The second step in the BillingBuilder setup process is configuring payers. Payers include Medicaid, Medicare, private insurances, self-paying clients, or any other entity from which your programs receive payments for services provided.
To configure a new payer, complete the following steps:
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- From the AWARDS Home screen, click Administration from the left-hand menu, and then click Fiscal. The Fiscal fly-out menu is displayed.
- Click BillingBuilder. The BillingBuilder Menu page is displayed.
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- Click Payers. The Payers page is displayed.
- Click ADD NEW PAYER. The ADD NEW PAYER page is displayed.
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- Configure the fields and options on this page as follows:
General Settings
Configure the fields and options on this tab as follows:
Payer Name -In this field, type the name of the payer; for example, "Medicaid”
Tip: If consumers can be liable for invoices, the Self-Pay payer can be used.
Payer Address - In these fields - Street Address, City, State, and Zip Code - enter the payer's address.
Receiver ID (Interchange Receiver ID - ISA08) -In this field, type the payer's Receiver ID. This is an ID number belonging to the insurance company or payer and can be retrieved from them.
Receiver Code (Application Receiver's Code - GS03)- In this field, type the payer's Receiver Code. If nothing is entered here the Receiver ID will be used as the payer's Receiver Code as well as the Receiver ID.
Receiver Identification Code (NM1*40-09)- In this field, type the Receiver Identification Code. If nothing is entered the Receiver ID will be used as both the Receiver ID and the payer's Receiver Identification Code.
Payer ID (Payers Identification Code - NM1*PR-09) - In this field enter the Payer's ID number. If nothing is entered here, the Receiver ID will be used as the Payer's ID as well as the Receiver ID.
Secondary ID (REF) - In this field enter the payer's Secondary ID. Once entered, another field will be displayed to the right labeled 837 ID Qualifier. Use this field to enter the desired qualifier for the ID previously entered.
Claim Filing Indicator Code (SBR09)- In this field, type the desired code to submit in the 837 claim file for the payer. If nothing is entered here AWARDS will submit the code as follows:
- MB - If the payer is Medicare
- MC - If the payer contains "Medicaid"
- ZZ - If the payer starts with "Tenncare"
- BL - If the payer contains "Blue" or "BC/BS"
- CH - If the payer contains "Champus"
- 16 - If the payer contains "Healthfirst"
- ZZ - For all other payer names
837 Options
Override Trading Partner ID Qualifier ZZ in 837 (ISA05) - In this field enter the two-character alphanumeric qualifier as requested by the payer. If left blank, "ZZ" will be inserted in the 837 claim files by default.
Override Interchange ID Qualifier ZZ in 837 (ISA07) - In this field enter the two-digit qualifier as requested by the payer. If left blank, "ZZ" will be inserted in the 837 claim files by default.
Billing Provider Name (NM1*85) - If it is necessary to report a specific name in the 837 file, enter the agency name in this field. If left blank, the default (agency name associated with your AWARDS database) will be used. Note: The data from this field will also populate box 33 of the HCFA-1500 paper claim form.
Report Service Facility Info in 837 (NMI*77) - Click this checkbox to send service facility information in the 837I and/or 837P electronic claim files. The service facility information data is pulled based on the Procedure setting called “Service Facility Info for 837”.
When this option is checked, the following additional options are made available on the page:
Service Facility Provider Name - If necessary, enter the name of the service facility provider in this text box. If left blank, the program name will be reported in the 837 files (as pulled from the Program Name field under System Setup > Agency Program Information > Add/Edit Entire Program > General Settings tab.)
Report Service Facility Secondary ID (REF) - Click this checkbox to report a service facility secondary ID in the 837 claim files for this payer. The service facility Secondary ID data is pulled based on the Procedure setting called “Service Facility Info for 837”.
Report Billing Provider Taxonomy Code in 837 (PRV*BI*PXC (837I and 837P)) - Click this checkbox to submit the billing provider's taxonomy code in the 837 claim files. This Taxonomy Code info is pulled from the "Taxonomy Code" field under Program Billing Groups configuration (for the program billing group associated with the generated batch of invoices).
Report Prior Invoice ID in 837 for Manual Adjustment & Void Invoices - Set to "No" by default. Set to "Yes" to report the original invoice ID in 837 claim files instead of the Void/Adjustment Invoice ID that is generated when Manual Adjustment or Void Invoices are created.
Report Rendering/Attending Taxonomy Code in 837 (PRV*AT*PXC*837I) / PRV*PE*PXC (837P)) - Click this checkbox to submit the rendering or attending provider's taxonomy code in the 837 claim file. The taxonomy code reported will be based on the Rendering/Attending NPI associated with the invoice; specifically, if the Rending/Attending NPI associated with the invoice is reported from one of the following locations, the taxonomy code from that same location will be included:
- Human Resources > National Provider Identifier
- BillingBuilder Procedures Setup > Incident to NPI
- BillingBuilder Program Billing Info > Default Rendering/Attending Provider Info for Program
Report Rendering/Attending Provider Secondary ID in 837 (REF)- Click this checkbox to report a Secondary ID and ID Qualifier within the 837P and 837I files for the rendering provider (837P) and attending provider (837I). This data is reported in the "REF" 837 segment within the 2310B loop (837P) and the 2310A loop (837I).
Report Hierarchy Parent HL ID in HL02 of 837 for both Subscriber and Patient HL segments - Click this checkbox if subscriber data is being reported to this payer and the consumer is not always the subscriber. Typically used for third-party/commercial insurance plans.
Report Claim Frequency Type Code 7 on Denial Re-bill Invoices (CLM05-03)- Click this checkbox to send all invoices that have been marked as Re-bill in a remittance worksheet as "Adjusted" invoices (CLM05-03 =7), and provide the payer's original CCN (claim control number) in the 837 claim file.
Tip: Only use this setting if the payer requires that Re-bill invoices need to be identified as adjustment/correct claims AND the prior invoices were posted as Re-bill within a remittance worksheet that was created from an 835 file. This setting CANNOT be used if invoices are being posted as Re-bill without an 835 file response.
Report Invoice ID and Invoice Line # in REF*6R segment of 837 (REF-02) - Click this checkbox to report the invoice ID + the invoice line number in the REF*6R segment. By default, AWARDS will report a 1 for a single line invoice and for multi-line invoices the first line will report a 1 and all subsequent lines will increase by 1 (eg. line 1 = 1, line 2 = 2, etc.).
HCFA-1500 Options
Box 1 – No Radio Button Pre-Selected - Click this checkbox to not have any radio buttons pre-selected in this box.
Box 1a – Leave Blank - Click this checkbox to not have any data reported in this box.
Box 4 – Leave Blank - Click this checkbox to not have any data reported in this box.
Box 5 – Report Consumer’s Phone Number - Click this checkbox to report the consumer’s phone number from their face sheet > Home Phone.
Box 7 – Leave Blank - Click this checkbox to not have any data reported in this box.
Boxes 10a, 10b and 10c – No Radio Button Pre-Selected - Click this checkbox to not have any radio buttons pre-selected in these boxes.
Box 11a – No Radio Button Pre-Selected - Click this checkbox to not have any radio buttons pre-selected in this box.
Box 11c – Leave Blank - Click this checkbox to not have any data reported in this box.
Box 11d – No Radio Button Pre-Selected - Click this checkbox to not have any radio buttons pre-selected in this box.
Box 13 – Leave Blank - Click this checkbox to not have any data reported in this box.
Box 21 – ICD Reporting – Click the desired radio button to indicate how and if the ICD-10 indicator should be reported:
Report 10 – Selected by default, 10 will be reported in this box
Report 0 – A 0 will be reported in this box
Leave Blank – No indicator will be reported in this box
Box 22 – Report Resubmission Code - Click this checkbox to report the claim frequency type code in Resubmission Code field (1 - Initial, 7 - Adjustment, or 8 - Void) and when reporting 7 or 8 the payers claim control number in the Original Ref. No field.
Box 24j (shaded area) - Report Rendering Provider Additional ID - Click the appropriate radio button to indicate what data needs to be reported in box 24j (the shaded area) of the HCFA-1500. Available options are:
Leave Blank - Selected by default. When selected, no data is reported.
Rendering Provider Secondary ID - When selected, the rendering provider's secondary ID is reported. Depending on where the invoice rendering/attending NPI is reported from, the associated secondary ID will be included:
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- Human Resources > Staff Information > Credentials > Rendering/Attending Provider Secondary ID
- Program Billing Info > Default Medical Providers Information > Secondary ID
- Edit Procedures > Incident to Secondary ID
Rendering Provider Taxonomy Code - When selected, the rendering provider's taxonomy code is reported. Depending on where the invoice rendering/attending NPI is reported from, the associated taxonomy will be included:
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- Human Resources > Staff Information > Credentials > Taxonomy Code
- Program Billing Info > Default Medical Providers Information > Taxonomy Code
- Edit Procedures > Incident to Taxonomy Code
Box 26 – Leave Blank - Click this checkbox to not have any data reported in this box.
Box 31 – Signature Options - Click the desired radio button to indicate how and if the providers name and credentials should be reported:
Report Provider Name/Credentials - Selected by default, the name of the service provider and their assigned credentials will be reported based om data found in Human Resources > Credentials tab > Authorization Credentials section.
Do Not Print Provider Name/Credentials - No service provider name and credentials will be reported in this box.
Report “(signature on file)” - (signature on file) will be reported in this box.
Printed Form – Omit Payer Name + Address in Header - Click this checkbox to not report the payer's name and address in the header of the printed HCFA-1500 form.
UB-04 Options
Box 2 - Report Sender Address from Program Billing Groups - Click this checkbox to report the sender's address from the program billing groups in box 2 of the UB-04. Additionally, the sender's phone number from the billing type will be reported as well as the billing provider's name.
Box 8a - Report Consumers Name - Click this checkbox to report the consumer's name in box 8a of the UB-04 in place of the default data, the consumer's SSN.
Box 38 - Report Payer Name and Address Information - Click this checkbox to report the payer's name and the payer's address within box 38 of the UB-04 claim form.
Box 51 - Report Locator Code from Program Billing Info - Click this checkbox to report the locator code from the Program Billing Info screen in box 51 of the UB-04 claim form.
HCFA-1500 & UB-04 Options
Report Multiple Invoices on HCFA-1500 and UB-04 Per Consumer - Check this checkbox to report more than one invoice/procedure per HCFA-1500 or UB-04 paper claim form from a single invoice batch.
Note: The following restrictions may cause invoices/procedure codes for an individual client in a single invoice batch to be reported on more than one form:
HCFA-1500
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- Rendering provider data in box 31 is different (also NPI in box 24J is different)
- Service facility address in box 32 is different
- Invoices are a mixture of both ICD-9/ICD-10 codes in box 21
UB-04
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- Attending provider data in box 76 is different
Additional Options/Data
Show Additional Configuration Options on Configure Billing Types Screen - Click this checkbox to enable additional 837I file options to be shown when Configuring Billing Types.
Entitlements Eligibility ID Entry Format - Click this drop-down arrow and indicate whether the entitlements identifier format should be all numbers, all letters, or a combination of numbers and letters.
Tip: The entitlements identifier format set here will determine which format can be used when entering ID numbers using the Entitlements module Certified Entitlements feature. For example, if "numbers" is selected and users enter letters in an entitlement's ID field, they will receive an error and the information will not be saved.
Assign Default Delay Code to Invoices 90 Days or Older – Click this dropdown to select the default delay code that should be assigned to all invoices where the Service Date on the Edit Invoice Batch screen is 90 days or older from the date the batch was created. The following valid delay codes and descriptions are below:
1 - Proof of Eligibility Unknown or Unavailable
2 - Litigation
3 - Authorization Delays
4 - Delay in Certifying Provider
5 - Delay in Supplying Billing Forms
6 - Delay in Delivery of Custom-made Appliances
7 - Third Party Processing Delay
8 - Delay in Eligibility Determination
9 - Original Claim Rejected or Denied Due to a Reason Unrelated to the Billing Limitation Rules
10 - Administration Delay in the Prior Approval Process
11 - Other
15 - Natural Disaster
Payer Contact Information (not used in claims) - In this field, type the payer's contact information.
Click SAVE. The payer information is saved and displayed on a confirmation page. Additionally, the payer name is automatically added to the list of eligibility types found in the Entitlements module > Certified Entitlements feature.
Click Back to Payers List. The Payers configuration page is displayed, and the payer you have just added will be found in the Payer selection list found there.
Repeat the same steps until all payers have been added.
The process of configuring payers is now complete.
Tip: If it is later necessary to update or delete a payer, complete steps 1 through 3 above, select the appropriate payer from the Payer selection list, and then click UPDATE or DELETE, respectively. Keep in mind:
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When updating - If any changes are made, you must be sure to click SAVE to have those changes applied.
When deleting - A payer can only be deleted if there are no billing types, procedures, rates, or programs associated with it. If you choose to delete a payer with which none of those items are associated, you will be shown a confirmation page after clicking DELETE. Be sure to click OK on that page to complete the deletion process. Once deleted, a payer cannot be restored.