Category: NEASU

In most cases, all you need to identify the provider on insurance claims is the provider’s NPI on the Provider Billing Profile you specified on your charge entry.

Sometimes, however, you may have an insurance payer that requires a different Rendering Provider NPI at the service detail level of the claim, or specification of a Supervising Provider, a unique Billing Provider (what used to be called “Supplier”) or one or more secondary ID’s. In SOS, you can cover these exceptional situations by creating Carrier Specific ID’s for any Provider Billing Profile that requires one:

1. Open the Provider form.
2. Click the Billing Profiles tab.
3. Open the desired Billing Profile details form.
4. Click the Carrier Specific ID’s tab.
5. Click the New button.

Because these are configurations meant to apply to a specific Carrier, or even a specific Plan of a specific Carrier, the first thing you must do is to select the appropriate Carrier at the top of the form.

Next, if the configuration is not meant to apply to every Plan of the selected Carrier, then be sure to specify the desired Carrier Plan as well. Otherwise, leave the Carrier Plan field empty so that the configuration will be used for all the Carrier’s Plans.

Now look through the available fields, and enter values for any of the fields that need non-generic data. For example, sometimes Medicaid requires that you use the NPI of the billing agency rather than the NPI of the actual rendering provider for service detail lines of the claim. In that case you would enter the agency NPI in the middle of this form. That will override the provider’s normal NPI with the one you enter on this screen. If that is the only exception or addition you need, then you can leave all the other fields (other than the first two or three at the top) blank. Save the form and you are all set.

Another scenario might require that you use a different provider’s information for the rendering provider fields on the insurance claim. Again, some Medicaid payers might require that you complete the claim with the Medical Director’s information rather than that of the person who actually rendered the service. In that case, you can select the appropriate Billing Profile of the Medical Director in the Rendering Provider Billing Profile field. That instructs SOS to get any needed rendering provider data from the selected Medical Director’s Billing Profile rather than the current provider’s. Just make that one change on this form and leave the other fields below Carrier Plan empty.

In SOS G5, insurance payers are known as Carriers. Carriers are entities that review and pay claims that you submit. In SOS G5, there are also Insurance Plans and Insurance Policies that are related, but not the same thing as Carriers.

---

• Carriers write the checks. Aetna and United Healthcare are Carriers. Many patients may share the same Carrier.
• Insurance Plans contain the default conditions of coverage, such as deductibles, co-insurance, and copays to save typing when you add new Insurance Policies for a patient. In addition, it is in the Insurance Plan that you will fine Plan Exceptions. Exceptions are the key to rapid, accurate assignment of payer responsibility when adding new charge entries. Every Carrier has one or more Insurance Plans. Many patients may share the same Insurance Plan.
• Insurance Policies include patient and insured identifying information, subscriber number (insured id), and other specifics the Carrier needs to process your claims. An Insurance Policy is unique to one and only one patient, but one patient may have an unlimited number of Insurance Policies.

---

Whenever you need a Carrier (insurance payer) that is not already in the list, you can readily add it. In the Navigation Bar on the left side of the screen, open Billing Lookups, then click Carriers/Insurance Plans to show the list of existing Carriers.

Use the New button in the left corner of the top toolbar, or press <CTRL><N> to add a new Carrier.

A simple, mostly empty form will appear. Just enter the Carrier Name, remembering that this is the name of the corporate entity that will be paying you, not the name of a specific coverage plan.  So, for example, you would be entering something like “Blue Cross Blue Shield of Florida” not “Blue Options”. Once you have the Carrier Name entered, click the Save button on the top toolbar, or even easier, just press <CTRL><S> to save without existing. The rest of the fields will now display, along with additional tabs that were hidden prior to saving the Carrier Name.

 

The second tab at the top is where you will add and maintain the Carrier’s Insurance Plans. The Checks, EFT, and Other tabs provide a central location where you can review all the payments you have received from the current Carrier.

There are just a few fields on this screen that may need further explanation.

Use Pointers For Detail Line Dx’s: On paper claims there are spaces for several diagnoses, and each space is numbered. In the lower part of the claim, each detail line has a box for the relevant diagnosis. In days gone by, some payers wanted the Dx code to be printed in that box and others just wanted the number of the diagnosis from the list above the detail section. In recent years, virtually everyone has standardized on using these pointers rather than the actual Dx code, which is why SOS defaults this option to use pointers.

Combine Services With the Same Revenue Code:  This option is for institutional claims. If you are filing only professional claims to this carrier, you can ignore this option entirely.

Payer ID’s, including E-Claim Number and E-Claim Qualifier: ?

Carrier Communications: At the bottom of this tab is a panel in which you can enter mailing/street addresses, email addresses, and phone numbers, exactly as you do for patients, providers, patient contacts, and others. You can find more details, if you need them, in the explanation of entering communications for patients.

Next: Adding Insurance Plans to a Carrier