Page History

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	From the Payers & Plans page, select the plan to be modified.

2

General Tab

Click Update. The Plan: [name]page opens with the General tab displayed.

Update the relevant information via the applicable steps below...

3

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

Note
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. If the plan creation is initiated by cloning an existing plan, the Payer field auto-populates with the payer on the original plan. This value can be changed, as needed.

4

Enter the name of the plan in the Plan Name field.


5	(Optional) Enter additional information to describe the plan in the Description field.


6	Open the Coverage Type drop down list and select the type of provider number generated during claim processing.


7	Open 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.


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


9	Enter the phone number of the primary contact of the plan in the Phone field.


10	Enter the facsimile number for the plan in the Fax field.


11	Enter the primary electronic mail address of the primary contact in the Email field.

12

Enter the URL of the web address for the plan in the Website field.


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


14	Enter of the street address for the plan in the Address line 1 and line 2 fields, if applicable.

15

Enter the zip code for the plan in the Zip Code field.

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

16

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

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

17

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

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

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

18

(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


19	In 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.


20	(Optional) In the Medigap ID column, enter the five-digit Medigap identification number of this plan next to the plan in the Carrier column.


21	In the Financial Reporting section, open the Plan Class drop down list and select the financial class of the plan.

22

Select the Inactive checkbox to deactivate or expire a plan.

To deactivate the plan, enter the Effective Date.
Toexpire the plan, enter the Expiration Date when the plan expires.


23	Click Apply.

24

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.

25

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

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

26

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

Electronic Claims Information	Additional Information
Clearinghouse	The clearinghouse through which the selected plan's claims are processed.
Payer

IDPayer I

ID	The 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 Type

The billing provider when claims are generated.

Primary Claims Format

For electronic claims, select Electronic.

For paper claims, select

either Drop to Paper or

Self-Print. If

one of these options are

this option is selected, the Paper Claim Format field should also be updated.

Non-

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

either Drop to Paper or

Self-Print. If

one of these options are

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 Number

Free text field to enter the identification number of the claim office, if applicable.

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

27

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

Plan Claim Option	Selection	Description
NPI Numbers	Plan requires provider NPI numbers	If checked, the plan requires provider NPI numbers.
Extreme Age	Plan allows extreme age modifier	If checked, the plan allows extreme age modifiers.
Pre-Authorization	Plan requires pre-authorization	If checked, the plan requires pre-authorization for treatment.
Zero Fee Amounts	Plan allows zero fee amounts in claims	If checked, the plan allows zero fee amounts in claims.
Narrative Record	Plan 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 Numbers	Plan requires group numbers	If checked, the plan requires group numbers.
PQRS Codes	Plan accepts PQRS codes	If checked, the plan accepts PQRS codes.
Allowed Claims	Plan disallows electronic claims beyond secondary	If checked, the handling of tertiary claims is disallowed.
Medicare	Plan is a Medicare replacement product	If checked, the plan is a Medicare replacement product. Some secondary insurances require this identification before they will process a claim.
Miscellaneous Plan	Always ask for updated plan name and address	If 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 Status	Convert physical status units to procedure minutes	If 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 Tax	Allow → Apply to claims; Disallow	There 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.

28

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.

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

29

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

30

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.


31	Click Apply.

32

Statements Tab

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


33	Select the Plan allows responsibility to roll to guarantor checkbox if the financial responsibility rolls to the guarantor in the case of non-payment.


34	(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.


35	Click Apply.

36

Anesthesia Tab

Click the Anesthesiatab to configure the anesthesia options for the plan.

37

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

38In the Concurrency section, open the Concurrency Scheme drop down list and select an option if the plan uses a

Note

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:

Check the Bill CRNA Only option for the plan.
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.)
Return to the plan and deselect this option.

38

In the Concurrency section, open the Concurrency Scheme drop down list and select an option if the plan uses a different concurrency scheme than the default concurrency scheme.

39

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

40

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)

41

Click Apply.

42

Provider IDs Tab

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

Note
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.

43

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

Click Unlink.
Record facility-specific or general provider ID numbers:

Facility-Specific

General Provider IDs

Open the Provider ID Type drop down list and select Facility-Specific.
Open the Practice drop down list and select the practice.
If adding a PAR provider:
1. Select the PAR checkbox to indicate the provider participates with the payer.
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.
If renewing a PAR provider:
1. Enter or select the expiration date in the Expiration field.
2. Click Add. A new line item, in red text, is created for the provider.
3. Select the PAR checkbox to indicate the provider participates with the payer.
4. Enter or select the effective date in the Effective column of the new line item.
5. Enter the identification number issued to the provider by the payer in the Provider ID column.
If changing a PAR provider to non-PAR status:
1. Enter or select the expiration date in the Expiration field.
2. Click Add. A new line item, in red text, is created for the provider.
3. Uncheck the PAR checkbox to indicate the provider no longer participates with the payer.
4. Enter or select the effective date in the Effective column of the new line item.
5. Enter the identification number issued to the provider by the payer in the Provider ID column.
If adding a non-PAR provider:
1. Enter or select the effective date in the Effective column.
2. Enter the identification number issued to the provider by the payer in the Provider ID column.
If changing a non-PAR provider to PAR status:
1. Enter or select the expiration date in the Expiration field.
2. Click Add. A new line item, in red text, is created for the provider.
3. Select the PAR checkbox to indicate the provider participates with the payer.
4. Enter or select the effective date in the Effective column of the new line item.
5. Enter the identification number issued to the provider by the payer in the Provider ID column.
Select the Suspend Claims checkbox to stop generating claims for the selected provider.
Enter the contract code for the selected payer in the Contract Code field.
Repeat the steps above for each provider to be added.

Open the Provider ID Type drop down list and select General Provider ID.
Open the Practice drop down list and select the practice.
If adding a PAR provider:
1. Select the PAR checkbox to indicate the provider participates with the payer.
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.
If renewing a PAR provider:
1. Enter or select the expiration date in the Expiration field.
2. Click Add. A new line item, in red text, is created for the provider.
3. Select the PAR checkbox to indicate the provider participates with the payer.
4. Enter or select the effective date in the Effective column of the new line item.
5. Enter the identification number issued to the provider by the payer in the Provider ID column.
If changing a PAR provider to non-PAR status:
1. Enter or select the expiration date in the Expiration field.
2. Click Add. A new line item, in red text, is created for the provider.
3. Uncheck the PAR checkbox to indicate the provider no longer participates with the payer.
4. Enter or select the effective date in the Effective column of the new line item.
5. Enter the identification number issued to the provider by the payer in the Provider ID column.
If adding a non-PAR provider:
1. Enter or select the effective date in the Effective column.
2. Enter the identification number issued to the provider by the payer in the Provider ID column.
If changing a non-PAR provider to PAR status:
1. Enter or select the expiration date in the Expiration field.
2. Click Add. A new line item, in red text, is created for the provider.
3. Select the PAR checkbox to indicate the provider participates with the payer.
4. Enter or select the effective date in the Effective column of the new line item.
5. Enter the identification number issued to the provider by the payer in the Provider ID column.
Select the Suspend Claims checkbox to stop generating claims for the selected provider.
Enter the contract code for the selected payer in the Contract Code field.
Repeat the steps above for each provider to be added.

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

44

Click Apply.


45	Referring Physician IDs Tab

45

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

Note
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.

46

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

Click Unlink.
Select the Plan issues referring physician IDs checkbox to indicate the plan issue identification numbers to referring physicians.
Navigate to the row for the referring physician and enter the identification number in the associated ID Number column.
Repeat the above steps for each referring physician to be updated with an identification number.

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


47	Click Apply.

48

Facility IDs Tab

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

Note
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.

49

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

Click Unlink.
Record place of service specific or general facility ID numbers:

Place of Service Specific	General Facility ID
Open the Facility ID Type drop down list and select Place of Service Specific. Navigate to the row for the facility and enter the identification number in the associated ID Number column. Repeat the above steps for each facility to be updated with an identification number.	Open the Facility ID Type drop down list and select General Facility ID. Navigate to the row for the facility and enter the identification number in the associated ID Number column. Repeat the above steps for each facility to be updated with an identification number.

50

Click Apply.

51

Group IDs Tab

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

Note
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.

52

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

1. Click Unlink.
2. Record facility-specific or general group numbers:

Facility-Specific	General Group ID
Open the Group ID Type drop down list and select Facility-Specific. Open the Practice drop down list and select the practice. 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 Repeat the above steps for each facility to be updated with a group identification number.	Open the Group ID Type drop down list and select General Group ID. 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 Repeat the above steps for each practice

to be updated with a group identification number.

to be updated with a group identification number.

53

Click Apply.

54

Practices Tab

Click the Practices tab to set the network status for plans at the practice level.

55

Select the practice to designate with a network status.

56

Click Create.

Note
If the Network has already been established, click Update to update the information or Delete to remove the information.

57

Open the Network Type drop down list and select the valid option.

58

Open the Contract Effective Date drop down and select the date from which the plan is effective.

59

Click Save to close the window and save the information.

60

Click Apply.

61

Paper Claim Options Tab

53Click Apply. 54

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

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

5556

62

(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.