Use this task to configure plans to which claims will be submitted. Plans are the products offered by payers. The plan and payer have a child/parent relationship. The coverage type, insurance type, and identification numbers for providers, referring physicians, facilities, and groups defined at the parent payer is inherited by the plan. The identification numbers configured at the payer can be overridden at the plan. At least one plan must be configured for a payer.

The plan configuration includes information collected on the following tabs:

Step-By-Step Guide

Step

Instructions

Additional Information

1

General Tab

From the Payers & Plans page, click Create Plan. The Plan: New page opens with the General tab displayed.


2In the General section, open the Payer drop down list and select the payer to associate the plan.

If the plan creation is initiated by clicking Create from the Linked Plans section on the Payer: [name] page > General tab, the Payer field auto-populates with that payer.

3Enter the name of the plan in the Plan Name field.
4(Optional) Enter additional information to describe the plan in the Description field.
5Open the Coverage Type drop down list and select the type of provider number generated during claim processing.
6Open the Insurance Type drop down list and select the type of claim, also referred to as the claim file indicator, generated for this plan during claim processing.
7

In the Contact Information section, enter the Contact Name of the primary contact for the plan in the Last and First fields.


8Enter the phone number of the primary contact of the plan in the Phone field.
9Enter the facsimile number for the plan in the Fax field.
10Enter the primary electronic mail address of the primary contact in the Email field.
11Enter the URL of the web address for the plan in the Website field.
12

In the Plan Address section, select the International Address checkbox, if applicable.


13Enter of the street address for the plan in the Address line 1 and line 2 fields, if applicable.
14Enter the zip code for the plan in the Zip Code field.

If International Address is selected, the State and Zip Code fields are replaced with Postal Code, Provide Code, and Country.

15(Optional) Enter the name of the city for the plan in the City field.

The City field auto-populates based on the value entered for the Zip Code field, but can be updated, if necessary. 

16(Optional) Open the State drop down list and select the state for the external collection agency.

The State field auto-populates based on the value entered for the Zip Code field, but can be updated, if necessary. 

If International Address is selected, the State and Zip Code fields are replaced with Postal Code, Provide Code, and Country.
17

(Optional) If International Address is selected, the applicable international details are populated:

  • Enter the Postal Code for the mailing address of the plan
  • Enter the Provide Code if the address is located in a province
  • Open the Country drop down list and select the plan's country 

18In the Medigap Plan Information section, select Yes if the plan provides supplemental insurance for the charges that Medicare or Medicare Part B does not pay. A list of plans with the insurance type of Medicare Primary or Medicare Part B are listed in the Carrier column.
19(Optional) In the Medigap ID column, enter the five-digit Medigap identification number of this plan next to the plan in the Carrier column.
20In the Financial Reporting section, open the Plan Class drop down list and select the financial class of the plan.
21Click Apply. 
22

Claims Tab

Click the Claims tab to collect information for claim filing as it relates to either electronic or paper, claim options specific to the plan, and types of service that require referrals.


23Select the Generate claims for this plan checkbox to indicate that claims will be generated for the plan.

If the General claims for this plan checkbox is not selected, claim generation is disabled for the plan.

24

In the Electronic Claims Information section, open the drop down lists and select the option to define:

Electronic Claims InformationAdditional Information
ClearinghouseThe clearinghouse through which the selected plan's claims are processed.
Payer IDThe identification number of the payer for electronic claim processing. Also referred to as the Electronic Claim Configuration (ECC) number of the payer.
Claim Type

The type of claims generated for the plan.

Billing Provider TypeThe billing provider when claims are generated.
Primary Claims Format

For electronic claims, select Electronic.

For paper claims, select Self-Print. If this option is selected, the Paper Claim Format field should also be updated.

Note: Drop to Paper should not be used to print claims in house.

Non-Primary Claims Format

For electronic claims, select Electronic.

For paper claims, select Self-Print. If this option is selected, the Paper Claim Format field should also be updated.

Note: Drop to Paper should not be used to print claims in house.

Paper Claim Format The applicable paper claim form. The selection of this option loads the applicable values on the Paper Claim Options tab for populating the boxes on the paper claim form.
Claim Office NumberFree text field to enter the identification number of the claim office, if applicable.

To quickly find a payer in the list, type one or more letters of the payer name.



25

In the Plan Claim Options section, select the relevant options to apply to the plan's claims:

Plan Claim OptionSelectionDescription
NPI NumbersPlan requires provider NPI numbersIf checked, the plan requires provider NPI numbers.
Extreme AgePlan allows extreme age modifierIf checked, the plan allows extreme age modifiers.
Pre-AuthorizationPlan requires pre-authorizationIf checked, the plan requires pre-authorization for treatment.
Zero Fee AmountsPlan allows zero fee amounts in claimsIf checked, the plan allows zero fee amounts in claims.
Narrative RecordPlan includes narrative (Box 19) in claims → Plan includes anesthesia time in narrative

If checked, the plan includes the narrative in Box 19 for claims. 

If Plan includes narrative (Box 19) in claims is checked, the Plan includes anesthesia time in narrative option is enabled.

Group NumbersPlan requires group numbersIf checked, the plan requires group numbers.
PQRS CodesPlan accepts PQRS codesIf checked, the plan accepts PQRS codes.
Allowed ClaimsPlan disallows electronic claims beyond secondaryIf checked, the handling of tertiary claims is disallowed.
MedicarePlan is a Medicare replacement productIf checked, the plan is a Medicare replacement product. Some secondary insurances require this identification before they will process a claim.
Miscellaneous PlanAlways ask for updated plan name and addressIf checked, the plan is designated as a miscellaneous plan under the parent player. When selecting this plan in charge entry or from the account, a prompt is displayed to update the plan name and address.
Physical StatusConvert physical status units to procedure minutesIf checked, 15 procedure minutes are added on the claim for each physical status unit billed on the case. For example, a case billed with a P4 (two units) and an original case time of 60 minutes will display as 90 minutes on the claim (two units x 15 minutes = 30 minutes added to the original procedure time value on the claim). Use this option only if a payer requires it.
General Excise TaxAllow → Apply to claims; DisallowThere is an option to select Allow or Disallow general excise tax on the claim. If Allow is selected, the Apply to claims option is enabled.

26

Enter or select from the calendar the ICD-10 Effective Date to specify the first Date of Service the system will start sending ICD-10 codes on claims.

All Dates of Service prior to the date entered will be sent using ICD-9 codes.

27Open the Address field and select the address to send in the 2010AA loop.
28

In the Types of Service Requiring Referrals section:

  • Select the Plan requires referrals for all types of service option if the plan requires a referral all types of service.
  • Select specific services from the list if only certain types of services require a referral.

29Click Apply.
30

Statements Tab

Click the Statements tab to designate if financial responsibility automatically rolls to the guarantor if there is non-payment from the plan.


31Select the Plan allows responsibility to roll to guarantor checkbox if the financial responsibility rolls to the guarantor in the case of non-payment.
32(Optional) If the Plan allows responsibility to roll to guarantor checkbox is selected, the Hold Statements option is enabled. Select this option to hold the plan's statements if the financial responsibility is rolled to the guarantor.
33Click Apply.
34

Anesthesia Tab

Click the Anesthesia tab to configure the anesthesia options for the plan.


35

In the Team Billing section, select the relevant billing method for the plan:

  • Bill Physician Only (default selection)
  • Bill Physician and CRNA on the same claim
  • Bill Physician and CRNA on separate claims
  • Bill CRNA Only

The Bill CRNA Only option is only used in situations where the case did not meet the seven steps of medical direction. In that scenario:

  1. Check the Bill CRNA Only option for the plan.
  2. Create and submit a case for the CRNA's time. (The claim will reflect solo CRNA and solo CRNA modifiers based on the concurrency scheme.)
  3. Return to the plan and deselect this option.
36(Optional) In the Concurrency section, open the Concurrency Scheme drop down list and select an option.

If the plan uses the default concurrency scheme, this step is not necessary.

37

In the Code Type Usage section, open the Use drop down list and select one of the options:

  • CPT if the plan uses CPT codes in claims

  • ASA if the plan uses ASA codes for expected fee calculations

38

In the Custom Logic section, select the relevant options:

  • Use Georgia Medicaid MAC logic (D9242) topopulate the D9242 pseudo code in place of the ASA code if GA Medicaid is the payer and MAC anesthesia was performed on the case
  • Set physical status modifiers to second position to place the physical status modifiers in the third position after the method of anesthesia modifiers (If unchecked, Modifier order is concurrency, method of anesthesia, physical status)

39Click Apply.
40

Provider IDs Tab

Click the Provider IDs tab to record the general or facility-specific provider identification numbers issued by the plan.

By default, all identification numbers recorded at the parent payer are inherited by the plan. It is only necessary to record provider identification numbers if the plan issues different identification numbers than its parent payer.

41

(Optional) If the plan issues different identification numbers for the providers:

    1. Click Unlink.
    2. Record facility-specific or general provider ID numbers:
Facility-SpecificGeneral Provider IDs
  1. Open the Provider ID Type drop down list and select Facility-Specific.
  2. Open the Practice drop down list and select the practice.

  3. If adding a PAR provider:

    1. Select the PAR checkbox of the applicable provider to indicate the provider participates with the payer.
    2. (Optional) If the provider does not accept assignment, uncheck the Accepts Assign checkbox.
    3. Enter or select the effective date in the Effective column.
    4. Enter the identification number issued to the provider by the payer in the Facility Provider ID column.

    If adding a non-PAR provider:

    1. (Optional) If the provider does not accept assignment, uncheck the Accepts Assign checkbox.
    2. Enter or select the effective date in the Effective column.
    3. Enter the identification number issued to the provider by the payer in the Facility Provider ID column.
  4. Select the Suspend Claims checkbox to stop generating claims for the selected provider.
  5. Enter the contract code for the selected payer in the Contract Code field.
  6. Repeat the steps above for each provider to be added.
  1. Open the Provider ID Type drop down list and select General Provider ID.
  2. Open the Practice drop down list and select the practice.

  3. If adding a PAR provider:

    1. Select the PAR checkbox of the applicable provider to indicate the provider participates with the payer.
    2. (Optional) If the provider does not accept assignment, uncheck the Accepts Assign checkbox.
    3. Enter or select the effective date in the Effective column.
    4. Enter the identification number issued to the provider by the payer in the Provider ID column.

    If adding a non-PAR provider:

    1. (Optional) If the provider does not accept assignment, uncheck the Accepts Assign checkbox.
    2. Enter or select the effective date in the Effective column.
    3. Enter the identification number issued to the provider by the payer in the Provider ID column.
  4. Select the Suspend Claims checkbox to stop generating claims for the selected provider.
  5. Enter the contract code for the selected payer in the Contract Code field.
  6. Repeat the steps above for each provider to be added.

Use the Find search box or the Hide Expired checkbox to filter the list of providers.

42Click Apply.
43

Referring Physician IDs Tab

Click the Referring Physician IDs tab to record referring physician identification numbers issued by the plan.

By default, all identification numbers recorded at the parent payer are inherited by the plan. It is only necessary to record referring physician identification numbers if the plan issues different identification numbers than its parent payer.

44

(Optional) If the plan issues different identification numbers for the referring physicians:

    1. Click Unlink.
    2. Select the Plan issues referring physician IDs checkbox to indicate the plan issue identification numbers to referring physicians.
    3. Navigate to the row for the referring physician and enter the identification number in the associated ID Number column.
    4. Repeat the above steps for each referring physician to be updated with an identification number.
Use the Find search box or the Hide Expired checkbox to filter the list of providers.



45Click Apply.
46

Facility IDs Tab

Click the Facility IDs tab to record the general or place-of-service-specific facility identification numbers issued by the plan.

By default, all identification numbers recorded at the parent payer are inherited by the plan. It is only necessary to record facility identification numbers if the plan issues different identification numbers than its parent payer.

47

(Optional) If the plan issues different identification numbers for the facilities:

    1. Click Unlink.
    2. Record place of service specific or general facility ID numbers:
Place of Service SpecificGeneral Facility ID
  1. Open the Facility ID Type drop down list and select Place of Service Specific.
  2. Navigate to the row for the facility and enter the identification number in the associated ID Number column.
  3. Repeat the above steps for each facility to be updated with an identification number.
  1. Open the Facility ID Type drop down list and select General Facility ID.
  2. Navigate to the row for the facility and enter the identification number in the associated ID Number column.
  3. Repeat the above steps for each facility to be updated with an identification number.

48Click Apply.
49

Group IDs Tab

Click the Group IDs tab to record the general or facility-specific group identification numbers issued by the plan.

By default, all identification numbers recorded at the parent payer are inherited by the plan. It is only necessary to record group identification numbers if the plan issues different identification numbers than its parent payer.

50

(Optional) If the plan issues different identification numbers for the groups:

    1. Click Unlink.
    2. Record facility-specific or general group numbers:
Facility-SpecificGeneral Group ID
  1. Open the Group ID Type drop down list and select Facility-Specific.
  2. Open the Practice drop down list and select the practice.
  3. Navigate to the row for the facility and enter the identification number in the respective column for:
    • Physician Group
    • PA Group
    • CRNA Group
    • AA Group
  4. Repeat the above steps for each facility to be updated with a group identification number.
  1. Open the Group ID Type drop down list and select General Group ID.
  2. Navigate to the row for the practice and enter the identification number in the respective column for:
    • Physician Group
    • PA Group
    • CRNA Group
    • AA Group
  3. Repeat the above steps for each practice to be updated with a group identification number.

51Click Apply.
52

Paper Claims Options Tab

Click the Paper Claim Options tab to configure the paper claim options for a claim form.

The Paper Claim Options tab includes a form with fields relevant to the Paper Claim Format option selected on the Claims tab.

53

(Optional) If any paper claim forms selections need to be updated:

    1. Navigate to the Field Name that corresponds with the box on the claim form.
    2. Open the related Primary or Secondary field drop down list to be updated and select the updated value.
    3. Click OK to any validation messages. 

54Click Apply.
55

Other Insurance Codes Tab

Click the Other Insurance Codes tab to add codes to uniquely identify plans for payers who require them.


56For the relevant insurance plan(s), enter the unique Code.
57Click Save to save and close the page. 






Related Topics

Payers & Plans

Payers & Plans Page

Payer Page / General Tab

Payer Page / Provider IDs Tab

Payer Page / Referring Physician IDs Tab

Payer Page / Facility IDs Tab

Payer Page / Group IDs Tab

Plan / General Tab

Plan Page / Claims Tab

Plan Page / Statements Tab

Plan Page / Anesthesia Tab

Plan Page / Provider IDs Tab

Plan Page / Referring Physician IDs Tab

Plan Page / Facility IDs Tab

Plan Page / Group IDs Tab

Plan Page / Practices Tab

Plan Page / Paper Claim Options Tab

Plan Page / Electronic Claim Options Tab

Plan / Other Insurance Codes Tab

Configuring Payers

Updating Payers

Updating Plans

Deleting Payers & Plans

Cloning Payers & Plans

Copying Paper Claim Settings to Other Plans

Related Training/Support Documentation

Not applicable for this topic

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