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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.
ANSI Reference: Prior Authorization Number = 2300 Loop, REF*G1 Segment
Resource Tab
This tab is to be used when a payer requires a Paperwork record on an eClaim. Often times, the “Box 19 on CMS-1500 Claim Form” field, in the Incident tab is sufficient for reporting additional information. When a Paperwork segment is required on a medical eClaim, the paperwork information is added in the Resource tab of the incident.
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ANSI Reference: 2300 Loop, PWK Segment
Billing Charges as Medically Necessary
Note on Medically Necessary: This is not an indicator to be used on any and all charges to prove that the charges were indeed medically necessary. Most procedure codes are deemed medically necessary by default, without special indicators. For Podiatrists (DPM), Medicare may require some procedures to be flagged as Medically Necessary in order for the claim to be paid. For example, the patient may have diabetes and the DPM cuts their toenails due to a loss of feeling in the feet. Medicare would not normally cover this procedure unless it was deemed Medically Necessary. In order for these eClaims to be paid, Medicare requires a Supervising Provider Loop and the Date Last Seen by the primary care provider.
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You will also need to make sure the Primary Care Provider is listed as a Referral on the charge when entering the Medically Necessary charge to the patient's ledger. The provider listed in the Referral area of this charge will pull as the Supervising Provider on the eClaim. Please remember that this is only recommended for Podiatry charges and will only work for Medicare claims. Please contact MacPractice Support for any further help with electronic claims.
Charge Window
In the screenshot below, the only areas notated will pull onto eClaims.
Procedure Date: The Procedure Date is the date of the procedure or date of service. It is also possible to do a range of dates and enter a To Date. Until September of 2008, dialysis claims sent to Medicare needed to be billed in month increments which required a range of dates. The Procedure Date prints in box 24a on paper claims. This date appears on eClaims if entered.
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ANSI Reference: Service Line = 2400 Loop, DTP*472 Segment
Code
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: The Code is the procedure code, also known as CPT codes, HCPCS codes or ADA codes. The code prints in box 24d on paper claims. This code appears on eClaims as well.
ANSI Reference: Service Line = 2400 Loop, SV101-2
Modifiers
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: Modifiers consist of two alphanumeric characters that give more detailed information on a procedure. For example, if a provider is billing the same procedure on a claim twice they might add a 51 modifier to one of the charges so it won't be denied as a duplicate. They might also use RT & LT to specify right and left limbs. The modifiers print in box 24d on paper claims.
ANSI Reference: Service Line = 2400 Loop, SV101-3, 4, 5, 6
Procedure Description
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: Some procedures require descriptions on claims, beyond just the procedure code. This information pulls to an eClaim exactly as it appears in the Procedure description field. This does not pull to an eClaim by default. In order for the Procedure Description to appear on an eClaim, the "Require Description on eClaims" box must be checked in the associated fee schedule record.
ANSI Reference: 2400 Loop, SV101-7
Fees & Units: Units are pulled into the claim in the service line information. The Fee Amount and Unit Type will pull from the selected Fee Schedule if applicable. They are printed in boxes 24f and 24g on a paper claim. This is the number of units or minutes for anesthesia that are billed, and the charge amount for the procedure. This information pulls to eClaims
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ANSI Reference: Unit Type = 2400 Loop, SV103; Hours, Sessions or Other = UN; Minutes = MJ. Minutes are only used for Anesthesia Units = 2410 Loop, CTP04; Number of Units = 2400 Loop, SV104
Total Fee
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: This is the product of Units times Fee. Total Fee pulls to eClaims, in the service line information. There can be several service lines per eClaim. This means that there can be several fee totals per individual eClaim, therefore the Total Fee is not necessarily going to be the same as the Total Charge Amount of the entire claim.
ANSI Reference: Total Fee = 2400 Loop, SV102
Diagnosis
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: The Diagnosis tab holds the diagnosis (ICD-10) codes per procedure. MacPractice has the capability of including 12 diagnosis codes per claim but only 4 diagnosis pointers per charge. Click HERE, to see more information about the number of diagnosis pointers per charge.
ANSI Reference: Diagnosis Codes = 2300 Loop, HI01-2, HI02-2, HI03-2, HI04-2, HI05-2, HI06-2, HI07-2, HI08-2, HI09-2, HI10-2, HI11-2, HI12-2; Diagnosis Pointers = 2400 Loop, SV107-1, SV107-2, SV107-3, SV107-4
Specialty
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: The Specialty tab is used by MD clients who need to add tooth information for dental claims. It is typically used by Oral and Maxillofacial Surgeons.
ANSI Reference: Tooth, Surface & Quad = Only pulls on EHG Template for Dental Claims. Tooth Number = 2400 Loop, TOO02; Surface = TOO03-1, TOO03-2, TOO03-3, TOO03-4, TOO03-5; Quadrant/Area of Oral Cavity = 2400 Loop, SV304-1
Notes
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: The Notes tab is for Line Level notes (per procedure). These are added when a note doesn't apply to the whole claim but only to a specific procedure. In MacPractice MD, 20/20 or DC, these notes will not print on a paper claim.
ANSI Reference: Line Level Notes = 2400 Loop, NTE Segment
10. RxRx: The Rx tab is for adding a Medication to a charge. Doing this will pull the NDC Number of the medication and calculate dosage per unit on a claim. Please see the documentation under Billing, NDC, National Drug Code, about adding NDC numbers to claims.
ANSI Reference: National Drug Code = 2400 Loop, LIN Segment; Unit Qualifier = 2410 Loop, CTP05
11. Attachment: This tab is used for dental eClaims only, and can only be used when the office has purchased the NEA FastAttach ability. The Attachments tab allows the user to submit attachments electronically. Once an attachment is submitted, the attachment receives a unique identifier. When an eClaim is created using the procedure that contains the attachment record, the attachment's unique ID is placed on the eClaim. Click HERE for more information on the use of NEA FastAttach.
ANSI Reference: 2300 Loop, PWK Segment
12. Provider Shown on Claim: The Provider on Claim pop-up menu is where the rendering provider on a claim is specified. This field is defaulted from the provider set on the Patient tab. See User Reference for more information.
ANSI Reference: Provider = 2310B Loop, or 2010AA when billing as an individual
13. Office: Office: The Office pop-up menu is where the billing office on the claim is specified. This information is defaulted from the office set on the Patient tab. See Office Reference for more information.
ANSI Reference: Office = 2010AA Loop. Not used when billing as an individual
14. Place of Service: The Place of Service pop-up menu identifies the place of service where health care service were rendered. The code selected must be a HIPAA compliant code or your claim will be denied. MacPractice comes with a default list of common place of service codes, however, you can add your own under References, Place Of Service. There are rules for certain place of service codes; i.e. Inpatient Hospital (21) requires an admission date on the claim, End Stage Renal Disease Treatment Facility (65) is required for submitting dialysis charges, and so on. The place of service prints in box 24b on a paper claim.
ANSI Reference: ANSI Reference: Place of Service = 2300 Loop, CLM05-
If Place of Service on a subsequent procedure does not match the Place of Service of the first procedure on the claim, the Place of Service Code for the subsequent charge will populate in 2400 Loop, SV105.
15. ReferralReferral: The Referral field is for designating the referring provider for the charges. A referral is only pulled onto a claim if this section is filled out. If a referral isn't specified on the incident, this information will have to be manually entered for each charge. See Referral Reference for more information.
ANSI Reference: Referral = 2310A Loop
16. FacilityFacility: The Facility is pulled into a claim to identify where the service was rendered. In Preferences > Ledger > New Charge there is a preference to Always Pull Facility From Incident. If this is not checked then this information will be need to be entered manually for each charge if the services were not rendered in the office. There can also be a default facility associated to the Office Reference. See Office Reference and Facility Reference for more information.
ANSI Reference: Facility = 2310C Loop
17. Admitted Admitted Date: The Admitted Date is the date that the patient was admitted to the facility. This is usually only required when place of service is Inpatient Hospital (21).
ANSI Reference: Admission Date = 2300 Loop, DTP*435 Segment
18. Discharged Discharged Date: The Discharge Date is the date that the patient was discharged from the facility. This is not necessarily required on a claim but it might be useful for an office to enter this information because it calculates LOS Days (Length of Stay).
ANSI Reference: Discharge Date = 2300 Loop, DTP*096 Segment
19. Lab Lab Name: The Lab Name field is where a lab needs to be entered to appear on the claim. For electronic claims there cannot be both a Facility and a Lab tied to the charge. In Preferences > Ledger > New Charge there is a preference called A Charge Can Have Either a Facility or a Lab, But Not Both. See Laboratory Reference for more information.
ANSI Reference: Lab = 2310C Loop
20. EmergencyEmergency: If Emergency is checked it flags the procedure as being an emergency procedure. This will print in box 24c on a paper claim.
ANSI Reference: Emergency = Service Line 2400 Loop, SV109
21. TaxableTaxable: Sales Tax information is only reported on health insurance claims in the states of Hawaii and New Mexico. If this is checked, the sales tax information will pull into the electronic claim when the provider's office location is in that state. The sales tax is calculated from the procedure fee multiplied by the sales tax rate entered in Preferences> Preferences > Financial> Sales tax.
ANSI Reference: Tax amount = 2400 Loop, AMT*T
References Ability
Continue reading below for ANSI specifications for items in the References ability.
Insurance
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Reference
Insurance Reference - Company Info
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Tab
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Insurance Company Information: The insurance company's name and address pull onto claims. If there is a Plan set for the patient, the Demographic information on the Plan tab overrides the information in the Company Info tab.
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ANSI Reference: Payer Name = 2010BB Loop
Practice Group ID (Electronic): This field only needs to be filled out if a carrier has assigned a payer-specific group number to the office. Any data in this field will only be sent on claims when the claim is being sent to Payer ID ‘MC059’, ‘J1438’, or '22099'. Many offices like to leave their numbers here as a reference even when the numbers aren't sent. Also, if there is a number in this field there will need to be an individual number on the Provider IDs tab as well. Having Bill as Individual checked will remove this information. See Bill as Individual for more information.
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ANSI Reference: Billing Provider Name = 2010AA Loop, REF02
Practice Group ID (Paper): This field only needs to be filled out if a carrier has assigned a payer-specific group number to the office. Any data in this field will only print on claims if using the NPI and Legacy or Only Legacy forms. Many offices like to leave their numbers here as a reference even when using the Only NPI form. Also, if there is a number in this field there will need to be an individual number on the Provider IDs tab as well. Having Bill as Individual checked will remove this information. See Bill as Individual for more information.
Claims Payer ID: The Payer ID is extremely important for electronic claims because it identifies the payer in the clearinghouse's system. Providers need to check with the clearinghouse for appropriate payer IDs.
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ANSI Reference: Payer Name = 2010BB Loop, NM109
Submitter ID: Submitter IDs are only used in special circumstances. They are only used if the payer assigns a unique Submitter ID per provider or office. The enrollment department will notify the office if a Submitter ID is needed. The Submitter ID in the Provider IDs tab will override the Submitter ID in the Company Info tab.
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ANSI Reference: Submitter Name = 1000A Loop, NM109 Also contained in Functional Group Header GS02
Trading Partner Number: This field is for UHIN and non-partner clearinghouse Payer IDs only. This is not used with Change Healthcare claims.
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ANSI Reference: Payer Name = 2010BB Loop, NM109
Carrier Code: This field is only used for certain carriers that require a Carrier Code for secondary electronic claims, notably MC024, MC029, MC039 and MC089. This field would be filled in the reference for the primary payer, when certain Medicaid payers are the secondary.
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ANSI Reference:
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Other Payer Name = 2330B Loop, NM109
Insurance Reference - Claims Tab
Sum of the Following in Box 29: The checkboxes in this area only affect paper claims and not electronic claims. All payment information tied to a charge pulls onto an electronic claim except for positive and negative adjustments.
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Plan Type: The Plan Type needs to be set correctly for claims to be paid properly. If a plan is configured for this patient, the Plan Type on the Plans tab will override the Plan Type on the Company Info tab.
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ANSI Reference: Subscriber Hierarchical Level = 2000B Loop, SBR09; Other Subscriber Information = 2320 Loop, SBR09
eClaims Template: If the eClaims Template is set, it will be the default form/template in the Claim Creation window. If no template is set, a paper form will be default.
CMS 1500 Legacy ID Codes: See the Glossary entry for Qualifier Codes for an explanation of qualifier codes used in eClaims. This entry is regarding paper claim qualifier codes only. The Qualifier Code is the 2 digit code in front of legacy ID numbers that identifies the type of legacy number. The Qualifier Code Overrides in MacPractice only apply to paper claims and print in box 17a for referrals and 32b for facilities. If in doubt, Automatic should be selected, and the qualifier code will be set based on the plan type of the insurance. For Legacy Referral ID Number, see Referrers Reference. For electronic claims, the qualifier code is controlled by the plan type and the template.
eClaims should include NPI only: This box only needs to be checked if the clearinghouse isn't stripping legacy numbers and the payer requires NPI only. The clearinghouse takes care of sending the correct identifiers to most payers. This checkbox is only used in special circumstances, such as when the clearinghouse can't strip legacy IDs.
Use Group Taxonomy: This box needs to be checked in order to send Group Taxonomy codes on claims that have been entered in the Office or User reference. You should only check this box if specifically instructed by either your insurance carrier, clearinghouse or MacPractice support to submit group taxonomy information on claims.
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ANSI Reference: Billing Provider Name = 2000A Loop, PRV*BI*PXC
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ANSI Reference: Rendering Provider Name = 2310B Loop, PRV*PE*PXC
Group Taxonomy Code: The Group Taxonomy Code is the specialty code of the practice. Group Taxonomy codes are only used in special situations, and you should not enter this information unless specifically requested by an insurance carrier, your clearinghouse or MacPractice Support to send group taxonomy information on claims. Entering the group taxonomy in the User reference overrides the group taxonomy in the Office reference.
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ANSI Reference: Billing Provider Name = 2000A Loop, PRV*BI*PXC
Group National Provider ID (NPI): The NPI number entered in this field should be the billing provider's group, or Type-2 (organizational), NPI number. Entering the group NPI in the Users reference overrides the NPI in the Office reference. The group NPI prints in box 33a on paper claims. If Bill as Individual is checked, no group information is sent/printed on claims. See Bill as individual for more information.
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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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