The Insurance Setup screen has multiple functionalities. This screen will allow providers to submit new EDI requests as well as set specific billing items required by the payer. Depending on how the provider is credentialed, some claims may need to be billed with an individual NPI or SSN while another is billed with the group NPI and TIN. This screen will allow you to set up the provider to bill claims for an individual payer/payers using the information they were credentialed with.
Let's take a look at all of the options the feature offers:
1. Hover over the Billing tab and select Insurance Setup
2. This screen will display all the insurances which you are billing along with the billing information (NPI, Tax ID, Organization Name, etc..) which you have updated in the Account > Account Settings > Billing Tab.
- If you do not see a payer that you need listed, simply click on the green + New EDI Enrollment and enter the info. Once you refresh your screen, the payer will be listed.
3. To edit or update any information, click on the pencil icon corresponding to the payer.
4. The "Add/Edit Payer" page has a lot of options, please find descriptions for each below:
Billing NPI - If you have two NPIs (Group and Individual), you can switch between the two depending on how you are credentialed with the payer. This will reflect in HCFA box 33a.
Eligibility NPI - If you get an eligibility error message regarding enrollment, you can switch the NPI depending on how you are credentialed with the payer for eligibility. This will be the NPI that the system uses to check a patient's eligibility and benefits.
Provider name - Select the provider/practice name and this information reflects in Box 33.
- Example: Select "Provider Name" if the billing NPI is individual.
Tax id number / TIN - Depending on how the provider is credentialed with the payer, you can switch between the billing with either the TIN or SSN.
Group Provider # - If the insurance is requesting the group provider number in box 33b (Shaded column), please enter the group provider number in this field and choose the "
- Example: Indicate whether it is Taxonomy, State License, etc.
Individual Provider # - If the insurance is requesting the individual provider number in box 24j (Shaded column), please enter the individual provider number in this field and choose the "Individual
- Example: Indicate whether it is Taxonomy, State License, etc.
Balance billing - If you are out of network with the payer and would like to bill the patient for any adjustment (sometimes listed as R & C amount), choose the option "YES". This will transfer the adjustment amount toward the patient column.
Filing limit days - If you know the Timely filing limit for the payers, update in this field. You can retrieve a claim report in the Billing > Live Claims Feed by placing a checkmark on the box TFL Warning. This will help ensure that you don't miss out on reimbursement because the claim was not submitted in time.
Accept assignment - If you uncheck this option, the insurance will send the payments directly to the patient and not to the doctor. To send claims with the accept assignment designation, please leave the box checked. Please note, that there are some payers that will not send payment directly to the provider, regardless of what is notated on the HCFA, if the provider is out of network.
Send facility provider number - This number populates from the Account > Offices > Edit > Billing > Facility Provider Number field. It will reflect in HCFA box 32b (Shaded field).
Referring doctor/Ordering doctor - If you want a specific Referring/Ordering provider to reflect for all the patients who have this particular payer, enter the doctor's name which will populate in this field. You would first add the doctor's information to the Message center as a contact.
Print license numbers in HCFA - This number populates from Account > Account Settings > eRx Info >
This feature will allow you to set up each provider, per payer with the requirements (TIN/SSN/Group vs Individual NPI/state license number/etc) to help ensure your claims are accepted for processing for the payer as quickly and efficiently as possible.
If you have any questions regarding this screen, please reach out to your account manager or support for assistance. In addition, here is a video that will walk you through the Insurance Set Up Screen.