Insurance/Third Party

The insurance/third party master file controls many billing decisions that are required to an insurance payer. Some of the these payers and their requirements have already been added to the file.  If you find that there are some missing then you will need to add the insurance payer or modify those that are listed.  The payer mailing and location address and contact names are known as the claim center information.  When a patient is registered, the insurance ID is selected and the appropirate claim center.  You can add multiple claim centers per insurance payer.  You can add additional claim centers to those payers already in the file.  You will need to select a 'default primary claim center' for each payer.  If you have special contract rates with a a payer, then you will create a fee schedule (see separate instructions) and enter the fee schedule code to the payer.

If your primary claims are submitted electronically, then you will need to go the ENSHEALTH.com website to obtain the ENS Alternate Payer code.  This is the master code for filing electronic claims - ANSI12/837 format.  Information for the actual transmission is already established. Be sure to select a Filing code from the PiMS screen to complete the 837 transmission fields.

When you add a new third party, you will need a unique ID - one that hasn't been used in the file - please view the list of insurance payers to find a numeric ID that has not been used.

Please note - when adding or updating on any screen for this file, you must click OK through all the screens in order for the update/add to take place.

For each new third party:

• Assign a four (4) character code - numeric sequence
• Identify claim centers ( where claims can be mailed or submitted)
• Identify financial classes and identify which payers belong to each class
• Identify claim centers. Assign up to an (8) character code to each claim center.
  

Add a Third party

1. Select Third Party from the File menu.
2. Select Add Third Party.
3. The screen to gather the third party ID displays. Enter the four (4) character third party ID.
4. Press enter or click OK.
5. The first third party detail screen displays.  Enter the Name of the third party.
6. Tab to the Financial Class field. Select a financial class.

Add Claim Center(s)

1. Click on the Add button.
2. The screen to gather the claim center ID displays.  Enter the eight (8) character Claim Center ID.
3. The claim center detail screen displays. Enter the claim center description.
4. Tab to the address fields. Enter the claim center address.
5. Tab to the city fields. Enter the claim center city.
6. Tab to the state fields. Select or enter the claim center state.
7. Tab to the zip code(s) fields. Enter the zip code(s).
8. If the claim center has a different address for location versus claim processing, tab to the location fields and enter the address, city, state and zip code(s).
9. Tab to the phone number field. Enter the phone number.
10. Tab to the contact field. Enter the name of the contact person or contact information.
11. Tab to the telephone, email address, and fax numbers. Enter the contact telephone, email and fax numbers.
12. Press enter or select OK, a message will appear at the bottom of your screen. "Please review this data before continuing", this allows you to review all the data before you commit the information.
13. Press or select OK a second time to add the claim center

After adding Claim Center(s), return to the first detail screen to continue with third party information:

1. You can add additional claim centers by clicking the ADD button. In addition, claim centers can be updated, deleted and viewed by clicking the corresponding button.
2. Each insurance must have a primary claim center identified or the claim center must be required when the patient is registered. If you want to require the user always identify the claim center during registration, click off the "Default Claim Center" option.  If you want to identify a primary claim center, highlight  a claim center from the list of claim centers and click on the "Set Primary" button.
3. Press enter or select OK, a message will appear at the bottom of your screen. "Please review this data before continuing", this allows you to review all the data before you commit the information.
4. Press or select OK a second time to add the claim center.

The second detail screen displays:

1. Select the insurance type. The insurance type determines the edits at registration and affect the formatting rules for claims.
2. If  the third party is Blue Cross or Blue shield, click on the appropriate option. These options determine the formatting of claims.
3. Select the screen presented under the drop down menu.
4. Click on Policy ID required if you want the policy ID to be required during registration.
5. Click on Co-Pay Amt Required if you want the co-pay amount to be required during registration.
6. Click Medicare R/R ID edit if this insurance is for Medicare Railroad.  
7. Tab to the Days to Worklist Filed Claims. Enter the number of days for follow-up for tracking insurance payments.  After the the number of days entered, the claim will appear on the Claim Worklist for non-payment.  The default is 30 days.
8. If the third party has a fee schedule, tab to the Fee Schedule field. Enter the Fee Schedule code. Click on the Fee schedule option. If "At Charge Time" is selected the charge will post at the discounted fee schedule price. If "At Bill Time" is selected, the charge will post at the CDM price and an adjustment for the difference between CDM price and Fee Schedule price will be posted when the account is billed. If "Capitated TP" is selected, an adjustment will be taken at bill time for the difference between the CDM price and the Fee Schedule Amount minus the Co-Pay amount.  If At Bill Time or Capitated TP is selected, tab to the Write-Off Transaction Code Field and enter the transaction code to be used for the contractual write-off.
9. The Cycle Code is defaulted. This the billing cycle code which controls when the billing will occur.
10. The Claim Set is defaulted. This is for the controls for the formatting of the claim.
11. Click on Complete Claims-Zero Account Balance if you want all the claims when the balance has been paid. PDM recommends this option be selected.

If you submit UB92 or Institutional claims, select the option for formatting procedure codes.

1. Click on the Print Zero Claim option if the insurance requires you to send zero claims. This option is typically used for Capitated third parties who track all services given to a patient.
   
2. Change the Transmit -Primary TP option if primary claims are going to be submitted electronically or printed.
   
3. Change the Transmit-Non-Primary TP option if non-primary claims are goint to be submitted electronically or printed immediately.
   
4. Enter a Provider Alternate Code, National Insurance and contract codes if you have been instructed by PDM. These codes are used for special formatting rules.
5. Enter the 837 claim codes for the Filing Code and the Alternate Payer Code.These codes are used when submitting 837 claim records directly. Contact ENSHealth to get the Alternate Payer Code.
6. Press enter or select OK, a message will appear at the bottom of your screen. "Please review this data before continuing", this allows you to review all the data before you commit the information.
7. Press or select OK a second time to continue to the next screen.
   

The third detail screen displays:

1. Enter the TP Authorization Policy information. Using the function, View TP Authorization, the user can view this information while registering the patient, verifying insurances or while following up on claim balances. THis screen is optional. But be sure to click OK on the screen so that all the previous information is updated.
   
2. Press enter or select OK, a message will appear at the bottom of your screen. "Please review this data before continuing", this allows you to review all the data before you commit the information.
3. Press or select OK a second time to add the third party.

Update, View, and Delete Third Parties

Once you have added the third party, you can use the additional Third Party functions to update, view and delete. Claim centers can also be added, updated, viewed and deleted from the Update Third party function.