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References - Insurance Companies

Company Info
The Company Info tab contains information that is related to an insurance carrier. Several fields in this tab are used for specific carriers and will not be used in all cases. Other fields are vital to ensuring payment from the insurance carrier and if set incorrectly could affect all claims.
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  • Insurance Company: The Insurance Company name is used to identify this insurance. It will appear in the sidebar under the Insurance Companies node. The name will print above the address on a paper claim and is also sent on electronic claims.
  • Street Address, Suite, City, State and Zip Code: Demographic information that would pertain to the company as a whole. If using insurance plans, the demographic information will be pulled from the Demographic information under the Plans tab, not from the Company Info tab.
  • Phone, Extension, Contact Person, Fax and E-mail Address: Additional demographic information. if using plans this information is stored in the Demographic information under the Plans tab. These fields are informational only and do not print on claims.
  • Default Fee Schedule: You may set a fee schedule to be associated to the carrier when an insurance is added to the patient's account. This is different than the fee schedule on the account, the user will be prompted if they want to change the patient's fee schedule to match that of the insurance.
  • Previous Plan Name: This is a free form field that can be used to store a carrier name change. The Previous Plan Name does not print on claims.
  • Practice Group ID (Paper): The Practice Group ID (Paper) is used for a Legacy Group Number. This will print in Box 33b on the CMS 1500 form if using the Legacy Only or NPI and Legacy forms.
  • Practice Group ID (Electronic): The Practice Group ID (Electronic) is used for a Legacy Group Number. This will be sent in the 2010AA Loop on an eClaim. If a group number is entered here, an individual number must be entered on the Provider IDs tab as well or the eClaim will be invalid.
  • Claim Office: The Claim Office field is a Payer-specific contract code for eClaims.
  • Payer ID: The Payer ID is assigned to the carrier by the clearinghouse and is not necessarily the same number as found on the patients' cards. You should always look up your Payer ID on from your clearinghouse's payer list. The clearinghouse will change the Payer ID when they send the claim to the payer. Payer IDs are only used in eClaims.
  • Submitter ID: A Submitter ID is number assigned to an eClaim submitter. Usually the submitter ID is assigned to the clearinghouse, but some carriers assign specific submitter IDs per provider or office. The Submitter ID field in theInsurance Company reference is mainly used by Noridian Medicare and BCBS to identify the provider in the header segments of an eClaim. If unsure, leave this field blank as it will most likely cause problems with claim submission if filled out incorrectly. The MacPractice Enrollment department will notify you if you need a submitter ID.
  • Trading Partner Number: The Trading Partner Number is used by UHIN clients to route claims to the Payer. It is similar to the payer ID for most clearinghouses. The Trading Partner Number field will only affect eClaims.
  • Carrier Code: Electronic claims use the Carrier Code field for Medicaid secondary claims to indicate the ID of the primary payer assigned by Medicaid. Paper claims will pull this info into box 9d on the CMS 1500, however this will require a custom form.
  • Website: This field is for the Web address URL of the payer. This field is informational only and does not affect claims.
Provider IDs
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The Provider IDs tab contains information related to the provider and the selected carrier specifically. The information stored here is the legacy provider ID otherwise called a PTAN, PIN number or provider number. Legacy numbers are not to be confused with NPI numbers which are stored in the Users Reference. NPI numbers should not be entered in the Insurance Company Reference or they will cause issues with claims.
  • Provider: This field will display the name of the provider and the User ID associated in the provider's UsersReference.
  • Paper ID: The Paper ID field is for the Legacy Provider ID assigned to the provider by the carrier to be used for paper claims.
  • Electronic Claims ID: The Electronic Claims ID field is for the Legacy Provider ID assigned to the provider by the carrier to be used for electronic claims. If the legacy provider number is the provider's tax ID or social security number, this field can be left blank and it will pull from the provider's Users reference.
  • Submitter ID: The Submitter ID field on the Provider IDs tab will override the Submitter ID on the Company Info tab. This is used if multiple providers in the office have different submitter IDs for a carrier. If unsure, leave this field blank as it will most likely cause problems with claim submission if filled out incorrectly. The MacPractice Enrollment department will notify you if you need a submitter ID.
  • Provider Accepts Assignment: Check the Provider Accepts Assignment checkbox if the provider Accepts Assignment with the carrier. According to Medicare, Accepts Assignment means that the provider accepts the carrier's allowed amounts. Definitions of Accepts Assignment vary by payer, the provider should contact the payer for clarification. Generally it means that the provider will receive the payment for the visit. This also controls if the amount of the claim will move to insurance portion or remain in patient portion when a claim is created.
  • Participate: Check the Participate checkbox if the provider is a participating provider with that carrier's network, or an in-network provider.
  • Bill as Individual: Checking the Bill as Individual checkbox strips any group information from both paper and electronic claims. This will print the individual NPI and legacy identifiers in box 33 on the CMS 1500 form or in the 2010AA Loop on eClaims. Bill as Individual also strips the rendering provider information in box 24J for paper or in the 2310B Loop for eClaims.
  • Qualifier Code: The Qualifier Code override changes the 2 digit qualifier code associated to the legacy provider ID. Qualifier codes designate what type of provider number the legacy number is. For example a Blue Cross qualifier would be 1B. If set to Automatic, the qualifier pulls based off of the Plan Type.
  • Legacy Number Type: This field is used specifically when a provider is setup to bill with the Tax ID to most carriers, but is credentialed with the Social Security Number with Medicare. If using this override, you must also check Bill as Individual for it to function correctly. This field will only affect eClaims.

Participate and Accept Assignment
Participate and Accept Assignment are two different fields within MacPractice. They serve similar functions, but it helps to understand how they differ.

Participate
This is for doctors who are in networks with an insurance company.

Accept Assignment
This shows that you are not in network but you accept an insurance company's allowed amount.

It is possible to both Participate and Accept Assignment.

Some payers will pay the patient directly if you don't mark Accept Assignment even if you mark the Primary or Secondary Signature on file. So non-participating providers can accept assignment at lower reimbursement rates and, if they have the Primary or Secondary signature on file, are more likely to get payment instead of the payment going directly to the patient.

Comments
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The Comments tab is a free form text field that allows you to enter pertinent information about the carrier, i.e., timely filing, expected time to pay or past issues with the carrier.
 
Claims
The Claims tab contains information related to claims for an insurance carrier.
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  • Diagnosis Code System: This lets you set your Diagnosis codes to ICD9, ICD10, or the Default set in the Preference.
  • eClaims Template: Sets the default template used when creating claims from the ledger. Set it to None if payer does not accept electronic claims. Setting a template in the insurance reference will cause MacPractice to override the default paper form and always default to an eClaim in the claim creation sheet. You may always override the defaulted value on the fly when creating claims.
  • Default Form: Sets the default paper form to use when creating claims from the ledger. Setting this allows to choose the correct form whether legacy, NPI or both should go on a claim to this carrier.
  • Plan Type: The Plan Type is a critical setting for claims. The Plan Type sets the legacy qualifier code and various other fields on both paper and electronic claims. Medicare, Medicaid and Blue Cross/Blue Shield especially need this setting to be correct.
  • Insurance Type: Allows you to switch between Dental and Medical.
  • Timely Filing Limit (Days): The number of days in which claims must be submitted.
  • Carrier Always Pays Provider: If a provider does not accept assignment and creates a claim on the ledger, the balance of the claim will remain in patient portion. Checking Carrier Always Pays Provider allows the balance of the charges submitted to stay in Insurance Portion until claim is paid/closed.
  • Write-Off Lab: Currently does not control any other feature in MacPractice.
  • eClaims should include NPI only: Forces all eClaims for this payer to be sent without the legacy provider number in all areas of the claim.
  • Leave 24 i/j Blank: This allows you to leave this boxes blank on the CMS Legacy forms.
  • Use Group Taxonomy: Sends the group taxonomy code as well as the provider's taxonomy code when checked. This setting only affects eClaims. MacPractice will notify you if you need to send a group taxonomy code.
  • Sum the following in Box 29 HCFA for Secondary Claims: These checkboxes allows the User to control if Patient Paid, Primary Paid or Insurance Write-Off are included in the calculation of Box 29 on the CMS 1500 form. They are used for secondary paper claims only and do not affect eClaims.
  • Sum following in Box 29 HCFA for Primary Claims: This checkbox allows the User to control if Patient Paid is included in the calculation of Box 29 on the CMS 1500 form. It is used for primary paper claims only and do not affect eClaims. Please keep in mind for eClaims if a patient payment is applied to a charge prior to claim creation, the patient payment will always appear on the eClaim.
  • CMS 1500 Legacy ID Codes: These pop-up menus allow the user to control the legacy qualifiers and/or legacy number on paper claims only. The Automatic setting will pull the qualifiers based on the Plan Type and will work in most cases. eClaim qualifier codes are controlled by the template.
    • Legacy Referral Qualifier Code: Controls box 17a, a two digit qualifier code which defines the type of legacy number being sent. The qualifier prints before the legacy number in this field. When set to Automatic, the code is set based on Plan Type.
    • Legacy Referral ID Number: Controls box 17a to pull the legacy number from an alternate field in the Referral Reference. Normally the referral legacy number pulls from the field corresponding to the Plan Type.
    • Legacy Facility Qualifier Code: Controls box 32b, a two digit qualifier code which defines the type of legacy number being sent. The qualifier prints before the legacy number in this field. When set to Automatic, code is set based on the Plan Type.
  • Box 25 ADA For Area of Oral Cavity: This checkbox allows you to print the a quadrant instead of a code for ADA forms.

Plans Tab
Any information entered under the Plans tab of the Insurance Company reference will override information entered on the Company Info tab, as long as the patient has a plan associated to their insurance. Information entered on the Notes tab doesn't affect claims.

Plan Coverage Tab (Claims)
Most fields on the image below are used in setting up Insurance Estimating and will not affect claims printing and/or creation
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  • Participate: Controls whether a write-off is automatically calculated when the plan is set up for the patient. Having Participate checked here also overrides the Participate setting on the Provider IDs tab.
  • Plan Type: Overrides the Plan Type on the Company Information tab as long as the patient has a plan selected.
Plan Coverage Tab (Insurance Estimating)
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  • Plan Name: Plans are used to modify the patient's coverage for the particular insurance. There can be many plans used by a single insurance company. Plans can be named in many ways, most commonly plans are named after an employer, group or by the plan address.

    These fields will pull forward into the patient's screen allowing the office to keep track of plan information for Insurance Estimating. This information can also be overridden on a per-patient basis.
  • Coordination w/Other Carriers: Controls how Secondary Insurance Estimating behaves in coordination with Primary coverage.
  • Deductible Applied To: Determines how many patients on the account must meet the deductible before an insurance portion will be calculated.
  • Procedure Type: Lists each Procedure Type you have created in your database.
  • % Insurance Pays: The percentage of an allowed amount that you expect to receive from the payer per their plan specifications.
  • Applies to Deductible: Determines whether the procedure type will apply toward a patient's deductible.
Plan Demographic Tab
All Insurance demographic information entered here will override the demographics on the Company Information tab if the Plan is associated to the patient. If an insurance claim prints with a blank insurance company address, and the address is entered correctly in the Company Info tab, confirm the address is also entered correctly in the Plans > Demographic tab.
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Plan Participation Tab
The Participate tab allows users to control the plan's participation per provider; this information overrides the participation checkbox on the Coverage tab per provider.
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Notes Tab
The Notes tab contains a text field that can be used for internal notes. These notes are not pulled into any claim information and is used for the practice's benefit only.
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Procedures Tab
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  • Procedure Code: The code for the procedure in the plan.
  • Allowed: The amount that insurance has agreed to pay.
  • Flat Rate: The rate that insurance will always pay regardless of the situation.
  • Copay: How much the patient's Copay will be for the procedure.
  • Work RVU: The Relative Value Units are entered here should they be required.
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