enabled.
- You can exclude invoices from automatic creation by configuring exclusion rules.
- Once enabled, the Exclusion Rules window opens
- Select Conditions in the drop down menu for fields When (condition) Equals (condition)
- Click +Add Condition to add as many conditions as needed.
- Click +Add Rule to add as many rules as needed
- Click Save for each rule.
- You can exclude invoices from automatic creation by configuring exclusion rules.
- Billing Automation: Claims Submission- When enabled, all claims (past, present and future) in Awaiting Submission status will be automatically submitted daily to the claim scrubber and if no errors are present, then to the configured clearinghouse once this setting is enabled.
- You can exclude invoices from automatic creation by configuring exclusion rules.
- Once enabled, the Exclusion Rules window opens
- Select Conditions in the drop down menu for fields When (condition) Equals (condition)
- Click +Add Condition to add as many conditions as needed.
- Click +Add Rule to add as many rules as needed
- Click Save for each rule.
- You can exclude invoices from automatic creation by configuring exclusion rules.
Billing Automation: ERA Processing- When enabled, the system will automatically post ERAs that match certain criteria configured within the ERA posting rules.
- By default, the following rules will automatically be configured and post ERAs accordingly:
- For All Insurers, CO-45, post as Write off
- For All Insurers, CO-253, post as Write off
- For All Insurers, PR-1, post as Patient responsibility
- For All Insurers, PR-2, post as Patient responsibility
- For All Insurers, PR-3, post as Patient responsibility.
- By default, any ERAs with codes not listed in these rules will be blocked from auto posting
- You can configure additional posting rules to determine how ERAs are automatically processed
- Once enabled, the Posting Rules window opens
- Select Conditions in the drop down menu for fields
- Insurer, Group Code, Reason Code and Post
- Click Save for each rule.
Claims Submission Tasks
PERMISSIONS REQUIRED: You must have Administrative Permissions.
- Once enrollment is complete, you are ready to begin submitting claims in the system.
- Please watch the following training videos to learn the workflow for submitting claims in the system.