Provider Credentials/Billing Settings FAQ

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.

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

Yes, all Medicaid insurance classes are formatted to hold for credentialing. To ensure claims are held, you’ll need to add a Billing Setting for the provider and select the desired locations and insurance class(es). Once you’ve obtained the credentials and updated the Billing Setting, you’ll need to manually release the related claims for that provider so they can be scrubbed and billed.

o release delayed claims, navigate to the Billing menu and choose Release Claim Delay. On this page, you can narrow your search results by selecting the Provider and/or Delay Reason before clicking Search. Once you’ve located your delayed claims, use the checkboxes to select the dates of service to release. Click the Save button to release the selected charges.

Can we set up credentials for the insurance code and will the claim hold if we create a setting and leave it blank?

The only insurance classes that will hold on claims delay are Medicare, Medicare Advantage, Medicaid, and the Department of Labor. One of the workarounds that we recommend is to set up the insurance to hold for authorization as this will hold claims for that insurance on the Delayed Claims worklist if an authorization is not attached to a date of service tied to that particular insurance code. This workflow will not work for insurances that actually require authorizations. Let’s review how to do this. 

  1. From Admin, open Insurances
  2. Use the search criteria to locate the insurance you want to set up to hold for authorization, double-click to open the record. 
  3. Locate the Authorization Required checkbox near the bottom of the page. Check this box and Save.
  4. Claims added without authorization will appear on the Delayed Claims report under the No Authorization delay reason.
  5. When credentialing has been completed for that insurance, remove the Authorization Required checkbox and use the Release Claim Delay page to manually release the impacted visits. 

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.

2310B loop (equals 24J)
2310B loop (equals 31)
2310 C loop (equals 32)
2310C (equals 32A)
2310C (equals 32B)
2010AA (equals 33)
2310AA (equals 33A)
2000A (equals 33B)
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