Post by peter@crystalpm on Feb 12, 2014 23:13:08 GMT -6
Billing formats keep changing and it keeps getting more political each year it seems. Right now in early 2014, we are suffering from something called a "Sequester" where the government payers (CMS, medicare, medicaid, etc.) are holding back 2% of everything and creating new "non-payment" reason codes all the time. It seems that the only thing constant is the change.
Extremely brief history of submitting insurance claims:
If you have been avoiding all the hoopla and rigamarole of billing, then you probably think ignorance is bliss. Sooner or later you will need to move into the new millennium and stop ignoring 20 years of change. Its easier than you think. Here is a quick guide on how to configure Crystal to start sending ANSI 5010 format without getting errors.
First here are some definitions of some terms that might be new to you:
So, here's how to set up CrystalPM to make sure that the correct information goes into the correct place in the claim.
First we should set up the big things, the important things, the things that you set up one time and never touch ever again, but affect everything that happens in Crystal. We find these things in Admin-> Company. You will need to have a company name and address that will be used for the billing provider. This address will need to have a full 9 digit zip-code.
On the "Billing and CMS" tab, you should enter in the TAX ID for the billing provider and mark it as EIN or SSN. On the other column, turn on the ANSI billing format. Here you have several fields to fill in, the first of which should be really easy. For your billing amounts are you using US dollars or Canadian dollars. Office ID is a unique identifier for your office that is usually provided by the clearing house that you use. For example, GatewayEDI calls this your SiteID, Availity calls this your CustomerID, others might call this your UserID, LoginName, etc. Still others might refer to this field as the code in the ANSI file, which is ISA-06. Some trial and error might be needed here, but this is not something that CrystalPM Support can help you with since this is between you and the group you send claims to. All we can do is tell you what type of information goes in this field. Similarly, the ETIN (IT IS NOT A TAX ID, but stands for Electronic Transaction Identifying Number) is a number that is specific to the people you send claims to. This is referred to as ISA-08 in the file and every clearing house seems to have a different idea of what to do with this. GatewayEDI users should put "431420764", Optum Ingenix users should put "INGENIX", everyone else (so far) including Availity should just leave this blank. For File Receiver, most everyone should just select "Normal" (called "Other" in older versions). Normal will use the headers identified by the standard and accepted almost universally. If you use a clearing house in this list, then we have made special non-standard headers to accommodate them, and select them in the list. Please, do not be worried if your clearing house is not in this list.
Referring Provider information needs to be added in to the "Professional Referrals" list. This list can be found by clicking through Admin-> Defaults-> Patient Page Defaults -> Professional Referral. You will want to add your office's doctors to this list, so we can start with them. To add a new person, simply click the add button and in the window, type in their name as you would like it to appear on the list. Once they are on the list, you can add more information by double-clicking on the name. For ANSI billing you will need to add an address with full 9 digit zip-code, and at the bottom where it says "box 17", add their NPI number and name in "Last, First" format without the titles or suffixes. Do this for each doctor in your practice and any physicians that refer patients to you.
If you are already using print image to send information to a clearing house, then these last two areas (Employees and Insurances) are probably already set up correctly, but you should verify that this is the case and that the information is correct.
Under Admin->Employees you should have a list of all users that use CrystalPM (for HIPAA compliance everyone needs a username and password), but doctors have some special fields that are used for billing, scheduling, etc. You want to make sure that your office doctors have an NPI number, an address that could be used for professional mail (not home address) including the full 9 digit zip-code, and a taxonomy code. Taxonomy code will default to Optometrist if it is left blank. The only numbers that should be used while doing ANSI billing are NPI, Tax ID, and DEA number. All the other old numbers, medicare number, Blue Cross number, license number, etc have been superseded by the NPI number and should be removed. Someday I'll actually remove the boxes, but that is for a future update. Click Update to save your changes, because this is one of the few places where changes do not automatically save.
Under Admin->Insurance, you can add new insurances to the list by pressing the "Add new insurance" button at the top right, but most of you will already have some insurances listed. You can fill out the "Information" tab, but most of the billing information will come from the "CMS Form" tab. First off, notice the instructions in dark blue text at the top right. Read them. People always call and ask this, so save a call and read it. The mailing address of the insurance company goes in the top box with insurance company name on the top line with the address below and city state zip below that.
For Box 1, choose medicaid or medicare and pretty much everything else gets group health plan.
Box "10d Reserved for local use" is where we put the Payer ID, which is a five character code that is unique to each insurance company. Ask your clearing house for a list of the codes they want you to use for this.
For Box 17a-b you can select "none" to leave it blank or "Doctor Name" to use the rendering provider as referring provider. "Other" is not used in ANSI billing.
Box 24, leave it all blank. NPI will fill in from the Employee record.
Box 27, unless you know for sure that you don't, select yes.
Box 31, doesn't affect ANSI
Box 32, this is your service facility, which is location dependent and can be changed for different locations in a multi location environment. The address should start with the facility name and the address on then ext line and the city state zip on the last line. Please note that CrystalPM only displays 3 lines in the box and there may be more information, so click in the box and use your down arrow to see all the lines. Address needs a full 9 digit zip code.
Box 32a, this is the group NPI number. If you don't have a group, leave it blank and we will use the NPI from the rendering provider.
Box 32b, leave it blank
Box 33, this is the address for the billing provider. If blank, the information should be pulled from the Admin->Company information, but there have been sporadic reports that there are errors in that process. If filling in this box, you must put the main phone number on the top line with parenthesis for the area code followed by a space, like this (XXX) XXX-XXX. Your company name should be on the next line, and the address after that and the city state zip on the last line. Again, the program only shows 3 lines of text so use your arrow keys to scroll down and make sure that the information is all there and nothing is there that shouldn't be there.
Box 33a, this is the group NPI number. If you don't have a group, leave it blank and we will use the NPI from the rendering provider.
Box 33b, leave it blank
The bad news is that you have to repeat this for each insurance. You can use the "set default globally" to copy all the boxes from this insurance to all the other insurances, but you still have to go set the payer ID and addresses for each of them.
That's it, now you are set up to ANSI. That wasn't so hard was it?
A few things to note:
Extremely brief history of submitting insurance claims:
- pre 1980s - handwritten or typed (typewriter) paper form
- 1980s - paper form, but computer to print on it
- 1990s - take away the paper and print information to a text file, which looks like form, but without all the boxes and lines (called print image)
- 2000s - electronic submission now has a standard called 4010 which is complex and not easily readable, but makes life easier for computers
- 2010s - improvements to the 4010 format make life even easier, called 5010, is adopted as the standard that all claims must use and finally changed the paper form to match the new requirements
If you have been avoiding all the hoopla and rigamarole of billing, then you probably think ignorance is bliss. Sooner or later you will need to move into the new millennium and stop ignoring 20 years of change. Its easier than you think. Here is a quick guide on how to configure Crystal to start sending ANSI 5010 format without getting errors.
First here are some definitions of some terms that might be new to you:
- Providers - there are many types of providers
- Billing Provider - this is the lone doctor providing care without a group, otherwise this is the group
- Rendering Provider - this is the individual doctor that provided the services. This is removed if the rendering is the same as the billing provider, i.e. no group.
- Referring Provider - This can be the cataract surgeon whose patient you are monitoring, or could be the same as rendering provider.
- Ordering Provider - This is required for "Durable Medical Equipment". It replaces the Rendering provider.
- Service Location - this is an address where the patient was seen. It is
only included if the address is different than the billing provider
address. For "Durable Medical Equipment", this is the location where the equipment will be used, so it may be the patient's home address. Although this is not a provider, for some reason it is in the providers section of the ANSI format, so I put it here.
- Billing Provider - this is the lone doctor providing care without a group, otherwise this is the group
- Subscriber - This is the person with the insurance. Sometimes this is referred to as the Guarantor. This is the person responsible for the bill.
So, here's how to set up CrystalPM to make sure that the correct information goes into the correct place in the claim.
First we should set up the big things, the important things, the things that you set up one time and never touch ever again, but affect everything that happens in Crystal. We find these things in Admin-> Company. You will need to have a company name and address that will be used for the billing provider. This address will need to have a full 9 digit zip-code.
On the "Billing and CMS" tab, you should enter in the TAX ID for the billing provider and mark it as EIN or SSN. On the other column, turn on the ANSI billing format. Here you have several fields to fill in, the first of which should be really easy. For your billing amounts are you using US dollars or Canadian dollars. Office ID is a unique identifier for your office that is usually provided by the clearing house that you use. For example, GatewayEDI calls this your SiteID, Availity calls this your CustomerID, others might call this your UserID, LoginName, etc. Still others might refer to this field as the code in the ANSI file, which is ISA-06. Some trial and error might be needed here, but this is not something that CrystalPM Support can help you with since this is between you and the group you send claims to. All we can do is tell you what type of information goes in this field. Similarly, the ETIN (IT IS NOT A TAX ID, but stands for Electronic Transaction Identifying Number) is a number that is specific to the people you send claims to. This is referred to as ISA-08 in the file and every clearing house seems to have a different idea of what to do with this. GatewayEDI users should put "431420764", Optum Ingenix users should put "INGENIX", everyone else (so far) including Availity should just leave this blank. For File Receiver, most everyone should just select "Normal" (called "Other" in older versions). Normal will use the headers identified by the standard and accepted almost universally. If you use a clearing house in this list, then we have made special non-standard headers to accommodate them, and select them in the list. Please, do not be worried if your clearing house is not in this list.
Referring Provider information needs to be added in to the "Professional Referrals" list. This list can be found by clicking through Admin-> Defaults-> Patient Page Defaults -> Professional Referral. You will want to add your office's doctors to this list, so we can start with them. To add a new person, simply click the add button and in the window, type in their name as you would like it to appear on the list. Once they are on the list, you can add more information by double-clicking on the name. For ANSI billing you will need to add an address with full 9 digit zip-code, and at the bottom where it says "box 17", add their NPI number and name in "Last, First" format without the titles or suffixes. Do this for each doctor in your practice and any physicians that refer patients to you.
If you are already using print image to send information to a clearing house, then these last two areas (Employees and Insurances) are probably already set up correctly, but you should verify that this is the case and that the information is correct.
Under Admin->Employees you should have a list of all users that use CrystalPM (for HIPAA compliance everyone needs a username and password), but doctors have some special fields that are used for billing, scheduling, etc. You want to make sure that your office doctors have an NPI number, an address that could be used for professional mail (not home address) including the full 9 digit zip-code, and a taxonomy code. Taxonomy code will default to Optometrist if it is left blank. The only numbers that should be used while doing ANSI billing are NPI, Tax ID, and DEA number. All the other old numbers, medicare number, Blue Cross number, license number, etc have been superseded by the NPI number and should be removed. Someday I'll actually remove the boxes, but that is for a future update. Click Update to save your changes, because this is one of the few places where changes do not automatically save.
Under Admin->Insurance, you can add new insurances to the list by pressing the "Add new insurance" button at the top right, but most of you will already have some insurances listed. You can fill out the "Information" tab, but most of the billing information will come from the "CMS Form" tab. First off, notice the instructions in dark blue text at the top right. Read them. People always call and ask this, so save a call and read it. The mailing address of the insurance company goes in the top box with insurance company name on the top line with the address below and city state zip below that.
For Box 1, choose medicaid or medicare and pretty much everything else gets group health plan.
Box "10d Reserved for local use" is where we put the Payer ID, which is a five character code that is unique to each insurance company. Ask your clearing house for a list of the codes they want you to use for this.
For Box 17a-b you can select "none" to leave it blank or "Doctor Name" to use the rendering provider as referring provider. "Other" is not used in ANSI billing.
Box 24, leave it all blank. NPI will fill in from the Employee record.
Box 27, unless you know for sure that you don't, select yes.
Box 31, doesn't affect ANSI
Box 32, this is your service facility, which is location dependent and can be changed for different locations in a multi location environment. The address should start with the facility name and the address on then ext line and the city state zip on the last line. Please note that CrystalPM only displays 3 lines in the box and there may be more information, so click in the box and use your down arrow to see all the lines. Address needs a full 9 digit zip code.
Box 32a, this is the group NPI number. If you don't have a group, leave it blank and we will use the NPI from the rendering provider.
Box 32b, leave it blank
Box 33, this is the address for the billing provider. If blank, the information should be pulled from the Admin->Company information, but there have been sporadic reports that there are errors in that process. If filling in this box, you must put the main phone number on the top line with parenthesis for the area code followed by a space, like this (XXX) XXX-XXX. Your company name should be on the next line, and the address after that and the city state zip on the last line. Again, the program only shows 3 lines of text so use your arrow keys to scroll down and make sure that the information is all there and nothing is there that shouldn't be there.
Box 33a, this is the group NPI number. If you don't have a group, leave it blank and we will use the NPI from the rendering provider.
Box 33b, leave it blank
The bad news is that you have to repeat this for each insurance. You can use the "set default globally" to copy all the boxes from this insurance to all the other insurances, but you still have to go set the payer ID and addresses for each of them.
That's it, now you are set up to ANSI. That wasn't so hard was it?
A few things to note:
- Use the system as normal, fill out the 1500 as normal, write claims to batch as normal. There are almost no changes in your day to day workflows. 95% of the time ANSI billing works the same as normal billing.
- When you find an exception, such as "Durable Medical Equipment" needs an ordering provider, or you need to send a corrected claim, or you need to include a CLIA number, you can use the "Additional ANSI Information" button to add/change/update/delete the ANSI claim. The fields for the section that was changed will change to an orange color on the HCFA billing form to alert you that the ANSI claim is different than the form shows. The ANSI button will turn orange as well, to remind you why the orange is there.