Create Your Own Insurance IDs

• Go to Admin > System Settings > General > INSAUTOASSIGN > NO. For example: The system may create 102 for Blue Cross; if you set the auto assign to NO, you can change it to BCBS or whatever works best for your office.

• No: Allows you to create your own insurance IDs.
• Yes: The Insurance ID is automatically assigned by the System.

Two ways to add a Payer to the Insurance Library

• Use the Clearinghouse Payer List to add multiple Payers at once. Most of the Insurance Library fields are auto-populated when added from the Clearinghouse Payer List. There will be instances where the payer cannot be found in the Clearinghouse Payer List, and you will have to manually add the payer.
• Manually add each payer one by one by completing the applicable fields.

Add Payer by using the Clearinghouse Payer List

1. From Admin on the Left Side Menu, select the Clearinghouse Payer List button.

2. Enter part of the Payer Name in the Name box. For example, enter Blue or BC instead of Blue Cross Blue Shield or BCBS.
3. Select the checkbox to the left of the Payer that you want to add.

• Continue looking up Payers and selecting checkboxes until you are finished.

4. Select Add to Insurance Library. This will add all of the chosen Payers to the Insurance Library.

 If you cannot find a payer ID, you will have to add the Insurance Manually in the Insurance Library.

Add Insurance Manually

Libraries > Insurances > Add button

Insurance Information Panel

1. Insurance ID: By default, the ID will prepopulate. If you want to use your own Insurance ID, the setting can be changed in System Settings.
2. Insurance Name: Enter or Modify the name of the Payer.
3. Active: If the checkbox is selected, the Insurance will be available to be added as a policy for new and existing patients.
4. Abbreviation: Enter an abbreviation that will be used on reports and on screens where space is limited.
5. From the Type dropdown list, select Insurance Company unless it is for Worker's Comp, Collection Agency, or other.
6. Review the Claims filing indicator (CFI) for accuracy. The most common options are:

• CI: Commercial Insurance
• MB: Medicare
• MC: Medicaid
• BL: BC/BS
• WC: Workers Comp

7. Claims Payer ID: Use the Lookup icon to search the Clearinghouse Payer List for the Claims Payer ID. If the Payer does not accept electronic Claims or there is not a Payer ID, enter PRINT in the Claims Payer ID field. When PRINT is used as the Payer ID, choose a Form Type of either:

• HCFA or UB04 as the Primary Form Type if you are printing claims in your office.
• ELECTRONIC if the Clearinghouse is going to print and mail Primary paper Claims for you.
• The Secondary and Tertiary Form Type must always be HCFA or UB04 because the clearinghouse does not print Secondary and Tertiary Claims. Those must be printed in your office.

8. ERA Payer ID: If this is the same as the Claims Payer ID, it can be left blank. However, if you receive Electronic Payments with a different ERA Payer ID, it can be added later.

• Multiple ERA Payer IDs can be entered in this field with a comma separating them (12345,54321). Sometimes Claims are submitted to one Payer ID but payments are returned with multiple ERA Payer IDs.

• Ensure that there is no space after the comma.

9. Eligibility Payer ID: The Eligibility Payer ID is usually the same as the Claims Payer ID. This can be confirmed by copying the Claims Payer ID into the Eligibility Payer ID field. Use the Lookup icon to verify that this is the correct Eligibility ID.
10. Claim Status Payer ID: If the Claim Status Payer ID is different than the Claims Payer ID, it will need to be entered in order to check the Payer Claim Status. This is a Premium Add-On Feature.

Insurance Settings Panel

1. Primary Form Type: If the Primary has a Claims Payer ID in the Clearinghouse Payer List, choose Electronic for Professional and Electronic/Institutional for Institutional Claims.

• If PRINT is used for the Claims Payer ID, select HCFA or UB04.

2. Secondary Form Type: If the Secondary Payer accepts Electronic Claims, choose Electronic for Professional and Electronic/Institutional for Institutional Claims.

• If the Secondary Payer does not accept Electronic Claims, select HCFA for Professional Claims or UB04 for Institutional Claims.

3. Secondary Hold Days: Some Payers deny/reject Secondary Claims when they are submitted too soon after the Primary Insurance has paid.

• This field will prevent Secondary Claims from batching after the Primary Payment is posted based on the number of days entered here.
• The Encounter will be placed in an Insurance Hold status.

• Counts from the date the balance was transferred to the Secondary.

• When the number of days has been reached, the Claims will become eligible to batch automatically.
• DO NOT use for temporary "hold" situations, such as, holding for the deductible. Use Tags for those types of issues.

4. Tertiary Form Type: Always select HCFA.
5. Tertiary Hold Days: Uses the same logic as Secondary Hold Days.

6. Accept Assignment: Deselect if this Payer is to be billed as NON-PAR.

• This will drive the default selection to Assignment = No for new policies added for this Payer.
• For most Payers, this results in the Insurance Payment being sent directly to the Policyholder.

7. Patient Responsible: Leave checked if the Patient is responsible for balances after the Insurance Pays.

• When unchecked, new Insurance Profiles built with this Payer will default the Patient as Not Responsible.

• This results in NO statements being sent.
• This is mostly used for Medicaid plans.

8. Credentialing Required: Select the checkbox to enable the Credentialing area on the Insurance and Provider Dashboards.

• When this feature is enabled, it provides the ability to assign an Effective Date for the Provider's Credentialing with each Insurance that requires Credentialing.
• A System delivered Charge Management Rule will trigger a WARNING during Charge entry when a Provider does not have a credentialing date for an Insurance that requires credentialing.

9. Capitation: This option is available based on the HMSACAP Hidden Setting. Contact the support or sales team to learn more about the Capitation features available.

10. Send Replacement Claim as Original: This option allows for Claims designated as Replacement Claims to be sent as if they are Original Claims.

• Example: Medicare will not accept Replacement Claim (7) on a resubmitted Claim. It must always be sent as an Original (1).

11. Billing Group: A Billing Group can be added at any time and is not required for initial setup. Timely Filing Limits can be set up on the Billing Group.

• The Insurance Billing Groups field will be grayed out for Databases linked to a Master Database.
• Billing Groups can be added and modified here. The Insurance Billing Group table has links to:

• IDs
• Insurance IDs
• Insurances

12. Reporting Group: Reporting Groups can be used to group Payers so they can be reported on together.

13. Payment Method

• Manually Posted Insurance Payments (Non-ERA): This setting can be used to choose the standard Payment Method to save keystrokes during the Receipt creation process. For example, if they always pay with a Visa Card, make the Payment Method = Card and Type = Visa.
• ERAs: This is not commonly used for ERAs because the System uses the Payment Method that is sent in the Electronic Remit.

• If the Payer is routinely reporting the wrong Payment Method, a default Payment Method can be set to use instead of the Method reported in the ERA.

• Example: The Payer issues the Payment via EFT, but paper check is indicated in the ERA. Set the Payment Method to EFT so the ERA Receipts reflect the Payment Method accurately.

14. ERA Management Profile: This defaults to System, but if you have a specific ERA Management Profile set up for this Payer, you can choose it here.
15. Hold Claim: Primary Claims can be held from Claim submission by a defined number of days using the Hold Claim feature in the Service Facility and Procedure Code Libraries. This Hold Claim setting on the Insurance allows the Hold to be overridden for specific payers.
16. Eligibility Time Frame: When checking Eligibility, determine how far to look back specific for this Payer.

• Current Calendar Month: Check the current month only. Eligibility will be checked for the current Calendar Month without having to change it each month.
• Current Calendar Year: Check the current year only. Eligibility will be checked for the current Calendar Year without changing it each year.
• Day Count: Enter a specific number of days for look back. If the days are set at 7, and the Patient has two Appointments during that 7 days, Eligibility will only be verified once.

17. Account Number Limit: This field is not commonly used and only applies in situations where the Insurance is truncating the Claim account number on the ERA.

• When this occurs, the account number in the ERA is different than the account number submitted on the Claim.
• The payer typically truncates the Encounter number, making it impossible to auto-match the Remit to the Encounter.
• By looking at the Account number returned on the Remit, it is possible to determine the maximum number of Account number digits allowed by the Payer.
• Enter this number into the field, and the system will use it as the maximum account number digits sent on a claim, but will do so by truncating the Patient number.
• When receiving ERAs, the system will use the full Encounter number and the (truncated) Patient number to match to an Encounter in the system.

18. Default Allowed: The % entered here will be used when reporting your "Expected" A/R for any Procedure out to this Insurance that does not have an Allowed Fee defined in the fee schedule. 

• If you expect to receive, on average, 60% of what is billed to this insurance, enter 60.

Insurance Address Panel

The Insurance Address must be entered to send Paper Claims (HCFA, UB04, Invoices).

1. Print Address on HCFA: Select the checkbox to print the Payer's address on Paper Claims. If this box is not checked, Paper Claims will not pass the System edits.
2. Enter the full Address of the Payer.
3. Country: Select the Country.

Insurance Contact Panel

This panel is optional but the information can be helpful when working your A/R.

• Enter the Payer Contact Information.

Timely Filing Submission Panel

Capture Timely Filing days for Payers to track, manage, and report to prevent delays or denials. The Limit fields are Day values, such as 45 days, 180 days, 365 days, etc. By default this is calculated from Billed Date.

1. Use From: System Setting, Insurance, or Insurance Billing Group
2. Primary Limit: The System will calculate this as the number of days between the current date and the Date of Service if there is no Billed Date.
3. Secondary/Tertiary Limit: The System will calculate this as the number of days between the current date and the most recent Receipt's Received Date when there is no Billed Date.
4. Primary/Secondary/Tertiary Review: The number of days after the Date of Service of a Claim to receive a Warning in regards to Timely Filing.

Additional Info

1. Web Address: Enter the Payer's Web Address.
2. ICD10 Active Date: Defaults from ICD10 Library.
3. Patient Facing Descriptions: This can potentially be used when integrating to Patient-facing portals to create a different description than the standard description used above.
4. Note: The information entered here is displayed when users hover-over the policy in Scheduling and on the Patient Dashboard. This is a way to communicate important information to Users about this coverage.
5. Select Save [F2}.

Insurance Billing Groups

Billing Groups are used to connect special billing setups (Insurance IDs) across multiple insurances.

• The setup used to meet Insurance billing requirements on one insurance is linked to all Insurances that share the same Billing Group.

• These setups will be initially provided by support or your trainer.

• Use Case: Workers Comp credentialed with SSN

• A common use case is Workers Comp which may require the SSN of the Provider on a Claim.

• The Billing Group can be set up to work on one W/C insurance, and shared across all W/C insurances by using the same Billing Group.
  

Create an Insurance Billing Group

An Insurance Billing Group can be added on the Insurance or using the Billing Group button.

Libraries > Insurance Billing Groups > Add   OR   Libraries > select the Insurance > select the Modify link.

1. Select the Lookup icon for Billing Group.

2. Select the Add button.
   

3. Group ID: WCSSN

4. Name: Workers Comp SSN

5. Abbreviation: WCSSN

6. ERA Management Profile: If applicable, select an ERA Management Profile to use for this Billing Group.

7. Update Linked Insurances to Use From Billing Group: Select the checkbox to update all Insurances that have this Billing Group assigned.

8. Timely Filing: Select Timely Filing guidelines for this Billing Group.

9. Select Save [F2].

Modify an Insurance

• Go to the Insurance Library. (Libraries > Insurances)
• Choose the Insurance ID.
• Select Modify and make changes.
  

• Insurance Library Overview
• Prevent the Creation of Statements (Patient Not Responsible)
• Reporting Groups
• General System Settings
• ERA Management Profile
• Replacement Claims
• Reporting Groups
• System Settings for Timely Limit