Insurance Carrier Setup

After setting up your providers and your referring providers, you will need to enter your insurance carriers. You will not have a comprehensive list of the necessary insurance carriers. You will, however, be able to set up the insurance carriers for which your office has participating providers.

Your insurance carrier list is accessed by clicking the Lists menu, Insurance, and Carriers.

Address


Code: The code field will be how this insurance carrier is referenced and accessed in other portions of the Medisoft Program. If you leave this field blank, the program will assign one for you. This code will be based on the insurance carrier name.

Tips and Tricks:

Similar to the Provider Code, it is recommended that you let the program assign your insurance codes for you. Insurance based reports will sort based on the insurance code. If you do not let the program assign the codes for you, the sorting may not be in an order that makes sense.

 

Inactive: You should never delete an insurance carrier record that has been tied to any other records such as patients, claims, or payments. Checking the Inactive will hide the record if you chose to do so in Program Options.

 

Name: You should enter the name of the insurance carrier as it appears on the insurance cards for your patients.

Address: Some insurance carriers have different addresses to which claims must be sent. Make sure you have the proper address entered into the address fields, or you could receive rejections on paper and some electronic claims.

Phone Number: It is important that you enter the phone number you would use to contact the insurance carrier with inquiries about claims. This number will print on your Insurance Aging report. If this number is entered and printing, your collections process will be streamlined, as you will not need to look up the number.

Contact: Similar to the phone number, this field will print on your insurance aging report. This will quickly let you know who you need to talk to at the insurance carrier.

Plan Name: The plan name field is going to be the specific plan name that is listed on the patient’s insurance card. This field will affect both paper and electronic claims. Paper claims print this field in box 11c for primary claims, and box 9d for secondary claims.

Tips and Tricks:

You may have different patients who have the same insurance carrier, but different plans under that insurance carrier. If this is the case, you will need to set up a different insurance carrier for each plan. You may want to name the carrier based on the plan name as well.

If you leave this field blank, paper claims will automatically populate box 11c with the Insurance Carrier Name.

 

Class: Insurance Classes contain the same functionality that Provider Classes do. They will allow you to link insurance carriers together for reporting purposes. One example of an insurance class would be a class for all Government carriers. Insurance classes are defined by the users.

In order to set up an insurance class, click the Lists menu, Insurance, and Classes. When clicking New, you will see the following screen.

The Class ID field is the value that will be entered into the individual insurance carriers, linking them to that class. Class Name and Description are self explanatory fields.

Note: This is for internal reference.

 

 

Options and Codes

 

Procedure Code Set: As you will see, when setting up procedure codes, you have the option to enter 2 alternate codes for each code entered. An alternate code allows you to submit a different code on your insurance claims, than the code entered into transaction entry. If you set this field to the number 1, the main code will be transmitted or printed on claims sent to this insurance carrier. If you set the field to 2 or 3, one of the alternate codes will be submitted on claims sent to this carrier. See the chapter on Procedure Code Setup for more information.

Tips and Tricks:

If you would like to avoid confusion, it is usually best to leave this field set to 1 (or the main procedure code). This will result in the claim containing the same code that was entered into transaction entry.

If you want the ability to modify the code that prints without modifying the actual code, set this value either 2 or 3 in order to pull one of the alternate codes.

 

Diagnosis Code Set: This field contains the same functionality as the Procedure Code Set, except it refers to alternate codes set up in the diagnosis codes, rather than the procedure codes.

Patient Signature on File: Similar to the provider setup, the patient setup contains a check box labeled Signature on File (on the Other Information tab). This field in the insurance carrier setup will determine what happens in box 12 of the CMS form when claims are sent to this insurance carrier.


The following are all possible scenarios and the result that will print in box 12. During original setup, you may not know the requirements for this particular insurance carrier. You can contact the insurance carrier and ask them what their requirements are, or you can submit a claim and wait to see which rejections are returned by the carrier.

Scenario 1:

Patient Signature on File field in the Insurance Carrier is set to Leave Blank AND the Signature on File box in the Patient setup screen IS checked.

Result 1:

Box 12 will print the words Signature on File.

Scenario 2:

Patient Signature on File field in the Insurance Carrier is set to Print name.

Result 2:

It does not matter whether or not the Signature on File box in the Patient setup screen is checked. Box 12 will print the patient’s name.

Scenario 3:

Patient Signature on File field in the Insurance Carrier is set to Signature on File AND the Signature on File box in the Patient setup screen is NOT checked.

Result 3:

Box 12 will be left blank. This will usually require the patient to manually sign the claim form.

Scenario 4:

Patient Signature on File field in the Insurance Carrier is set to Signature on File AND the Signature on File box in the Patient setup screen IS checked.

Result 4:

Box 12 will print the words Signature on File.

For information on how this field will affect your electronic claims, refer to your electronic claims documentation.

Insured Signature on File: This field works exactly the same way as the Patient Signature on File field. A patient may be set up within a case to be the insured party for that case. The patient set as insured party will be the patient whose file will affect the results that will come from this field. Paper claims will print the results into box 13. See your electronic claims documentation for information on how this affects electronic claims.

Physician Signature on File: The same results and scenarios that applied to the previous two fields will also apply to this field. The only differences will be that the result will be printed in box 31, and that the corresponding name and Signature on File fields will be located in the provider setup screen.

Tips and Tricks:

These fields were placed in the insurance carrier setup screen because different insurance carriers may have different requirements for these fields.

 

Print PINs on Forms: This field will only affect paper claims. Box 24k on a CMS-1500 form states that it is reserved for local use. Some insurance carriers have requested that this field contain the attending provider’s PIN number. Others have requested that it contain both the attending provider’s name and PIN number. You can also leave the field blank. The values in the drop down menu for this field correspond with these requirements.

Every patient is assigned a provider in Medisoft and this provider’s information appears in Box 33 of the claim form.

Current Medicare and Medicaid regulations require if the attending provider is not the assigned provider (shown in Box 33), that the attending provider’s (the one providing the services) name and PIN be entered in Box 24K on the CMS-1500 claim form.

At this time, only Medicare and Medicaid have this rule.  When setting up these two carriers, select the provider name and PIN for this field, otherwise leave it blank.

Default Billing Methods: These fields will allow you to specify whether claims sent to this carrier will default as paper claims or electronic claims. Since some carriers (or some clearinghouses) are limited to sending/receiving electronic Primary Claims, but not electronic Secondary Claims, the practice can designate by carrier the best mode of transmission.

Default Payment Application Codes:
The codes tab will let you enter default codes that will be used when applying payments through the deposit list. These codes must be created in the procedure code list prior to entry into these fields. For information on this subject, refer to the chapter on Payment Application.

 

EDI Eligibility

The EDI/Eligibility tab contains various fields that are going to be needed when transmitting claims electronically to this carrier. Refer to your electronic claims documentation for more information on what to enter in these fields.

EDI Receivers (Primary and Secondary): Click the dropdown arrow or the magnifying glass to choose an existing receiver to which you will be sending claims for this carrier. If the receiver does not exist in the drop down menu, press the [F8] button in order to enter a new receiver. Specifications for receiver setup can be found in your electronic claims documentation.

Claims Payer ID (Primary and Secondary): These fields will contain Payor numbers assigned to this carrier for the EDI Receiver to which you are sending claims for this carrier. If you are submitting to RelayHealth or Capario clearinghouse, you can click the magnifying glass to choose from the clearinghouse payer lists. You may also free type the ID if connecting to other payers.

Eligibility Payer ID (Primary and Secondary): These fields will contain Payor numbers assigned to this carrier for the EDI Receiver to which you are eligibility verification requests for this carrier. If you are submitting to RelayHealth or Capario clearinghouse, you can click the magnifying glass to choose from the clearinghouse eligibility payer lists. You may also free type the ID if connecting to other payers.

 

National Plan ID (Primary and Secondary): These fields are open fields for use by external programs.

Type: This field affects the SBR09 element in Loops 2000B and 2320 in electronic claims.

Paper claims will place an X in box 1 of the CMS form under the insurance type that corresponds with this field in Medisoft.

Tips and Tricks:

Insurance types have been expanded in version 17 to include all types permitted in electronic claims. Not all types are currently used by carriers. The following types are available:

Other, Medicare, Medicaid, Tricare/Champus, ChampsVA, Group, FECA, Blue Cross/Blue Shield, Worker’s Comp, HMO, PPO, Self-pay, Central certification, Other non-federal program, HMO (Medicare Risk), POS, EPO, Indemnity Insurance, No charge, Unknown, Automobile Medical, Disability, Liability, Liability Medical, Medicare Part A, Other Federal Program, Title V, Mutually Defined, Federal Employees Program and Commercial Insurance Carrier.

When sending claims, there may be times you are required to enter an insurance type other than the one you would expect to enter for a particular carrier. Refer to your electronic claims documentation for information on situations when this may be required.

 

Alternate Carrier ID: This field is an open field for use by external programs.

NDC Record Code: This field is an open field for use by external programs.

EDI Max Transactions: Certain carriers or clearinghouses have a limit to the number of transactions that can be submitted on an electronic claim. If a carrier or clearinghouse rejects a claim stating that too many transactions were submitted on one claim, you can enter the maximum number for this carrier in this field. Zero is the default and does not limit transactions per claim.

EDI Extra 1/Medigap: This field will contain different information depending on your EDI receiver. If you are submitting claims that contain this carrier as a secondary claim, and this carrier is a Medigap crossover carrier, you should enter the Medigap number in this field.

EDI Extra 2: This field is an open field for use by external programs.

Complimentary Crossover: In certain circumstances, a carrier may not be issued a Medigap number by Medicare, yet Medicare will still forward the claims on to the secondary carrier. This is called a Complimentary Crossover. If this carrier is a Complimentary Crossover carrier, place a check mark in this field. It is recommended that you first establish with certainty that the secondary claims are being forwarded before checking this box.

Tips and Tricks:

In most cases, Medicare is not a crossover secondary carrier.

 

Delay Secondary Billing: This field is one of the more critical fields on the Insurance Carrier setup screen. Standard billing practice states that you wait until the primary insurance carrier has paid before billing out a secondary claim. If this box is checked, when this carrier is the secondary carrier for a patient, the secondary claim will not print until a primary insurance payment has been entered and marked complete. See the chapters on applying payments and billing claims for more information on this process.

Tips and Tricks:

Many times, you may receive a call from a customer asking why a secondary claim is not printing. It can be tempting to remove the check mark from this box in order to get the claim to print. It is important that you explain to the customer that this could result in the rejection of the secondary claim.

If the primary insurance carrier has paid, and they still cannot print the secondary claim, they will want to verify that the payment entry was done properly.

 

Send Ordering Provider in Loop 2420E: Select this box if you need to send ordering provider information on electronic claims to this payer.

Send Practice Taxonomy in Loop 2000A: Select this box to send taxonomy in Loop 2000A for electronic claims. Loop 2000A is usually used to report taxonomy for individual providers though some carriers require here and in Loop 2310. Contact your carrier for more on their taxonomy requirements.

Allowed

The Allowed tab is designed to store the allowed amounts that each insurance carrier has set for each procedure code set up in your system. Allowed amounts apply to charges only.

Insurance companies generally don’t publish a directory of allowed amounts. Specific allowed mounts are given to you on an EOB that comes back from the insurance carrier. EOBs are generally entered into the system through the insurance payment application process. For this reason, Medisoft will allow you to enter allowed amounts from the Deposit List. We will cover allowed amounts in the Payment Application chapter.

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The wait is over… the federal Health IT Policy Committee met to discuss public feedback on the Meaningful Use Workgroup’s initial recommendations published in June. You can view the “Meaningful Use Matrix” on the Department of Health and Human Services (HHS) Health IT Policy Committee Web site. The matrix sets forth goals, objectives and measurements for meaningful use beginning in 2011 — the first year physicians are eligible to apply for incentive payments. The Committee also discussed workgroup recommendations for information exchange and certification/adoption requirements.

And of course Medisoft Clinical is an approved CCHIT software program, so this is good news.  Please contact us with any questions you may have on the Stimulus plan or EMR Software.  Medisoft Clinical uses the Bright Note technology to reduce physician time to click on an electronic chart note.

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Important news concerning medisoft medical billing software.  Now Medisoft released a new product called Medisoft Clincial.  This new emr software \ practice management software combination brings together two best of breed software programs.  The two programs are Practice Partner EMR Software and Medisoft medical billing software.  As a result, now existing users of Medisoft can transfer all their current patients into the Medisoft clinical database and instantly work with their patients in an EMR software solution.

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