Understanding Billing Providers, Providers, and Billing Profiles

In your use of SOS, you will find there are several sorts of “providers”, and it is pretty easy to confuse one with another.

To start, there are “Billing Providers”, which in the past used to be known as “Suppliers” on the paper claim forms. In short, a Billing Provider is an entity that files insurance claims. Sometimes the billing entity is a person, but more often it is a business such as a C corp, S corp, LLC, Partnership, or some other kind of legal organization. On paper 1500 claims, the Billing Provider is printed in the lower right corner. On electronic 5010 claims, the Billing Provider shows up in the 2000A and 2010AA loops. You might even think of Billing Providers as bank accounts rather than actual people. In SOS you can add, view, and modify Billing Providers by expanding Billing Lookups in the navigation panel, and opening the item called Billing Providers (Suppliers).

In SOS G5, a Provider, on the other hand, is most always an actual person. A patient can have an appointment with a “Provider”, but will never have an appointment with a “Billing Provider”. That would be like having an appointment with a bank account. A Provider can have different roles, such as primary provider, rendering provider, or both. A primary provider is the healthcare professional who has the primary responsibility for a patient’s care, even if she does not provide much of the direct care personally. A provider who personally provides the direct care is known as the rendering provider. In SOS you can add, view, and modify Providers, whatever their treatment roles, by expanding Common Lookups in the navigation panel, and then opening the item called Providers.

Prior to SOS G5, it was sometimes necessary to create multiple entries in the Provider List to handle different billing requirements or practice compensation policies. SOS G5 simplifies these situations by allowing each Provider (again, the Provider is an actual person) to have any number of Billing Profiles. Each of a Provider’s Billing Profiles details how the Provider will be presented on insurance claims and statements, but also how the provider will be paid by the practice for her work. Here is a quick example: in many group practices a Provider may bill and be compensated differently for patients whom she has brought into the practice personally, as opposed to patients who came to the practice as a result of the practice’s advertising or web site. Each of these scenarios can be covered by a different Billing Profile. For more specifics about the use of Billing Profiles, see Managing Provider Billing Profiles. In SOS you can add, view, and modify Billing Profiles by opening a Provider and selecting the Billing Profiles tab.

See also:
Managing Billing Providers
Managing Providers
Managing Provider Billing Profiles

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