Insurances Setup

1. Exclude Legacy ID should always be checked.
2. Enter a unique Code or “short name” for the Insurance for internal purposes.
3. Choose a Financial Class. The Financial Class can be thought of as a “Master” Insurance. It groups like insurances together to be able to easily assign them to a clinician€™s user template to bill the same. It groups like payers for reporting and staff setup. Example: Commercial Insurance Institutional.
4. The Submitter ID is payer-specific and not used for paper claims. This is to be used for Medicaid, if you are submitting directly to Medicaid and not using the clearinghouse. If you are submitting directly to Medicaid and using the clearinghouse, leave blank.
5. Practice Billing ID- This is a legacy feature and is not used. Leave blank.
6. In the NAIC Code field, enter the Payer ID assigned by the clearinghouse, specific to individual clearinghouses (i.e.: ABILITY, Zirmed, etc.) This code tells the clearinghouse what insurance company to send the claim to.
   • ID 99999 can be used on paper claims.
7. Choose the appropriate Place of Service (POS) code.  This can be populated at the Insurance level.
8. Choose the appropriate Claim Filing ID from the drop-down menu. Select either Medicaid, Medicare, Blues, CI (Commercial Insurance), etc, based on the payer.
9. The Location Identifier is a legacy feature and is not used. Leave blank.
10. For the Ref Identifier, always choose G2 - Provider Commercial Number from the drop-down menu.
11. For the ICD-10 Effective Date, always enter 10/01/2015. In doing this, the ICD-10 will be sent for any claim with this DOS and later.
12. 270 Eligibility Receiver is used with the purchase of the clearinghouse/eligibility module.
13. Insurance Type is a legacy feature.  Leave blank.
14. The use of the General Ledger # field depends on the purchase of an interface to external input point financial system and integrates eCR charges and payments with an external general ledger. Leave blank.
15. Enter the Eligibility Payer ID provided by the clearinghouse.
16. For the Eligibility Submitter ID, this is specific to clearinghouse requirements. 10e11 is the standard entry.
17. If a Payer Group is appropriate, choose from the drop-down menu.  Payer Groups are used for posting remittances and grouping individual payers together. Example: Metro Plus falls under the Beacon payer group. Payer Groups are entered under Administration 🡪 Payer Groups. 
18. Enter a numerical value, up to 3 digits, in the Delay Reason Code Override field. The number entered here will override the default of 90 days when the system will determine that a claim requires a Delay Reason Code.
19. Check the box for Require Delay Reason Code to require a Delay Reason Code on the charge entry screen.
20. Select a Billing Format from the drop-down menu. The appropriate selection is payer-specific, either institutional or professional, electronic or paper format.
    • Check the box for Electronic Format, if submitting claims electronically.
21. Select a Drop to Paper Format from the drop-down menu that the claim will be printed on. The appropriate selection is payer-specific.
22. The Patient Status Code is used situationally. It defaults to 30 Still Patient. It can be set to another Patient Status Code on the program billing record. Some payers require something other than 30 Still Patient.
23. The Frequency refers to the period of time submitted on the claim. It defaults to 3 Interim - Continuing Claim. It can be set to a different default on the program billing record. Some payers specify what they want. It can be customized per payer on the insurance screen.
24. Check if any apply to the insurance being entered:
    • Check the box for Medicare for both traditional or Managed Medicare payers.
    • Check the box for Medicaid for both traditional or Managed Medicaid payers.
    • Check the box for School District only in unique billing situations. Confirm with your Project Manager if this should be used.
    • Check the box for Family Health Plus only in unique billing situations. Confirm with your Project Manager if this should be used.
    • Check the box for Managed Care only in payer-specific situations. This is used with APG billing logic in eCR.
    • Check the box for County only in unique billing situations. Confirm with your Project Manager if this should be used.
25. MD Information
    • The Location field is used for Medicaid only, required by NYS Medicaid. If required, the default is 003.
    • The Specialty field is a legacy feature and no longer needed.
    • The Medicare Crossover Payer ID field is used in autoposting payments from Medicare. If applicable, it is populated from a list provided by Medicare to identify the insurance Medicare will send the claim to after they pay their portion.  

Check all that apply.

• Always check Bill as Group.
• Always check Accept Assign.
  
  

Bill as Group- This is required when billing under organizational NPI. Program setup required.

Send Taxonomy From Staff- This is rarely used in 5010. When this is checked, the Taxonomy code sends in 837, UB and CMS 1500.

Send PayTo Info- This will send an address other than billing provider. Program setup required.

PPO HMO- Plan/payer-specific.

Accept Assign- Always check. Otherwise, the payment will go to the patient.

Authorization Alert- Payer-specific.  This is used for charge creation.

Authorization Required- Payer-specific. This is used for change creation. An authorization is required when billing with this insurance.

Bill Using Staff Modifier-  Procedure/Staff/APG program setup required.

Bill Using LOE Modifier (U4)- APG program setup required (Language other than English).

Bill Using After Hour Add-On (99051)- Procedure/APG program setup required.

Bill Bed at Discharge- When checked, inpatient claims will only be allowed to be processed out of My Billing when the Patient Chart has been discharged.

Require Taxonomy- When checked, when claims are billed to this insurance, despite the billing format, a taxonomy will be required to go out on the claim.

Send Taxonomy in Loop 2000A- When checked, the Billing Provider Taxonomy will send in 837 Loop 2000A for Professional Billing Formats.

Do not send Contractual Writeoff (CO)- When checked, this option will not send any CO in the 837.

Do not send Other Adjustment (OA)- When checked, this option will not send any OA in the 837.

Do not send admitting diagnosis on UB-04- When checked, the admitting diagnosis will not send on the UB04.

CMS1450 - Print facility in Box 1- Payer/billing format specific. When checked, the Taxonomy code will send in the 837, UB and CMS 1500.

CMS1500 - Print Group NPI/Box 24J- Payer/program (MH)/billing format specific. When checked, the CMS1500 paper format will print the Group NPI from Program Billing Defaults in box 24-J.

CMS1500 - Always Print Payer Info- When printing, the CMS1500 paper format will always print the Payer Info.

Bundle same-day procs in My Billing- This is used situationally. My Billing will bundle same-day procedures into a single claim when the program is marked as ‘Use APG’ in the Program/Billing Defaults and the patient has Medicaid.  Additional setup is required.

Print Daily Fee for Inpatient Services- This is used specific to payer requirements on Inpatient Paper claims to Print Daily Fee in Box 44 on UB04 for Inpatient Services.

Send Home Address for POS 12- Check if the payer requires a home address for Place of Service. The home address for the patient will be sent if the Place of Service code is 12.

BHRS Do Not Combine School POS- This is only used in BHRS billing.  When checked, eCR will not combine procedures on visits with POS School (03) with other POSs for Service Types marked TSS.

HCBS Separate Transportation Claims- This is used in HCBS billing to put the transportation procedure on a different claim than the visit procedure.

Bill for PROS CT Medicare addons- This is used in PROS billing to allow CT Medicare addon charges to be created for this insurance if the patient doesn’t have Medicare.

837 Options Tab

Check all that apply.

837 - Use Group NPI for Rendering- This is used situationally. When checked, the Group NPI for the company (program billing record) will be sent in place of the rendering/attending provider NPI. The provider's name is also sent with the Group NPI.

837 - Send Address- This is used situationally. Check if the payer requires the payer address to be sent in the 837. When checked, the Insurance Address/City/State/Zip will be sent in loop 2010BB .

837 - Send Value Codes- Check if the payer requires value codes to be sent in 837 Institutional Formats even if the insurance is not Medicaid.

837 - Send Authorization Number- Check to send the authorization number in the 837 even if there is no referring provider.

837/UB - Send Diagnosis PoA- Check to include the Present On Admission (PoA) status as the principal diagnosis on the 837/UB CMS-1500.

837/UB - Send Principal Procedure-  Check to send the Principal Procedure in Loop 2300 of an 837 or Box 74 of a UB if the format is Institutional, the insurance is flagged to send it and the Principal Procedure is filled in on the procedure.

837 - Send Adj/Void for Inst Formats- Check to send a 7 or 8 in the 837 when the claim is marked as Adjust/Void for Institutional formats.

837 - Include Discharge Date in 2300 Loop for Inpatient Claims-  When generating an 837 for inpatient claims if the claim runs up against the Discharge Date, include that day in the date range in the 2300 loop DTP segment.

837 - Include Discharge Time in 2300 Loop for Inpatient Claims-  When generating an 837 for inpatient claims, include the discharge time in the 2300 loop DTP segment.

837 - Include Admit Date/Time in 2300 Loop for Inpatient Claims- On non-institutional attendance inpatient claims, when checked, the admit date and time will be included in the 2300 DTP segment.  Add Admit Time Date to Inpatient Attendance Billing must also be checked on Attendance Billing Setup at the time of Billing Processing.

837 - Do Not Send Medical Covered Days (Value Code 80)-  When checked, this option will not send Medicaid Cover Days (Value Code 80) in the HI segment.

837 - Send Address from Facility- When checked, the address of the facility on the visit will send in Loop 2010AA. This only works with Bill as Group.

837/CMS-1500 - Send Ordering/Referring Provider- When checked, the Ordering/Referring Provider will send in the 2420E loop of an 837 or Box 17 of a CMS-1500.

Company/Contact Info Tab

Enter relevant demographic information for the insurance company.

DCF, MDOC and DARTS are state-funded programs.  If applicable, these fields will be completed with the assistance of your Project Manager.

1. If DCF is checked, it is denoting that this payer record as being associated with a DCF contract.
   • Enter the DCF Contractor ID Number.
   • Enter the DCF Contractor NPI.
   • Select the DCF Fund that is associated with the contract.
   • Enter the Site ID Number associated with the DCF contract.
   • The Contract Numbers section allows you to enter information associated with the DCF contract.
2. MDOC is checked to enter specific billing options for the Michigan Department of Corrections.
   • In the MDOC Rules section, enter any rules for MDOC Billing.
     • Enter the Minimum Number of Patients required.
     • Enter the Maximum Number of Patients allowed.
     • Enter the charge to bill Per Patient in the group.
     • Enter the Whole Group Charge to bill an entire group.
     • Check the box to Merge With Another Group.
3. Any option selected in the Inpatient Daily Charge Creation Override will override the program/billing defaults set for the program on the payer level.
   • Select Bill Daily to create a daily inpatient charge.
   • Select Bill Monthly to create a monthly charge for inpatient days.
     • If Single Line is selected, the monthly claim will have one service line for the entire month.
     • If Daily Lines is selected, the monthly claim will have one service line per day.
   • Select Bill All to bill all the days in any given time span processed in My Billing.
     • If Single Line is selected, the claim will have one service line for all encompassed days.
     • If Monthly Lines is selected, the claim will have one service line per month encompassed in the time span.
     • If Daily Lines is selected, the claim will have one service line per day.
4. The DARTS fields, if applicable to your agency, will be filled out with the assistance of your Project Manager.

The Modifier Exclusions tab is used to prevent a billing modifier from being sent on claims for specific insurances. Enter the insurance and the modifier that needs to be removed from the billing. This will remove the modifier from the claim even if the modifier is already appended to the procedure in Charge Entry.

The Insurance Authorization tab is used when an insurance company provides a blanket authorization for services by procedure that is not specific to the patient/client. Enter the procedure and the matching authorization number. When the 837 is created, the authorization number will be included on the claim.

All of the fields in the Admin Override tab are populated on other tabs of this insurance. This tab would override the values entered on other tabs on this specific insurance. This tab is only visible to staff logged in as Admin.

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