Provider Credentials/Billing Settings FAQ

In this article, we have listed a few questions and answers that members experience regarding Provider credentialing and Billing Settings. Please review the answers below, along with their corresponding articles that dive deeper into each topic.

What are the ways I can hold claims and how do they work?

There are 3 ways that claims can fall on claim delay: Insurance Class Claim Delay, Provider Claim Hold Delay, and Manual Claim Hold Delay.  WebPT Billing’s nightly scrubbing process determines if the claim remains on delay or is released. 

• An Insurance Class Claim Delay holds claims when the Insurance on the charge is associated with an Insurance Class where the Provider Credentials Required flag is set. Once credentials have been added to the Provider’s Billing Settings, charges that pass the claim scrubbing process will automatically be billed out, and charges that fail appear on the Delayed Claims page. 

Scenario: Since the Provider Credentials Required flag impacts all insurances under the specific Insurance class, we recommend this method if you are a new Member to WebPT Billing and currently going through Onboarding, adding a new Location, or adding multiple new providers that are awaiting credentialing.

• A Provider Claim Hold Delay holds claims when the provider on the charge meets the criteria of an active Provider Claim Hold rule. The charges will only bill out when the Provider Claim Hold rule is inactivated and the charges pass the claim scrubbing process.  Charges that fail will appear on the Delayed Claims page.  

Scenario: Provider Claim Holds only impact the specific Provider you apply a rule to. Utilize this method when you add a new Provider and only need to hold their claims until they are credentialed. 

• A Manual Claim Hold Delay is set through the Charge Review or Pended Charges pages.  Charges from the Charge Review and Pended Charges are released automatically or manually and will either pass the claim scrubbing process or fail.  If charges fail, then they will appear on the Delayed Claims page.  

Scenario: A Manual Claim Hold charge can be held for various reasons such as No Authorization, Pending Addendum, or Audit Required. Use this method for reasons other than Provider Credentialing Required. 

Are all Medicaid classes set to automatically hold claims while waiting for credentialing?

The Insurance Class Provider Credentials Required box is checked for Medicaid Insurance Classes if the claims are to be held while waiting for credentialing, along with the five main government payers (Medicare, Medicare Advantage, Medicaid, Medicare Railroad, US Department of Labor). Once you have obtained the Provider’s credentials and updated their Billing Setting, charges that pass the claim scrubbing process will automatically be billed out, and charges that fail will appear on the Delayed Claims page. 

Can we set up credentials for the insurance code?

If the Insurance Code is associated with the Insurance Class that has the Provider Credentials Required flag checked, the claim will be on Delayed Claims until the Provider’s Credentials are added to their Billing Settings.

If the Insurance Class does not have the Provider Credentials Required flag set, you’ll need to create a Provider Claim Hold rule to hold the claim until you inactivate the provider rule. 

How can I override the TIN (Box 25) on the claim form?

Enter the Tax ID Number on the setting for the insurance class/code and location. It’s important to note that this change will only show on paper claims. Any claims billed electronically will bill with the default Company TIN.

If a payer requires an individual provider number (Medicaid) and if we put that number in the Individual/Group Number fields does that print on the claim?

Yes, for paper claims. You can populate the Individual Number field in the Billing Settings with a provider number. This will place the Individual Provider number in 24J, and any number entered in the Group Number field will place the Group Number in 33B.

If Individual and Group Numbers are not required, you can put PROVIDER in these fields, and this will pull the taxonomy codes for those corresponding fields. This will populate for paper or electronic claims.

How can I bill claims out under the rendering or billing provider? 

If you populate the individual field but leave the group field blank, the claims will bill out individually under the rendering provider’s information. 

For Medicare, Medicare Advantage, and Medicaid insurance classes, if you populate the Group Number field, but leave the Individual field blank, the related claims will be automatically placed on claim delay because you are telling the system that these claims need to be billed under the Group but the individual is not yet tied to the group. 

For all other insurance classes that are not formatted to hold on the claim delay report, populating the Group Number field and leaving the Individual field blank will format the claims with the billing provider's information and strip the rendering provider’s information.

When would I use the Individual Qualifier? Will this show up on the claim for that class or payer?

Individual qualifiers are used when entering actual provider numbers in the Individual or Group Number field. For example, if you are adding a provider’s Medicaid Number with the company’s Medicaid Group Number you would select the 1D qualifier for both the Individual Qualifier and Group Qualifier fields. These only show on paper. Alternatively, if Medicaid only wants the taxonomies, you would put PROVIDER in both the Individual and Group Number fields with NONE as the Qualifiers. 

Finally, the qualifier does show on the claim, with the exception of Medicare. Medicare PTANS and 1C Qualifiers do not transmit on the claims electronically.

Can we have provider-specific settings pull on the claim by the insurance code like qualifier and provider number?

Yes, most billing guidelines have already been formatted to pull the appropriate billing required information. One of the most common explanations for claims not billing with the expected information is if the insurance is not tied to the correct insurance class.  

Loops and Segments

Loops and segments and their crosswalk to their CMS-1500 boxes.