Medisoft Claims

Medisoft Claim Generation FAQ

FAQs

Before sending claims do I have to complete any setup activities

If you are a new user, you will need to setup your practice and enter rules on various IDs grids in the application (Practice, Provider, Referring Provider, Facility, and Insurance). For more information on setting up your practice, see An Overview of Setting up a Practice and the various topics in the Getting Started section of the help file.

If you are converting data from an existing Medisoft practice, then you will need to review/select your claim filing status (individual or group) for each provider in your practice.

To select your filing status

Click Lists, select Provider, select Providers.
On the Provider List window, select a provider and click Edit.
Review the data on the Address tab and update as necessary. Click the Provider IDs tab.
The conversion process will have created at least one entry for the provider. On the Provider IDs grid, select the first entry and click Edit. The Edit Provider IDs window opens.
If you file claims as an individual, make sure the Files Claims As Individual button is selected.
If you file claims as a group, make sure the Files Claims As Group button is selected.
Click OK.
Repeat steps 4-7 for any other entries in the grid. When complete, repeat steps 2-6 for any other providers in the practice.

To provide the highest level of data integrity and accuracy, the conversion process for Medisoft 16 provider/practice setup, does not delete information while creating grid entries that might still be needed, such as legacy information (Blue Cross provider numbers, Medicare provider numbers, etc.) but converts this data to a grid entry in Medisoft 16. Before filing claims, you will also need to finalize your grid entries making sure to remove unnecessary data such as out-of-date legacy numbers.

This activity is especially important for any data entered on PINs tab of the Providers window in previous versions of Medisoft and also if you used the NPI Only check box on the Insurance Companies tab. Since data was converted instead of deleted to provide a high level of data accuracy in Medisoft 16, you will need remove out-of-date legacy numbers from the new grid entries.

For instance, if you had an entry in the PINS tab in Medisoft 15 for a Medicare provider number and then at a later date selected the NPI only check box on the Insurance Carrier window for this insurance carrier, this legacy number will be converted in Medisoft 16. Before filing a claim with this carrier, you would need to remove this from the grid entry in Medisoft 16. In this example, you would click Lists, select Provider, and select Providers. On the Provider List window, select the provider. Click the Provider IDs tab. When the data converted, the insurance carrier that had required the Medicare provider number will have a specific row on the Provider IDs grid. Select that row and click Edit. Then in the Legacy Identifier 1 field, select the None button. Click Save. You would repeat this process for any other legacy data that is out-of-date.

You will also need to examine each IDs grid (Practice, Provider, Referring Provider, and Facility) before completing print or electronic claims. This step is critical for success, especially when converting data, with multiple legacy numbers. For instance, if your practice in Medisoft 15 had a referring provider record that had multiple entries on the PINs tab, Referring Provider window, the conversion process will re-create these entries as separate rows, for instance four entries in Medisoft 15 would translate into four entries on the Referring Provider IDs grid. All of these entries would be generic (wild card) rows without any selection of an insurance carrier. These gird entries, however, need modification since all four would be generic/ wild card rows in which all is selected for insurance carrier.

Before filing claims, you would need to first examine the legacy numbers and see if all are still needed. Then, you would begin adding, deleting, or editing entries to match your claim filling needs. For instance, you might keep the generic/wild card row since this information is needed for most of the insurance carriers you file claims with. Then, you might select one of the other legacy wild card rows (the rows in which All insurance carriers and all insurance classes are selected) and apply this rule to a specific insurance carrier or class. If needed, you could add a second legacy number if the carrier required it. You could delete the other entries or apply an insurance carrier or class to the entry.

TIP: Press CTRL + DELETE to delete all ID entries in the Practice, Provider, Referring Provider, or Facilities IDs grids. Use this with caution since all your entries will be removed. If you have numerous legacy ID entries that no longer apply and only a few rows that need to be set up, you save time by deleting all entries and setting up the few rows you need.

If you do not review and modify you ID grid entries, you can potentially have problems when filing claims if you leave multiple wild card rows (all selected for insurance carriers and insurance classes) since the rules engine would not know what rule to select. In this case, the rules engine might select the correct (most complete wild card row) row but could also pull one that contained the wrong legacy id resulting in a claim rejection.

For more information, see the topics: Entering and Editing Practice Information , Entering and Editing Provider Information , Entering and Editing Facility Information , and Entering and Editing Referring Provider Information

How is a row on a grid selected when generating claims and How Do you Assign Rules

Medisoft claim processing for both print and electronic claims depends on a series of flexible rules that you define on the various ID grids in the application. When setting up or updating your practice data, you will create a series of grid entries (rules) on the Practice IDs and Provider IDs grid. You may also use the Facility IDs and Referring Provider IDs grids depending on your practice structure. These grid entries that you complete contain your basic practice information such group or individual NPI, taxonomy, tax IDs, claim filing status (group or individual) and connect this information to the insurance carriers that your practice accepts and the doctors in your practice as a series of rules.

You begin by creating general entries for each provider on the Provider IDs grid and at least one entry on the Practice IDs grid level.

NOTE: the setup for solo providers offers more flexibility. Also taxonomy requirements or NPI setup considerations can impact how you create your practice. For more information, see An Overview of Setting up the Practice.

In these general entries you enter information that would apply the most generic situation. Then you would create other grid entries that apply to a specific insurance carrier, insurance class, facility, provider etc.

TIP: when creating or editing IDs grid entries, do not create matching wild card entries (all selected for insurance carrier and insurance class) since the rules engine would not know which row to select. If you had different legacy numbers, for instance in each entry, the system might not select the correct row. In this case, modify one of the wild card rows and apply it to a specific insurance carrier or class.

When you create claims, the application gathers general data and then selects data from the IDs grids by analyzing the entries (rows) on the various IDs grids. The process of selecting the correct row involves first selecting a row that applies to the insurance carrier, provider or provider class. If more than one row is present on the various ID grids, the application matches the row on an IDs grid to the data gathered for the claim. The logic looks for a specific match on an IDs grid first before moving to a general match (All button); for instance the application searches for insurance carrier X before looking for a row that applies to all insurance carriers.

The logic continues matching the other various selections on the grids. For instance, if one or more entries are on the grid, the application would see which entries matches the facility on the claim. This pattern has a specific order and follows the left to right layout on the IDs grid. For instance, on the Practice IDs grid, the logic looks at provider code first, then insurance carrier, then facility, etc.

For instance if you are setting up a group practice with three doctors, you would need to have at least one rule (grid entry) on the Practice IDs grid and one rule on the Providers IDs grid for each provider (three rules). You must include an entry for each provider on the Provider IDs grid since you define your claim filing status (individual or group) here. For this general rule on the Practice IDs grid, you could apply it to all providers, all insurance carriers, and all facilities (assuming you have no facilities associated with your practice or all facilities would use the same details.

NOTE: for more information on setting up a facility, see the topic Entering and Editing Facility Information .

In this entry, you could include your group NPI, taxonomy, and tax ID numbers. Then on the Providers ID grid, you would create one grid entry for each provider. Each of these initial entries would be general and could apply to all insurance carriers and facilities. You would also select Group for your claim type and could select From Practice to pull NPI, taxonomy and Tax IDs from the Practice IDs grid. If one of the insurance carriers that your practice accepts requires a legacy identifier, you would create a second entry on the Practice IDs grid. By creating a second entry on this grid instead of the Provider IDs grid, you save time and effort since one specific entry could be applied to all the providers at the practice level instead of creating an entry for each provider on the provider level. In this second entry, you would select the insurance carrier and select all providers. Importantly, you would need to include your NPI, taxonomy, and Tax IDs since each grid entry needs to be complete. You would also select the legacy number your carrier requires. When the application gathers claim data it would select this row for the specific insurance carrier and pull the data for the claim.

If one of the providers in your practice files claims as an individual with an insurance carrier the other providers do not use, you would need to create another rule on the Provider IDs grid for that provider. In this grid entry, you would specify the insurance carrier. You would also change your filing status to Individual and enter the provider's NPI number, not the group NPI number. You could also include the taxonomy and tax ID/social security number in this grid entry.

Practice Window

Settings on the Practice window determine if pay to address should be populated in Loop 2010AB. If the Practice Pay To tab is not completed, Loop 201AB is not generated.

If you file claims as a group, taxonomy is sent in 2310b from the taxonomy setting on the Practice IDs grid. For more information, see Taxonomy .

Provider Window

Settings on the Provider IDs grid settings determine individual or group status and populate appropriate ID’s.

Referring Provider Window

Settings on the Referring Provider grid populates the referring provider’s information in Loop 2310A.

Facility Window

Settings on the Facility grid populate the Facility address and determine if facility information is sent on claim in Loop 2310D. Loop 2310D is generated if the Send Facility on Claim box is selected.

Facility address is always sent in 2010AA.

Insurance Carrier Window

Settings on the Insurance Carrier window determine data sent in Loop 2010BB and whether to send ordering provider information in Loop 2420E (Send Ordering Provider in Loop 2420E box) and if taxonomy is sent in Loop 2000A (Send Practice Taxonomy in Loop 2000A). The taxonomy value is pulled from the Practice IDs grid.

The National Plan ID field (not yet required) will populate in Loop 2010BB if selected for primary and secondary receivers. For more information, see the topic Entering and Editing Insurance Carrier Information .

Key Logic Changes in the ANSI Crosswalk

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1000A

1000B

2000A

2000B

2010AA

2010BA

2010BB

2300

2310A

2310C

2310D

2400

2420B

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Different billing address and a pay to address

If you are a billing service or have a different billing address from the pay to address, you will need to complete the Practice Information window, Practice Pay To tab. The pay to address is populated in Loop 2010AB from information entered on this tab. Fields on this tab are used for sending electronic claims and in reports (designed through the Custom Report writer).

For more information, see the topic Entering and Editing Information for a Billing Service or Bill Flash Users

Bill Flash User

If you use Bill Flash for electronic statement generation, you will need to complete the Practice Information window, Statement Pay To tab. Data included in a Bill Flash report is pulled from this location.

How does the new claim generation specifically impact printed claims

The setup in Medisoft 16 for print or electronic claims is essentially the same. You will have to set up your practice and providers and select your claim filing status along with deciding how you will submit your NPI, Tax ID, and taxonomy (on the practice or provider level). You will also set up any legacy information that your carrier requires (Medicare numbers, Blue Cross numbers, etc).

When completing electronic claims, you will complete additional information for carriers that you submit these claims to such as creating an EDI receiver and completing most of the fields of the Insurance Carrier window, EDI/Eligibility tab.

Any custom report, either created or modified, in a version of Medisoft prior to version 16, such as the CMS 1500, will not pull some data if the field in question was impacted by the new fields on the various IDs grids. For this reason, the simplest solution is to re-create your custom CMS 1500 form using the CMS 1500 form included with Medisoft 16; you can also correct your existing form and adjust the fields that changed.

Major changes to the CMS 1500 form include the logic behind 17a, 17b, 24i, 24j, 25, 32a, 32b, 33a, and 33b. These fields now pull data from the various IDs grids in Medisoft 16. For more information on what fields are pulled in these fields, see the Clickable CMS 1500 topic. Also before modifying the CMS 1500, consider reviewing the topic CMS 1500 Report Changes with Medisoft 16 which calls out the logic now used in the custom report designer to pull data.

How do we do taxonomy?

Medisoft 16 implements a new, flexible method for including taxonomy information on claims. The new implementation method provides a flexible method to address specific taxonomy requirements for different carriers. You can easily address your carrier’s needs with options to send taxonomy in Loop 2000A PRV, in Loop 2310B PRV, or in both segments, or even send mixed taxonomy (group taxonomy number in one segment and individual taxonomy in the other segment).

The Loop 2000A PRV only creates if the Insurance Carrier window, EDI/Eligibility tab Send Practice Taxonomy in Loop 2000A box is selected. A BI is sent in PRV01 if the Practice Type Individual button is selected (Practice Information window, Practice tab). A PT is sent in PRV01 if the Practice Type Group button is selected. In either case PRV02 sends a ZZ and PRV03 pulls the practice taxonomy number entered on the Practice Information, Practice IDs grid.

The Loop 2310B PRV segment only creates the Practice Type Group button is selected (Practice Information window, Practice tab) or if the Practice Information, Practice Pay To tab is filled in. The taxonomy number is pulled from the From Practice button (pulls taxonomy from the Practice Information, Practice IDs grid) or the Taxonomy button on from the Provider IDs grid—the button is selected and a taxonomy number is entered.

Taxonomy Scenarios

Need Taxonomy in 2000A only

This setting is used if you file claims as an individual. Select the Send Practice Taxonomy in Loop 2000A box on the Insurance Carrier window, EDI/Eligibility tab for each insurance carrier that requires taxonomy in 2000A. On the Practice Information, Practice IDs grid, create/edit at least one record that includes all insurance carriers, the specific insurance carrier or the insurance class along with selecting the Taxonomy button and entering a taxonomy number. On the Provider window, Provider IDs tab, create/edit at least one record that includes all the insurance carriers, the specific insurance carrier, or the insurance class along with selecting the From Practice button on the taxonomy line.

Need Taxonomy in 2310B only

This setting is used if you file claims as group. Make sure that the Send Practice Taxonomy in Loop 2000A box on the Insurance Carrier window, EDI/Eligibility tab is not selected for each insurance carrier that does not require taxonomy in 2000A. On the Practice Information, Practice IDs grid, create/edit at least one record that includes all insurance carriers, the specific insurance carrier or the insurance class along with selecting the Taxonomy button and entering a taxonomy number. On the Provider window, Provider IDs tab, create/edit at least one record that includes all the insurance carriers, the specific insurance carrier, or the insurance class along with selecting the From Practice button on the taxonomy line.

Need Taxonomy in both 2000A and 2310B

This setting is used if you file claims as a group. Make sure that the Send Practice Taxonomy in Loop 2000A box on the Insurance Carrier window, EDI/Eligibility tab is selected for each insurance carrier that requires taxonomy in 2000A. On the Practice Information, Practice IDs grid, create/edit at least one record that includes all insurance carriers, the specific insurance carrier or the insurance class along with selecting the Taxonomy button and entering a taxonomy number. On the Provider window, Provider IDs tab, create/edit at least one record that includes all the insurance carriers, the specific insurance carrier, or the insurance class along with selecting the Taxonomy button on the taxonomy line and entering the taxonomy number.

Need Mixed Taxonomy in both 2000A and 2310B

This setting is used if you file claims as a group and the carrier requires the group taxonomy and the provider's taxonomy number. Make sure that the Send Practice Taxonomy in Loop 2000A box on the Insurance Carrier window, EDI/Eligibility tab is selected for each insurance carrier that requires taxonomy in 2000A. On the Practice Information, Practice IDs grid, create/edit at least one record that includes all insurance carriers, the specific insurance carrier or the insurance class along with selecting the Taxonomy button and entering the group taxonomy number. On the Provider window, Provider IDs tab, create/edit at least one record that includes all the insurance carriers, the specific insurance carrier, or the insurance class along with selecting the Taxonomy button on the taxonomy line and entering the provider’s taxonomy number.

How do you file claims? As an individual? As a group? Mixed?

You set your claim filing status on the Providers window on the Provider IDs matrix by selecting either the Individual or Group buttons. If you always file claims one way (either as an individual or a group) you can select that button and apply this setting to all insurance carriers set up in the system by selecting the All button (still might need to create other entries to address issues with NPI numbers, taxonomy, legacy numbers); if some insurance carriers require you to file as group or individual (opposite of your first entry on the grid), you could create a second entry to address this situation on the Providers ID in which select the insurance company and select group.

NPI Numbers

Depending on the setup of your practice and your claim submission requirements, you can enter the NPI number on the Practice window, Practice IDs grid, on the Provider window, Providers IDs grid, or on both windows.

Solo Provider (file claims as an individual)

If you are a solo provider (file claims as an individual) with the same pay to as your billing address (the Pay To tab is blank), you can enter your NPI information on the Practice IDs grid. In this case, you would select on the Providers IDs grid the From Practice button instead of selecting the National Provider ID button and entering an NPI number.

If you are a solo provider with different billing information and pay to information (the Pay To tab is complete), you can enter your NPI information on the Provider IDs grid. In this case, you would select on the Providers IDs grid the National Provider ID button and enter your NPI number. Entering the NPI number on the provider level is required in this case to pull your NPI number in Loop 2010AB. If you left it only on the practice level, the NPI number would not pull for this Loop.

If you are a solo provider that has insurance carriers that require mixed NPI numbers (some require individual while some require a group) you would enter your group NPI number on the Practice IDs grid. You would then create an entry on the Provider IDs grid in which you would enter your individual NPI number on Provider IDs grid and apply it to all insurance carriers, an insurance class, or a carrier (you could create several records if needed to address other issues such as legacy numbers, taxonomy, etc.). For those carriers that require the group NPI you would create at least one other separate entry on the Providers IDs grid (might need more depending on other issues such as legacy numbers, taxonomy, etc.) for that carrier or that insurance class in which you select the From Practice button instead of selecting the National Provider ID button and entering an NPI number.

Member of a Group (file claims as a group)

If you file claims as a group, you can enter your NPI information on the Practice IDs grid. In this case, you would select on the Providers IDs grid the From Practice button instead of selecting the National Provider ID button and entering an NPI number.

Mixed NPI Numbers

If you have insurance carriers that require mixed NPI numbers (some require individual NPI numbers while some require a group) you would enter your group NPI number on the Practice IDs grid. You would then create entries on the Provider IDs grid in which you would enter your the specific provider’s individual NPI number on Provider IDs grid and apply it to a specific insurance company or an insurance category (you could create several records if needed to address other issues such as legacy numbers, taxonomy, etc.). For those carriers that require the group NPI you would create at least one other separate entry on the Providers IDs grid (might need more depending on other issues such as legacy numbers, taxonomy, etc.) for that carrier or that insurance class in which you select the From Practice button instead of selecting the National Provider ID button and entering an NPI number.

For more information, see the topic Entering and Editing Provider Information .

How Do I set up an Insurance Carrier

When setting up an insurance carrier, you will enter data on the Insurance Carrier window accessed by clicking Lists, selecting Insurance, and selecting Carriers. Each insurance carrier requires a record in the database.

For more information, see the topic Entering and Editing Insurance Company Information .

How Do I set up a Practice

Before setting up a practice, consider reviewing the topic An Overview of Setting up a Practice . This topic reviews setup order and has links to other topics with specific instructions for setting up providers, for instance. Also consider reviewing the material in the various topics in the Getting Started section of the help file.

If you are a solo provider, you can use two different methods to set up your practice.

For instance, you can enter key elements like NPI, taxonomy, and tax ID/social security number, on the Practice level or in the Practice IDs grid. Then you would need to create at least one record (can create more if you have a different requirements from various insurance carriers) on the Provider IDs grid in which select the From Practice button for these data elements. Selecting From Practice will pull these values for claims from the Practice IDs grid.

Or when setting up your practice (assuming you do not need to send taxonomy in Loop 200A), you could on the Practice IDs grid select None for NPI, taxonomy, tax ID/social security number and enter a minimal amount of information of Practice IDs grid (still need at least one record). You would then create at least one record on the Provider IDs grid in which you specify your NPI, taxonomy, tax ID/social security number.

If you a group practice, then you will complete at least one grid entry on the Practice IDs grid for the practice. You will also create at least one grid entry on the Provider IDs grid for each provider. If you have a provider that in some instances bills using his/her own NPI number, for a specific insurance carrier, you can create an extra grid entry for this provider, in which you specify the insurance company and select to pull the provider's NPI number from the Provider IDs grid.

For more information, see the topics Entering and Editing Practice Information .

How Do I set up Providers

Provider information is entered on the Provider window accessed by clicking Lists, selecting Provider, and selecting Providers. Depending on the structure of your practice (group or individual/solo), you can enter data either at the Provider level (on the Provider window) or at the Practice level (on the Practice Information window).

If you are a solo provider, you can use two different methods to set up your practice.

If you are a solo provider with different billing information and pay to information (the Pay To tab is complete), you can enter your NPI information on the Provider IDs grid. In this case, you would select on the Providers IDs grid the National Provider ID button and enter your NPI number. Entering the NPI number on the practice level is required in this case to pull your NPI number in Loop2010AB. If you left it only on the practice level, the NPI number would not pull for this Loop.

For more information, see the topic Entering and Editing Provider Information .

How Do I set up a Facility

Medisoft 16 introduces a new method for setting up facilities and labs. You create/edit facilities in the Facilities window accessed by clicking Lists and selecting Facilities.

If you have a facility attached/affiliated with your practice, you will need to create a record for it. There are two components to the record: contact/demographic data entered on the Address tab and billing-specific information entered on the Facility IDs tab.

If you have enumerated a separate NPI number for your facility and need to send facility billing information in Loop 2420D or pull data for box 32 of the CMS 1500 form, you can specify the type of facility and qualifier (77- service location, FA - Facility, LI - Independent Lab, or TL - Testing Laboratory) along with including a separate facility NPI number and if this information is sent on the claim by selecting the Send Facility on Claim check box.

For more information, see the topic Entering and Editing Facility Information .

How Do I include a Different SSN on a Claim

If you need to use a different social security number for a particular insurance carrier, you could create a grid entry on the Provider IDs window for the provider that files claims with the carrier. In this case, you would click Lists, select Provider, and select Providers. On the Provider List window grid select the provider that files with this insurance carrier. Then click the Provider IDs tab and click New. On the New Provider IDs window, you would click the Insurance Carrier button and click the magnifying glass to select the insurance carrier that requires the information. You would then complete the rest of the information on the window making sure that you include all the data needed for a claim since when the rules engine selects this specific entry, it would not have the other information such as taxonomy, NPI number, etc. unless you included it in the grid entry. Then you would select the Social Security Number button and enter the value in the field next to the button.

How Do I set up a Referring Provider

You create/edit referring providers in the Referring Providers window accessed by clicking Lists and selecting Referring Providers.

If you have referring providers affiliated with your practice, you will need to create a record for each referring physician. In this record, you can link the referring provider to a particular insurance carrier/class, if needed, and include other billing details such as the referring provider's NPI, taxonomy, and other legacy IDs.

For more information, see the topic Entering and Editing Referring Provider Information .

How Do I generate claims with only NPI data

The process for sending only NPI only data is simplified in Medisoft 16 with the implementation of the Practice, Provider, Referring Provider, and Facilities IDs tabs. If a carrier requires NPI only data, make sure that you have at least one general or one specific grid entry that includes that insurance carrier in which no values are selected in the Legacy Identifier fields (the None button is selected). If most of your carriers require NPI only data, then a general rule (grid entry) on each IDs tab that includes all insurance companies while not selecting any Legacy Identifier fields, would create an NPI only environment. Then for those few carriers that require some type of legacy data, you could write a specific rule (grid entry) for that insurance carrier and include the legacy information.

If you are converting data from a previous version of Medisoft, you will need to finalize your grids before sending NPI only data. To provide the highest level of data integrity and accuracy, the conversion process for Medisoft 16 provider/practice setup, does not delete information while creating grid entries that might still be needed, such as legacy information (Blue Cross provider numbers, Medicare provider numbers, etc.) but converts this data to a grid entry in Medisoft 16. Before filing claims, you will also need to finalize your grid entries making sure to remove unnecessary data such as out-of-date legacy numbers.

This activity is especially important for any data entered on the PINs tab in previous versions of Medisoft and also if you used the NPI Only check box on the Insurance Carrier window. Since data was converted instead of deleted to provide a high level of data accuracy in Medisoft 16, you will need remove out-of-date legacy numbers from the new grid entries.

For instance, if you had an entry in the PINs tab in Medisoft 15 for a Medicare provider number and then at a later date selected the NPI only check box on the Insurance Carriers window for this insurance carrier, this legacy number will be converted in Medisoft 16. Before filing a claim with this carrier, you would need to remove this from the grid entry in Medisoft 16. In this example, you would click Lists, select Provider, and select Providers. In the Provider List window grid, select the provider. Click the Provider IDs tab. When the data converted, the insurance carrier that had required the Medicare provider number will have a specific row on the Provider IDs grid. Select that row and click Edit. Then in the Legacy Identifier 1 field, select the None button. Click Save. You would repeat this process for any other legacy data that is out-of-date.

How Do I generate claims with Legacy Information

The process for sending legacy information is simplified and improved in Medisoft 16 with the implementation of the Practice, Provider, Referring Provider, and Facility IDs tabs. In previous versions of Medisoft, legacy information was entered on the PINs tab. In Medisoft 16 you can use the IDs grids on the various tabs to create a specific rule (grid entry) and associate it at the practice, provider, referring provider, or facility which in turn determines in which ANSI Loop the information populates.

For instance, if you file claims with an insurance carrier that requires a Medicare provider number on claims, you could create a rule at on the Provider IDs grid in which you specify this legacy data. In this case you would click Lists, select Provider, and select Providers. On the Provider List window grid, select the provider and click Edit. Click the Provider IDs tab and click New. On the New Provider IDs window, you would click the Insurance Carrier button and click the magnifying glass to select the insurance carrier that requires the legacy information. You would then complete the rest of the information on the screen making sure that you include all the data needed for a claim since when the rules engine selects this specific entry, it would not have the other information such as taxonomy, tax ID, NPI number, etc. unless you included it in the grid entry. Then you would select the Legacy Identifier 1 button, enter the number, and select the qualifier (in this case Medicare Provider Number).

How Do I generate Claims with Mammography Information

If you need to include mammography information on a claim, you associate this data with the provider that files mammography claims and would create a grid entry on the Provider window for the provider. In this case, you would click Lists and click Providers. Using the magnifying glass in the Provider Code field, select the provider that files this type of claim. Then click the Provider IDs tab and click New. On the New Provider IDs window, you could click the Insurance Company button and click the magnifying glass to select a specific insurance company or click All to apply the rule to all insurance carriers. You could also apply the rule to an insurance category. You would then complete the rest of the information on the screen making sure that you include all the data needed for a claim since when the rules engine selects this specific entry, it would not have the other information such as taxonomy, tax ID, NPI number, etc. unless you included it in the grid entry. Then you would select the Mammography Cert button and enter the number in the field next to the button. Click OK.

How Do I generate claims with CLIA information

You enter CLIA information in Medisoft in one of two areas depending on if the CLIA number belongs to a lab/facility or provider.

If you have a CLIA number associated with a lab/facility then:

Create a rule (grid entry) on the Facility IDs grid in which you include this value. Click Lists and select Facilities. On the Facility List window, either select a grid entry and click Edit or click New. Then click the Facility IDs tab and click New. If you clicked New, you will need to also complete the fields on the Address tab. On the Facility IDs window, you would click New and then click the Insurance Carrier button and click the magnifying glass to select an insurance carrier that requires the information or you could select the All button to apply the rule to all insurance carriers. You could also select an insurance class instead. You would then complete the rest of the information on the screen making sure to select the Send Facility on Claim box and select the correct ID qualifier. Also make sure you include all the data needed for a claim since when the rules engine selects this specific entry, it would not have the other information such as taxonomy, NPI number, etc. unless you included it in the grid entry. Then you would select the CLIA button and enter the value in the field next to the button. For more information on setting up a facility, see the topic Entering and Editing Facility Information .

If you have a CLIA number associated with a provider then:

Create a rule (grid entry) on the Provider IDs grid in which you include this value. Click Lists, select Provider, and select Providers. Then on the Provider List window grid, click a grid entry and click Edit. Click the Provider IDs tab and click New. On the New Provider IDs window, you could click the Insurance Carrier button and click the magnifying glass to select an insurance carrier that requires the information or you could select the All button to apply the rule to all insurance carriers. You could also select an insurance class instead. You would then complete the rest of the information on the screen making sure you include all the data needed for a claim since when the rules engine selects this specific entry, it would not have the other information such as taxonomy, NPI number, filing status, etc. unless you included it in the grid entry. Then you would select the CLIA button and enter the value in the field next to the button. For more information on setting up a provider, see the topic Entering and Editing Provider Information .

Do I have to change any EDI module settings for 2010?

The Group Practice box on the EDI Receivers window, IDs tab is removed. This functionality is moved to the Provider window, Provider IDs. On this window you can assign to all insurance carriers, an insurance class, or a specific insurance carrier per provider whether you file claims as a group or as an individual. This change provides greater flexibility since you will no longer need to possibly create two versions of the same receiver to address cases in which you had sent claims as a group and as an individual. Now you can create as many records on the Provider IDs grid as needed to address you claim submission needs using the same receiver.

If you had taxonomy triggers in Medisoft 15

The new Provider and Practice IDs grid changes how taxonomy is implemented in Medisoft 16. The new implementation provides a flexible system that you can quickly change depending on your insurance carriers requirements.

If you used Taxonomy utility in Medisoft 15 you will need to enter these settings depending on how you set up your practice and submit taxonomy. These settings were not converted and entered into the grid to support data integrity and accuracy since your practice setup and carrier needs dictate where taxonomy is located (practice level, provider level, both, etc.).

For more information, see Taxonomy .

How Do I Send Ordering Provider Information in Loop 2420E

For any claim on which you need to include ordering provider information in Loop 2420E, you will need to select the Send Ordering Provider in Loop 2420E check box on the EDI/Eligibility tab of the Insurance Carrier window. Select this box for each carrier that you intend to submit claims with this data.

Element	Element Name	Requirements/Description
NM1	Individual or Organizational Name	Send NM1
NM101	Entity ID Code	Send 41
NM102	Entity Type Qualifier	If the Practice Information window, Practice tab, Entity Type is Person, then send a 1. If the Practice Information window, Practice tab, Entity Type is Non-Person, then send a 2. If the Practice Information window, Practice Pay To tab, Practice Name field has a value, then send a 2.
NM103	Submitter Name Last/Org	If the Practice Information window, Practice tab, Entity Type is Person, then send the (billing provider) Providers window, Address tab, Last Name. If the Practice Information window, Practice tab, Entity Type is Non-Person, send Practice Information window, Practice Settings tab, Practice Name field.
NM104	Name First	If the Practice Information window, Practice Settings tab, Entity Type is Person, then send the (billing provider) Providers window, Address tab, First Name. If the Practice Information window, Practice Settings tab, Entity Type is Non-Person, send Practice Information window, Practice tab, Practice Name field.
NM105	Name Middle	If the Practice Information window, Practice tab, Entity Type is Person, then send the (billing provider) Providers window, Address tab, Middle Initial if present.
NM106	Name Prefix	Not used
NM107	Name Suffix	Not used
NM108	ID Code Qualifier	Send 46
NM109	Submitter ID	EDI Receiver, ID tab, Submitter ID 1
NM110	Entity Relationship Code	Not used
NM111	Entity ID Code	Not used

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