This document will provide you with information about each field in MacPractice used in electronic claims. It will also explain how paper claims and eClaims differ with respect to those fields and provides the ANSI 5010 837 specifications for each.
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Patient Ability
Continue reading below for ANSI specifications for items in the Patients ability.
Primary/Secondary Tabs
The determination of whether guarantor information pulls onto claims depends on the Plan Type and the patient's relationship to guarantor.
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Subscriber/Guarantor Information:
From the Primary/Secondary tabs, guarantor name, address, date of birth and sex pull into electronic claims, only when the patient relationship to the subscriber is ‘Self’ and for certain payers.
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Keep in mind, Primary Tab and Secondary Tab in the Patients Ability do not refer to the Primary or Secondary Subscriber on insurance. These tabs indicate the personal financial responsibility regarding the patient. The secondary guarantor could very easily be the one who subscribes to the primary insurance under which the patient is covered.
ANSI Reference: Subscriber Name = 2010BA Loop
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Signature on File: Signature on File pulls onto both electronic and paper claims. This refers to whether the patient's signature is on file for authorizing the benefits to be assigned to the provider.
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Please click the following link for more information on the importance of subscriber Signature on File.
ANSI Reference: Claim info = 2300 Loop, CLM08
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Release of Info: The checkbox for Release of Info only prints on paper claims.
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Insurance
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(Guarantor Screen)
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Carrier Name: See Insurance Reference.
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Subscriber #: A Subscriber ID might also be referred to as a member ID, guarantor ID or HIC number.
ANSI Reference: Subscriber Name = 2010BA Loop, NM109
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Group #: The Group Number can be set per Employer. If no employer name is needed on the claim, the office can enter the group number directly in this field if desired. The group number on an eClaim cannot be the same value as the subscriber ID.
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ANSI Reference: Subscriber Hierarchical Level = 2000B Loop, SBR03
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Employer: If an employer name is needed on the claim, the Employer needs to be selected per Insurance after associating an Employer to patient. Please note that an employer name will not be sent on a claim if a group number is entered.
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ANSI Reference: Subscriber Hierarchical Level = 2000B Loop, SBR04
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Patient Tab
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For electronic claims, if relationship to guarantor is set to Self, the patient loop gets stripped and only the subscriber loop is sent, meaning no separate patient information is sent for this patient. This causes the carrier to pay claims for the guarantor as if they were the patient. For paper claims, when relationship to guarantor is set to Self, the patient information prints in boxes 2 and 5, and box 4 and 7 are either blank or say Same. Self is the only relationship allowed by Medicare.
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Relationship to Primary/Relationship to Secondary: The Relationship to Primary and Relationship to Secondary needs to be set properly for claims to be accurate. Note that this is referring to the primary or secondary Guarantor, not necessarily the primary or secondary Insurance.
ANSI Reference: Subscriber Hierarchical Level = 2000B Loop, SBR02 (if "self") Patient Hierarchical Level = 2000C Loop, PAT01 (if anything other than "self")
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Patient Information: Patient name, address, date of birth and sex pull onto electronic claims if the relationship to guarantor is anything but Self. Patient name, address, date of birth, sex, marital status, employment status and telephone number pull onto paper claims.
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ANSI Reference: Patient Name = 2010CA Loop
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Social Security: The patient's Social Security Number is only used in ANSI Version 4010 Workman's Comp claims. 5010 eClaims do not use the Social Security number for the patient in any circumstance.
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Insurance Tab (Patient Screen)
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The order of insurances in this tab controls the order in which insurances are billed. The top insurance is the primary insurance unless disabled. If the first insurance in the list is enabled, the next insurance in the list is the secondary insurance.
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Enabled: The Enabled checkbox controls whether the insurance is used for this patient or not. If Enabled is not checked, the insurance is not pulled onto the claims in any manner.
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Carrier: See Insurance Reference.
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Subscriber ID: The subscriber ID on the Patient tab automatically pulls from the Guarantor tab. If the office overrides the subscriber ID in the Patient tab, the link to the ID on the Guarantor tab is broken. The subscriber ID on the patient screen will override the subscriber ID for payer IDs MC002 and MC006 only. Otherwise, the subscriber ID on the patient screen is not used.
If the plan type is Worker's Comp, the patient relationship to subscriber isn't self, and the payer ID is PAPER or PRINT, MacPractice will not populate the subscriber ID onto the eClaim.
ANSI Reference: Subscriber Name = 2010BA Loop, NM109
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Medicare Type: When Medicare is a Secondary Payer, the Medicare Type needs to be set. This identifies the reason why Medicare is secondary. MacPractice comes with a populated list of HIPAA compliant MSP (Medicare as a Secondary Payer) Codes.
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ANSI Reference: Subscriber Hierarchical Level = 2000B Loop, SBR05
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HIPAA Release: The HIPAA Release is the electronic claims equivalent of the Release of Info box on the guarantor screen. This is usually set in the template overrides. If HIPAA Release is not indicated on an eClaim, the eClaim will reject. A value of 'Y' (Yes, Provider has a Signed Statement Permitting Release), is required for all electronic claims.
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In 5010 electronic claims, only the settings of “Informed Consent to Release Medical Information” and “Yes, Provider has a Signed Statement Permitting Release” are HIPAA valid settings. Most payers do not accept “Informed Consent to Release Medical Information”, but all payers accept “Yes, Provider has a Signed Statement Permitting Release”.
ANSI Reference: Claim info = 2300 Loop, CLM09
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EPSDT: Early Periodic Screening Diagnosis and Treatment is used in pediatric offices for children with Medicaid. This will print in box 24h of a paper claim.
ANSI Reference: Service Line = 2400 Loop, SV111
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Family Planning: Required if applicable for Medicaid claims. This will print in box 24h of a paper claim.
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ANSI Reference: Service Line = 2400 Loop, SV112
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Relationships on Electronic Claims
When checking relationships on the claims themselves, please be aware that the relationships on the patient screen refer to the relationship to the person on the Primary and Secondary tabs, not necessarily the primary or secondary insurance.
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Ledger
Continue reading below for ANSI specifications regarding items in the Ledger.
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Ledger - Incident
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Incident Tab
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Referral Source: To add a referral, select the Referral drop down in the Incident tab. If no referral is available, one can be added in the drop down, by selecting "New Referral Record".
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If a referral is selected here, they will automatically pull into the New Charge window for all new charges that are created in the incident. Please note this does not retroactively update charges and will only pull into new charges. This information is required by some payers. See Referrer Reference for more information.
ANSI Reference: Referring Provider = 2310A Loop
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Box 19 on Insurance Form: The Box 19 on Insurance Form field will need to be filled in when there are Claim Level notes that need to be entered on an electronic claim. Information filled out in this field will pull onto all claims created in the incident.
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ANSI Reference: Claim Level Notes = 2300 Loop, NTE Segment
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Reason For Treatment Sub-Tab
Reason for Treatment: If any accident information is filled out, the Accident Date and Condition Related To both have to be entered. If the Condition Related To is set to Auto Accident, then the Accident State also needs to be entered. Accident information is commonly required for Workman's Comp claims.
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ANSI Reference: Condition Related To = 2300 Loop, CLM11-1, 2 & 3; Accident Date = 2300 Loop, DTP*439 Segment; Accident State = 2300 Loop, CLM11-4
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Facility Sub-tab
Facility: If you add a Facility to the incident, and also have the Preference checked to Always Pull Facility from Incident (Preferences > Ledger > New Charge), it will automatically pull the facility into the New Charge window for all new charges that are created in the incident. Please note this does not retroactively update charges and will only pull into new charges. See Facility Reference for more information.
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ANSI Reference: Service Facility = 2310C Loop
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Claims Tab
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Claims Tab - Symptom Dates Sub-tab
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Payers may require certain dates under varying circumstances. If a payer requests the following then they need to be entered in this section.
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Onset of Current Illness: This date is labeled in the Symptom Dates sub-tab as First Symptom Date. This reflects the first time that a patient starts to exhibit particular symptoms pertaining to an illness or injury. If "None" or "Routine Services" is selected in the 'First Symptom Date Type' pop-up menu this date will not pull on a paper claim.
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The actual First Symptom (Onset of Current Illness) Date appears on eClaims when populated.
ANSI Reference: 2300 Loop, DTP*431, DTP03
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First Symptom Date Type: When this is set to "Last Menstrual Period", rather than appear in a "Onset of Current Illness" element on the eClaim, the First Symptom Date appears as an "LMP Date" on the claim. No other value than LMP is specifically indicated on an eClaim.
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ANSI Reference: 2300 Loop, DTP*484, DTP03
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Other Date: This date is not used on eClaims, but it does print in Box 15 of paper claims. This will need to be entered in the Similar Symptom field if requested by a payer. This is the date the patient started having similar symptoms pertaining to an illness or injury.
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Initial Treatment Date: This will need to be entered in the First Consultation field if requested by a payer. This is the date the patient was first treated for particular illness or injury, commonly required for chiropractic claims. This information populates eClaims if entered.
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ANSI Reference: 2300 Loop, DTP*454, DTP03
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Date Last Seen: This date will need to be entered if requested by a payer. This is the date that the patient was last seen by this provider. This date appears on eClaims if entered.
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ANSI Reference: 2300 Loop, DTP*304, DTP03
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Assumed Date: This will need to be entered if requested by the payer. This is the date that a provider assumed care for a patient from another provider. This is mainly used for Hospice, Home Health Care, and Nursing Home claims. This date appears on eClaims if entered.
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ANSI Reference: 2300 Loop, DTP*090, DTP03
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Relinquished Date: will need to be entered in the Relinquished Date field if requested by a payer. This is the date that a provider relinquishes care for a patient to another provider. This is mainly used for Hospice, Home Health Care, and Nursing Home claims. This date appears on eClaims if entered.
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ANSI Reference: 2300 Loop, DTP*091, DTP03
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Prior Authorization Tab
Prior Authorizations are sometimes required when specified by a payer. Usually a payer will only give a provider an approved Number of Visits or an Expiration Date, although some do give both. The payer will assign a prior authorization number that needs to be included on all claims pertaining to a particular illness, injury, or set of procedures needed for the patient.
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If you click the green Plus button to add a prior authorization number, all appropriate fields need to be filled in for the claim creation sheet to be able to recognize it as a valid number to attach to a claim. The Expiration Date is not required. MacPractice will count down the Remaining Visits for claims created for the selected insurance in the incident until the remaining visits are gone. If Remaining Visits is '0', then MacPractice will not add the Prior Authorization to the claim. This date appears on eClaims if entered. On paper claims, this information appears in Box 23.
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ANSI Reference: Service Facility Location = 2310C Loop, NM109
QuickTime
Referring Lab and Referring Lab CLIA: Typically labs reported on claims are not referring labs. These fields should only be used in circumstances where the lab is acting as a referring entity. Non-referring lab CLIA numbers should be entered in the Provider IDs tab of the provider's Users reference. The Place of Service needs to be Independent Laboratory (81) in order for the Referring Lab and Referring Lab CLIA to be populated on the electronic claim.
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