Referring Provider Setup

After setting up the providers in your provider list, you will need to set up your Referring Provider list. The Referring Provider list contains a list of doctors who refer patients to you. When dealing with HMOs, and in some other circumstances, Referring Providers are required for specialists.

Generally, the Referring Provider list will not contain doctors who are in the same practice as the providers entered into the Provider List. The exception to this is if a supervising provider is required for the claim. This usually occurs when billing claims where the provider is not a doctor, but a Nurse Practitioner or PA under the supervision of a provider in the office. Medisoft v12 and earlier pulls Supervising Provider information from the Referring Provider List. Because of this, you may need to enter some doctors as both Providers and Referring Providers. Since v14 Supervising Provider can be pulled from either the Referring Provider List or from the Provider List.

The referring provider list is accessed by clicking the Lists menu and Referring Providers.

 

 

Within the Referring Provider screens, you will see many of the same fields that exist on the Provider screen. We will focus on the fields that are different or that have unique functionality.

Specialty: If you are sending electronic claims, select the referring provider’s special field of practice from the Specialty list. If you need to use a specialty code that is different than the usual code, select “Not Listed” and enter your specialty code in the data entry box that appears next to the Specialty list.

Referring Provider IDs Tab: The IDs tab available for Referring Providers mirrors the functionality of the grids for Providers. You will need to create a record in the grid for each referring provider. In this record, you can link the referring provider to a particular insurance carrier/class, if needed, and include other billing details such as the referring provider’s NPI, taxonomy, and other legacy IDs.

 

 

 

TIP: If upgrading from a previous version, you may have numerous multiple legacy Referring Provider ID entries that no longer apply and only a few rows that need to be set up. You may save time by deleting all entries and setting up the few rows you need. Press CTRL + DELETE to delete all ID entries in the Practice, Provider, Referring Provider, or Facilities IDs grids. Use this with caution since all your entries will be removed.

 

Once you have entered all applicable information for a Referring Provider, click Save.

Tips and Tricks:
Many Primary Care Providers and some specialty practices that do not participate in HMOs may not have the need to enter or track referrals and referring providers.
When an office first begins their data entry, they may not know which providers to enter into the referring provider list. This list will grow as patients are seen and bring their referrals with them.

 

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Provider Entry – Eligibility Tab
This tab is where you set up the provider to perform eligibility verification inquiries.

Allow Eligibility Verification: Click this check box to allow eligibility verification for this provider’s patients.

Eligibility Enrollment IDs
Some payers require that individual providers enroll for eligibility verification. To use the online eligibility verification feature, the provider needs to enroll with the payer through the clearinghouse and obtain an enrollment ID. This table is where you enter the enrollment ID, user ID, and/or password. The other columns display read-only information. Also, not all of the payers in the list will require the enrollment ID, user ID, and/or password. Those that do require some extra eligibility verification information may not require information in all three fields.

Eligibility Payer, Payer ID, Receiver ID, Service Type, Payer Type: These columns display information about each payer and are read-only.

Enrollment ID: If applicable, enter the enrollment ID for the corresponding payer.

Enrollment User ID: If applicable, enter the enrollment user ID for the corresponding payer.

Enrollment Password: If applicable, enter the enrollment password for the corresponding payer.

This information is provided for entering and setting up your practice management software program from Medisoft.

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Provider Entry – PINs Tab
Depending on the type of claims you file, you could have separate PINs and/or Group IDs for each provider for different insurance carriers.  The PINs tab provides a PIN matrix where you can store these additional PINs and Group IDs.  This matrix is also available in the Insurance Carrier window, PINs tab.  You can enter information through either window.

If you send electronic claims, you are also required to enter qualifiers to the PINs and Group IDs, if applicable.  These qualifier codes indicate the PIN or Group ID type.

NOTE: If you converted data from Medisoft 10 or previous, the qualifiers may have been converted as well.  Verify that the qualifiers are correct for each PIN and/or Group ID.  See Converted EDI Fields for the PIN Matrix.

For a list of valid qualifiers, click here.

0B = State License

1A = Blue Cross Provider Number

1B = Blue Shield Provider Number

1C = Medicare Provider Number

1D = Medicaid Provider Number

1G = Provider UPIN Number

1H = Champus Identification Number

1J = Facility ID Number

B3 = Preferred Provider Organization Number

BQ = Health Maintenance Organization Code Number

EI = Employer’s Identification Number

FH = Clinic Number

G2 = Provider Commercial Number

G5 = Provider Site Number

LU = Location Number

N5 = Provider Plan Network Identification Number

SY = Social Security Number

U3 = Unique Supplier Identification Number

X5 = State Industrial Accident Provider Number

Refer to the implementation guide for your insurance carrier if you are not sure which qualifier to use.  This is not provided by Medisoft practice management software, but by your carrier.

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Provider Entry – Default Group IDs Tab
This tab is where you store default group numbers assigned to this provider from various sources.

Provider Class: You can assign a provider to a class or group.  First set up provider classes in the Provider Class List.  Then click the down arrow in this field to select a class for the provider.

Group Number: Enter the provider’s group number.

Medicare Group ID: Enter the provider’s Medicare group number.

Medicaid Group ID: Enter the provider’s Medicaid group number.

BC/BS Group ID: Enter the provider’s Blue Cross/Blue Shield group number.

Other Group ID: Enter the provider’s group number for other insurances.

We hope you appreciate our information concerning setting up our practice management software program.  Please Contact us at 888-691-8058 or 941-743-6666 for all your technical support or medisoft training needs.

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Provider Entry – Default Pins Tab
This tab is where you enter default PINs as well as other settings pertaining to this provider.

SSN/Federal Tax ID: Enter the provider’s Social Security or Federal Tax ID number.  This number prints in Box 25 of the CMS- or HCFA-1500 claim form.  Choose a radio button to indicate whether the number entered is the Social Security Number or the Federal Tax ID. If you select Federal Tax ID, an “X” prints in the EIN box (Box 25 of the claim form).  If you select Social Security Number, an “X” prints in the SSN box of Box 25 on the claim form.

PIN Fields: In the PIN (Personal Identification Numbers) fields, enter all applicable PINs assigned by each of the major insurance types, e.g., Medicare, Medicaid, Tricare, Blue Cross/Blue Shield, Commercial, PPO, and HMO carriers.

UPIN: If the provider is part of a group practice which has been assigned a group number by Medicare, that number is entered in the UPIN field.  The UPIN is necessary for designating a referring provider on the CMS- or HCFA-1500 claim form.

EDI ID: This field for electronic claims.  Follow the instructions in your Medisoft EDI instruction book to enter the required information.

CLIA Number: If you are sending electronic claims for lab charges, enter the CLIA number in this field.

TAT Number: If applicable, you receive this number when enrolling in electronic claims.  It has 11 digits. If you receive a TAT number that has less than 11 digits, add leading zeros to complete the 11 spaces (e.g., if you receive the number 1234567, enter “00001234567”).

Hospice Emp: This field is for electronic claims.  Click this box if the provider is a employee of a hospice.

CPO Number: This field is for electronic claims.  Enter the provider’s care plan oversight number.

National Identifier: Enter the provider’s National Provider ID.  This 10-digit number is a standardized identifier that provides each provider with a unique identifier to be used in transactions with all health plans.

Payee Number: This field is for when you send GPNT (IL Medicaid) claims only.  Enter the provider’s payee number.

Taxonomy Code: This field is for electronic claims.  Enter the provider’s taxonomy code in this field.  The taxonomy code replaces the provider’s specialty code.

Mammography Certification: This field is for electronic claims.  If the provider is certified to perform mammography procedures, enter the certification number in this field.

Extra 1 and Extra 2: These fields are for entering miscellaneous information in our practice management software program.

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Provider Entry – Address Tab
This tab is where you enter demographic information for the provider.

Code: The provider code can be up to five alphanumeric characters and identifies the provider in the program.  A provider can be a doctor, nurse, technician, or physician’s aide who deals with patients.  Enter the provider’s name, address, and telephone numbers.

Inactive: For information on the Inactive check box, click here.

Last Name, First Name, Middle Initial, Street, City, State, Zip Code: Enter the provider’s demographic information.

When entering a new address, the focus of the program moves to the Zip Code field after the Street field.  Enter the zip code.  If that code has already been entered in the program database, the city and state information is automatically entered in their respective fields.  If the zip code is not found in the database, the focus of the program returns to the City and State fields for your input.  This information is then saved to the database and available the next time the zip code is entered.

After entering a Zip Code and auto populating the City and State fields, if you then go back to the Zip Code field and change the value entered without first saving it, the system will not change the City and State value previously entered, producing an inaccurate record. Use care when changing an auto populated City and State field without first saving the initial entry.

Credentials: Enter up to seven alphanumeric characters to indicate the provider’s credentials.

E-Mail/Phone Numbers: Enter the provider’s E-Mail and other Phone Numbers in the spaces provided.

Signature on File/Signature Date: Signature on File would be checked if the provider has signed an agreement with Medicare to accept its charges and an affidavit is on file.  If it is checked, the Signature Date field becomes active to display the date on which the signature was placed on file.  To enter a date in this field, either type the date or click in the Signature Date field or the down arrow to the right of the field and the calendar opens.  For information on how to use the program calendar, click here.

Medicare Participating: This check box should be clicked if the provider is committed to working with Medicare.

License Number: Enter the provider’s license number in the field by that name.

Specialty: If you are sending electronic claims, select the provider’s special field of practice.  If you need to use a specialty code that is different than the usual code, select “– Not Listed –” and enter your specialty code in the data entry box that appears next to the Specialty field.

NOTE: This field is not used for sending paper claims unless you have modified your claim form to include this information.

Entity Type: The Entity Type field is to identify whether the entity is a Person or a Non-person.  This is for sending electronic claims.

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Provider Entry
This window contains important information about the providers associated with your practice. Each provider in the practice needs to have his or her own record set up in the database.

Go to the Lists menu, select Provider, then select Providers. In the Provider List window, click New or Edit to create a new record or modify an existing one.

For more information on entering NPI data see Entering NPI Information in Medisoft.

There are four tabs in the Provider window. Click a tab name below to move directly to information concerning that tab.

Address Tab

Default Pins Tab

Default Group IDs Tab

PINs Tab

Eligibility Tab

Each of the above “Tab” will be discussed in a separate blog post for our practice management software.

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