PROVIDER SETUP FOR COMMERCIAL CLAIMS PC-ACE PRO ANSI 4010A1

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PROVIDER SETUP FOR COMMERCIAL CLAIMS PC-ACE PRO32

1 PROVIDER SETUP FOR COMMERCIAL CLAIMS PC-ACE PRO ANSI 4010A1 Modified 02/12/2008)

2 Contents Setup Information...2 The Provider File...3 Helpful Hints...4 Matrix of Commercial Payers...5 The Provider Files Setup #A Blue Shield Group Record...9 Setup #1 Commercial Generic Setup...11 Setup #2 Carrier Assigns Unique Provider ID...13 Setup #3 Carrier Requires N5 Qualifier...15 Add Payers to the Payer File

3 Setup Information 1. The Provider file Your provider file must be set up properly so each carrier will be able to receive the information they need to properly adjudicate your claims. Without this information, your commercial claims will reject. You will need to download and review your electronic reports and make any necessary corrections to the claims that have been returned to you. Remember, any claims that are returned to you will not be forwarded to the carrier for processing. Unless you make the proper corrections and resubmit these claims, you will not be paid. These modifications are all made through the Reference File folder. Codes/Misc Tab for the Submitter file Provider Tab for the Provider additions Payer Tab for the Payer file modifications National Provider Identifier National Provider Identifier (NPI) The NPI field will not be used for the BS Group, COM Group, and the IND s. Commercial claims currently do not recognize the NPI number. Always leave blank for commercial claims. Please follow these directions to set up your files. We have also included a matrix, which lists the specifications for certain carriers. If you have any questions regarding the setup or carrier specifics, please contact the IES Help Desk at Thank you. 2

4 The Provider File It is extremely important that the provider files be set up properly. A matrix is included in this manual, which identifies the necessary requirements for certain payers. Please refer to this matrix when processing claims for those payers. Payers that do not have any special requirements will be labeled Generic Providers and you will be using Setup #1 for them. Setup #A This setup is a Blue Shield Group Record. This must be set up in addition to the Blue Shield instructions in your reference guide. This setup is used for your commercial billing only. This Blue Shield must be set up for the provider, and the provider type must be GROUP. For commercial billing you will be using Group for the provider type. Setup #1 - Commercial Generic Setup: This is used when there are no specific requirements for the Payer. Setup #2 - Commercial Setup used when the Payer assigns a unique Provider ID to the provider. Setup #3 - Commercial Setup used when the Payer requires an N5 Qualifier on the individual. The matrix lists the setup that is necessary for the individual payer. You must inherit and associate the commercial group with the Setup #A Blue Shield Group Record each time you create a new commercial group. If the payer is not listed, or does not have any specific provider requirements, use Setup #1 Commercial Generic Setup. 3

5 Helpful Hints 1. Each commercial must have a group provider and an individual set up for each provider that you bill for. You must check with the commercial carrier for specific requirements necessary for the processing of their claims. 2. Commercial group s must be inherited and associated with the Group Blue Shield Provider Record. 3. When entering a commercial claim, F2 in the Billing Provider field and select the appropriate provider group ; F2 in the Rendering Physician field and choose the appropriate individual provider. 4. The Blue Shield Group that is used to set up commercial group s is not to be confused with the Empire Blue Cross Blue Shield Solo provider number. They are two separate s. When billing Blue Shield claims, use the BS Solo provider ID. 5. If entering provider s for more than one doctor, you may use the doctor s initials for the Group Label (ex., John Smith would be JS instead of COM1). 6. For Commercial Provider s, always use the value of E for the Tax ID/type; therefore, for the Group Blue Shield Provider Record, use E for the Tax ID/type. 7. Never use the NPI (National Provider Identifier) for the Group Blue Shield Provider and the Commercial Provider Records. 4

6 Matrix of Commercial Payers PAYER ID PROVIDER SETUP # PAYER NAME SUBSCRIBER ID REQUIREMENTS (SUBS) #3 CONNECTICARE INC Subs ID Must = 9 or 11 Numeric #3 HEALTHNET Subs ID Must Equal 9 or 11 Alphanumeric Characters #2 OXFORD Subs ID Must Equal 8 or 9 Numeric PROVIDER ID NUMBER REQUIREMENTS (PIN) Need Individual PIN Number PIN Must be at least 5 but not greater than 7 alphanumeric characters Six-position PIN must be numeric Ten-position PIN must be numeric in positions 1-6, and positions 7-10 must alphanumeric. Need Individual PIN number PIN must equal 6 alphanumeric positions Need Individual PIN number MISCELLANEOUS REQUIREMENTS Needs Referring DR. Must be at least 5 alphanumeric characters in length. May not be greater than 7 characters in length # BENEFITS FUNDS Plan Provider ID# #3 MONTEFIORE CMO Need Individual PIN number Use generic SEABURY & SMITH Subs ID Must = 9 or 11 Numeric #3 GHI GROUP HEALTH INC #3 STAYWELL #3 WELLCARE Use generic GIC INDEMNITY Subs ID Equal to or less than 12 alphanumeric Subs ID Equal to or less than 12 alphanumeric Subs ID must be equal to in positions 1-5 Need Individual PIN number PIN must be equal to 7 positions Need Individual PIN number PIN at least 5 but not greater than 9 Alphanumeric Need Individual PIN number 5

7 PAYER ID PROVIDER SETUP # PAYER NAME #3 AMERIHEALTH MERCY #3 VYTRA #3 HORIZON MERCY SUBSCRIBER ID REQUIREMENTS (SUBS) PROVIDER ID NUMBER REQUIREMENTS (PIN) Need Individual PIN Number PIN Equal to 1-13 Alphanumeric Characters Need Individual PIN Number Need Individual PIN Number Equal to 1-13 Alphanumeric Characters #3 SOUTHERN HEALTH Need Individual PIN Number PIN Must Be Numeric PIN Not Greater Than 11 Alphanumeric Characters #2 COVENTRY HC Need Individual PIN Number #2 AMERICAN IMAGING Need Individual PIN Number Use generic AMERICAN POSTAL Subs ID Must Be 9 Numeric #3 HIP HEALTH INSURANCE PLAN OF GREATER NY Use generic CORPORATE BENEFITS SVC Subs ID Must Be 9 Numeric Need Individual PIN Number PIN must be at least 6 but less than 13 positions in length; Positions Must Contain Alphanumeric Characters Positions 7-12 Must Contain Alphanumeric Characters or Spaces. MISCELLANEOUS REQUIREMENTS Facility Record Required Need Name, Address, City, State, Zip of Rendering Provider Need Qualifier of #2 CHRISTIAN BROTHERS Need Individual Number #3 BETTER HEALTH PLANS INC OF MONROREVILLE PA Need Individual PIN Number 6

8 PAYER ID PROVIDER SETUP # #3 CIGNA PPO PAYER NAME #1 MAIL HANDLERS BENEFIT PLAN SUBSCRIBER ID REQUIREMENTS (SUBS) Subs ID > 8 < 13 Positions 1-9 Must Be Numeric Positions Must Be 0-9, A- Z, Spaces, And/or Special Characters. Subscriber's 9-Digit Number SSN - No Plan Assigned Provider ID Number. PROVIDER ID NUMBER REQUIREMENTS (PIN) N5 Need Individual PIN Number PIN Must Be Numeric MISCELLANEOUS REQUIREMENTS Facility Record Required Need Name, Address, City, State, Zip of Rendering Provider Need Qualifier Of 77 Related Causes Code = AA - Accident State Required Use generic Use generic Use generic Use generic Use generic GUARDIAN LIFE INS Subs ID Must Be 9 Numeric GUARDIAN LIFE INS Subs ID Must Be 9 Numeric BELL ATLANTIC EXCLUSICARE Subs ID Must Not Contain In Positions 1-6 BENEFITS PLANNER Subs ID Must Be 9 Numeric Payer Name Must Not Be AARP, A.A.R.P #3 HEALTH FIRST N5 Need Individual PIN Number #3 HEALTH PARTNER N5 Need Individual PIN Number Subs ID equal to or #3 GIC INDEMNITY less than 12 Alphanumeric Subs ID N5 Need Individual PIN Number Must Not Equal XE or Xl #2 ALTA HEALTH & LIFE INS Need Individual PIN Number 7

9 PAYER ID PROVIDER SETUP # PAYER NAME SUBSCRIBER ID REQUIREMENTS (SUBS) PROVIDER ID NUMBER REQUIREMENTS (PIN) MISCELLANEOUS REQUIREMENTS Use generic Use generic UNITED HEALTH CARE GROUP HEALTH OF PUGET Subs ID Must Be > 8 Alphanumeric Subs ID Must Be 9 Numeric #2 GROUP HEALTH COOPERATIVE Need Individual PIN Number Please note: If your Payer is not listed above you must contact them directly and ask if they have any additional requirements for processing claims. You may use your Generic Record to send claims to these carriers. 8

Provider File Setup PROVIDER SETUP FOR COMMERCIAL ANSI 837 4010A1 SETUP #A BLUE SHIELD GROUP RECORD This must always be set up for each provider.

10 Provider File Setup PROVIDER SETUP FOR COMMERCIAL ANSI A1 SETUP #A BLUE SHIELD GROUP RECORD This must always be set up for each provider. Use this to inherit and associate each commercial group for the same provider. From your main menu: Click on Reference File Maintenance icon Click on Provider Tab Click on New Click on Create a completely new provider Click OK FILL IN THE FOLLOWING FIELDS: PROVIDER TYPE: GROUP NAME: ADDRESS: CITY/ST/ZIP: PHONE: CONTACT: GROUP ID/NO: LOB: BS PAYERID: BLANK TAG: GROUP LABEL: Group Practice Individual Provider Name Fill in the Blue Shield 10-digit Provider Identification Number (PIN) COM1 (For additional providers, you may use their initials (e.g., John Smith would be JS in the Group Label field) NPI: Individual NPI number for doctor (NOT group or facility NPI) TAXID/TYPE: Use Type E SPECIALTY: TYPE ORG: ACCEPT ASSIGN?: PARTICIPATING?: SIGNATURE IND: DATE: 9

SET UP #A BLUE SHIELD GROUP RECORD (cont.) SECOND TAB EXTENDED INFO - In field marked Secondary Provider ID S ID/Type #1, enter positions four through seven of the doctor s individual NPI number.

11 SET UP #A BLUE SHIELD GROUP RECORD (cont.) SECOND TAB EXTENDED INFO - In field marked Secondary Provider ID S ID/Type #1, enter positions four through seven of the doctor s individual NPI number. For example, if the provider has an NPI number of , you would put in that field the number (NPI = ) Place a G5 in box to the right. Click on Save. Positions four through seven of provider s individual NPI, plus G5 qualifer. SAVE 10

12 Each commercial requires: 1A Group 1B Individual SETUP #1A COMMERCIAL GENERIC GROUP SETUP Highlight Blue Shield Group Record Click on New Check Inherit and Associate Click OK PROVIDER TYPE: Group Practice ALL FIELDS WILL POPULATE AUTOMATICALLY LOB: COM PAYER ID: Leave Blank TAG: GEN GROUP LABEL: COM1 NPI: Individual NPI number for doctor (NOT group or facility NPI) CLICK ON Save Positions 4 through 7 of the provider s NPI number plus G5. This information should already be here. 11

SET UP #1B COMMERCIAL GENERIC INDIVIDUAL RECORD Click on New FILL IN THE FOLLOWING FIELDS: PROVIDER TYPE: Individual in group NAME: ADDRESS: CITY/ST/ZIP: PHONE: CONTACT: GROUP ID/NO: LOB: COM

13 SET UP #1B COMMERCIAL GENERIC INDIVIDUAL RECORD Click on New FILL IN THE FOLLOWING FIELDS: PROVIDER TYPE: Individual in group NAME: ADDRESS: CITY/ST/ZIP: PHONE: CONTACT: GROUP ID/NO: LOB: COM PAYERID: BLANK TAG: GEN Fill in the Blue Shield 10-Digit PIN Number GROUP LABEL: COM1 NPI: Individual NPI number for doctor (NOT group or facility NPI) TAXID/TYPE: Type use E SPECIALTY: TYPE ORG: ACCEPT ASSIGN?: PARTICIPATING?: SIGNATURE IND: DATE: CLICK ON Save ID/Type #1 Should be blank. 12

14 SETUP #2A GROUP SETUP (Carrier assigns unique ID) Highlight Blue Shield Group Record Click on New Check Inherit and Associate Click OK PROVIDER TYPE: Group Practice ALL FIELDS WILL POPULATE AUTOMATICALLY GROUP ID/NO: PIN number assigned by payer LOB: COM PAYER ID: Use appropriate value, F2 to list. TAG: Three character field used to identify payer. (example: ELD, COV, OXF) GROUP LABEL: COM1 NPI: Individual NPI number for doctor (NOT group or facility NPI) CLICK ON Save Each commercial requires: 2A Group 2B Individual Positions 4 through 7 of the provider s NPI number plus G5. This information should already be here. 13

SET UP #2B INDIVIDUAL RECORD (Carrier assigns unique provider ID) Click on New FILL IN THE FOLLOWING FIELDS: PROVIDER TYPE: Individual in group NAME: ADDRESS: CITY/ST/ZIP: PHONE: CONTACT: GROUP

15 SET UP #2B INDIVIDUAL RECORD (Carrier assigns unique provider ID) Click on New FILL IN THE FOLLOWING FIELDS: PROVIDER TYPE: Individual in group NAME: ADDRESS: CITY/ST/ZIP: PHONE: CONTACT: GROUP ID/NO: PIN number assigned by payer LOB: COM PAYERID: BLANK TAG: GEN GROUP LABEL: COM1 NPI: Individual NPI number for doctor (NOT group or facility NPI) TAXID/TYPE: Type use E SPECIALTY: TYPE ORG: ACCEPT ASSIGN?: PARTICIPATING?: SIGNATURE IND: DATE: CLICK ON Save ID/Type #1 Should be blank. 14

SETUP #3A GROUP SETUP (Carrier requires N5 Qualifier) Highlight Blue Shield Group Record Click on New Check Inherit and Associate Click OK PROVIDER TYPE: Group Practice ALL FIELDS WILL POPULATE

16 SETUP #3A GROUP SETUP (Carrier requires N5 Qualifier) Highlight Blue Shield Group Record Click on New Check Inherit and Associate Click OK PROVIDER TYPE: Group Practice ALL FIELDS WILL POPULATE AUTOMATICALLY GROUP ID/NO: PIN number assigned by payer LOB: COM PAYER ID: Use appropriate value, F2 to list. TAG: Three character field used to identify payer. (example: GHI, HIP, CIG) GROUP LABEL: COM1 NPI: Individual NPI number for doctor (NOT group or facility NPI) CLICK ON Save Each commercial requires: 2A Group 2B Individual Positions 4 through 7 of the provider s NPI number plus G5. This information should already be here. 15

SET UP #3B INDIVIDUAL RECORD (Carrier requires N5 Qualifier) Click on New FILL IN THE FOLLOWING FIELDS: PROVIDER TYPE: Individual in group NAME: ADDRESS:

doctor (NOT group or facility NPI) TAXID/TYPE: Type use E SPECIALTY: TYPE ORG: ACCEPT ASSIGN?: PARTICIPATING?

17 SET UP #3B INDIVIDUAL RECORD (Carrier requires N5 Qualifier) Click on New FILL IN THE FOLLOWING FIELDS: PROVIDER TYPE: Individual in group NAME: ADDRESS: CITY/ST/ZIP: PHONE: CONTACT: GROUP ID/NO: PIN number assigned by payer LOB: COM PAYERID: BLANK TAG: GEN GROUP LABEL: COM1 NPI: Individual NPI number for doctor (NOT group or facility NPI) TAXID/TYPE: Type use E SPECIALTY: TYPE ORG: ACCEPT ASSIGN?: PARTICIPATING?: SIGNATURE IND: DATE: CLICK ON Save ON SECOND TAB EXTENDED INFO Add the Provider ID Number given to you by the Commercial Carrier and enter the N5 qualifier in field marked Secondary Provider ID s-id/type #1 16

The Payer File TO ADD COMMERCIAL PAYERS TO THE PAYER FILE Go to Reference File Maintenance Click on the Payer File tab Click on New FILL OUT THE FOLLOWING FIELDS: PAYER ID: Enter the

18 The Payer File TO ADD COMMERCIAL PAYERS TO THE PAYER FILE Go to Reference File Maintenance Click on the Payer File tab Click on New FILL OUT THE FOLLOWING FIELDS: PAYER ID: Enter the five-digit Payer ID LOB: COM for Commercial FULL DESCRIPTION: Payer Name SOURCE: CI EDIT IND: CI MEDIA: E CARD: B USAGE: H CLICK ON Save The Payer will now be added to your list. CLICK ON NEW 17

19 Verify values are as follows: Payer ID Five-digit ID LOB COM for Commercial Full Description Payer Name Verify values are as follows: Source = CI Edit Ind = CI Media = E Card = blank Address = blank CLICK ON Save Usage = H 18

PC-ACE Initial Setup. Last Revision: January 14, 2019 P a g e 1 o f 21

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