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.

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.

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.

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.

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.

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.

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.

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.