Page Comparison

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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.

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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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.

• 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.

• 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.

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.

• 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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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.

• 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.

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.

• ANSI Reference: Service Line = 2400 Loop, SV112

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Relationships on Electronic Claims

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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.

• 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.

• 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.

• 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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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

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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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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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.

• ANSI Reference: Billing Provider Name = 2000A Loop, PRV*BI*PXC

Insurance Reference - Provider IDs Tab

As with the Company Info Tab, there is a field for Practice Group IDs in the Provider IDs tab for each provider. This occurs in MacPractice versions 3.5 and higher. See Practice Group ID under the Insurance Reference - Company Info Tab heading for more information. These fields only need to be filled out when an office has more than one group for a carrier. The extra fields allow the office to add Group IDs per provider in one Insurance reference.

Electronic Claims ID: The Electronic Claims ID field only needs to be filled out if a carrier has assigned a payer-specific individual number to the provider. Any data in this field will only be sent on claims when the clearinghouse is sending legacy numbers to the payer. Many offices like to leave the provider's numbers here as a reference even when the numbers aren't sent.

• ANSI Reference: Rendering Provider Name = 2310B Loop, REF02

Paper ID: The Paper ID field only needs to be filled out if a carrier has assigned a payer-specific individual number to the provider. Any data in this field will only be printed on claims if using the NPI and Legacy or Only Legacy forms. Many offices like to leave the provider's numbers here as a reference even when using the Only NPI form.

Submitter ID: Submitter IDs are only used in special circumstances. They are only used if the payer assigns a unique Submitter ID per provider. 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.

• ANSI Reference: Submitter Name = 1000A Loop, NM109 Also contained in Functional Group Header GS02

Accepts Assignment: Accepts Assignment should be checked if the provider accepts the carrier's allowed amounts. Definitions of Accepts Assignment vary by payer, the provider should contact the payer for clarification. For Medicare, Accepts Assignment means that the provider agrees to Medicare's allowed amount for the procedure and cannot charge the patient more than the contracted allowed amount. The provider needs to either use Medicare's fee schedule or needs to write off the difference between the office charge for the fee and Medicare's allowed amount. Having Accepts Assignment checked will also move the balance to the insurance portion in the Ledger upon claim creation when not using insurance estimating.

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• ANSI Reference: Claim Information = 2300 Loop, CLM07

Participate: Participate should be checked if the provider participates in the insurance plan. Definitions of Participate vary by payer, the provider should contact the payer for clarification. In Medicare, Participation means the provider agrees to always Accept Assignment of claims for all services furnished to Medicare beneficiaries. By agreeing to always Accept Assignment, the provider agrees to always accept Medicare-allowed amounts as payment in full and to not collect more than the Medicare deductible and coinsurance from the beneficiary. If a plan is set for this patient, the Participate checkbox on the Plan tab will override Participate in the Provider IDs tab. If Participate is checked, a write-off will also be calculated in the Insurance Payment window if the total fee is greater than the saved Allowed Amount.

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• ANSI Reference: Claim Information = 2300 Loop, CLM16

Bill as individual: Bill as individual should only be checked if there is group information entered in for the provider (group NPIs or practice group IDs) that needs to be stripped from the claim. If in doubt, this box should not be checked. For electronic claims, the 2310B loop is stripped and all rendering information is transmitted in the 2010AA loop. The taxonomy code is moved to the 2000A loop, in a PRV*BI segment. Also, in the 2010AA loop, NM102 is changed from 2 -- Non-Person Entity to 1 -- Person. For paper claims, the provider's name is printed in box 33, along with his/her individual NPI (Also referred to as the Rendering Provider NPI, or Rendering NPI) in 33a and individual legacy number (if applicable) in box 33b. Box 24J is left blank.

Qualifier Code: 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 boxes 33b and 24i. If in doubt, Automatic should be selected, and the qualifier code will be set based on the Plan Type of the insurance. For electronic claims, the qualifier code is controlled by the Plan Type and the template.

Legacy Type Override: The Legacy Number Type override controls whether the provider's Tax ID or Social Security Number is sent on electronic, but not paper, claims. This should only be set if the provider is getting denials for using his/her typical Tax ID/SSN set up. The appropriate numbers need to be entered in the Provider Numbers tab in the provider's Users reference. If Use User Reference is selected, the number set in the Provider Tax ID on Claims pop-up menu in the provider's Users reference will be used on the claim. Otherwise, this can be overridden per Insurance reference by selecting the Legacy Number Type override on the Provider IDs tab.

• ANSI Reference: Billing Provider Name = 2010AA Loop, REF01-2

Insurance Reference - Plans Tab

If a plan is set for a patient, the information in the Plans tab will override data in the Company Info or Provider IDs tabs.

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Information that will override from the Plans tab includes Address, Claims Payer ID, and Eligibility Payer ID. If the information is empty in the Plans tab, but present in the Company Info tab, the Company Info data will pull to the eClaim.

Insurance Reference - Plans Tab - Demographics Sub-tab

Sub ID: The Sub ID is only used for one payer, Advocate Claims, 65093 and 36320, to designate the Plan ID, or secondary payer identification. The patient will need to have a plan selected.

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• ANSI Reference: Payer Name = 2010BB Loop, REF*FY

User Reference

Is Provider: Is Provider must be checked in order for this user to appear on claims.

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Provider Information: The provider's first, last and middle initial is included on eClaims. Paper claims print the provider's name in box 31. If "Bill As Individual" is checked for the provider in the associated insurance reference of a claim, Provider IDs tab, the provider's name will appear in the billing provider loop of eClaims.

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• ANSI Reference: Rendering Provider Name = 2310B Loop

• ANSI Reference: (When Billing as Individual) Last: Billing Provider Name = 2010AA Loop, NM103 First: Billing Provider Name = 2010AA Loop, NM104

User Reference - Provider Tab

Nothing under the 'User Information' tab or 'Privileges' tab will populate eClaims. The focus of this section of the document will be on on the 'Providers' tab of the user reference.

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Provider Shown on Claim: Usually the Provider Shown on Claim is set to the same provider's Users reference that is selected. In some circumstances, notably nurse practitioners and hygienists, another provider might need to be sent on claims. Usually the office still wants to keep track of the nurse or hygienist's work separately from the provider on claim. This pop-up menu allows the office to keep track of the providers' work separately in MacPractice while sending only one provider's information on claims.

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Name Printed in Box 33: The name printed in box 33 of the CMS 1500 form can be controlled by changing the name in this field. This will also affect the name printed on statements, depending on the statement settings. The Name Printed in Box 33 field does not affect electronic claims.

User Reference - Provider Tab - Claim Credentials Sub-tab

National Provider ID (NPI): The NPI number entered in this field should be the billing provider's individual, or Type-1, NPI number.

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• ANSI Reference: Rendering Provider NPI = 2310B Loop, NM109. 2010AA, NM109, when billing as individual.

Provider Taxonomy Code: The Taxonomy Code is the specialty code of the provider. This information is not printed on paper claims, but is required for electronic claims submission.

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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: Billing Provider Name = 2010AA Loop, NM109

SSN: The Social Security Number should be entered if the provider ever uses his/her Social Security Number to file claims. The number used on claims, whether it be the Federal Tax ID or Social Security Number, is controlled by the pop-up menu at the bottom of the screen that says Provider Tax ID on Claims. This can be overridden by the Legacy Type Override in the Insurance reference. See Legacy Type Override for more information.

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• ANSI Reference: Billing Provider Name = 2010AA Loop, REF*SY

Federal: The Federal Tax ID should be entered if the provider ever uses his/her Federal Tax ID to file claims. The number used on claims, whether it be the Federal Tax ID or Social Security Number, is controlled by the pop-up menu at the bottom of the screen that says Provider Tax ID on Claims. This can be overridden by the Legacy Type Override in the Insurance reference. See Legacy Type Override for more information.

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• ANSI Reference: Billing Provider Name = 2010AA Loop, REF*EI

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Provider Tax ID on Claims: This sets the default as to which identification number will populate the eClaim, Federal or SSN. This can be overridden by the setting of Legacy Type Override in the Claims Provider IDs tab of the associated insurance reference.associated Insurance Company Reference.

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• ANSI Reference: Billing Provider Name = 2010AA Loop, REF*EI or REF*SY (Never both)

CLIA: CLIA or Clinical Laboratory Improvement Amendments numbers are assigned to offices/laboratories that perform lab work. There must be a lab tied to a charge, the Type of Service must be set to Diagnostic Lab (Pathology) (5), and the Plan Type has to be set to Medicare Part B in the Insurance reference in order for the CLIA number to be printed in box 23 on paper claims. Electronic claims only require the Lab to be tied to a charge and that the provider have a valid CLIA number entered in the User Reference.

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• ANSI Reference: Claim Information = 2300 Loop, REF*X4

State License: State License numbers are not typically used on Medical claims, but are pulled onto Dental claims in boxes 50 and 55 of the ADA form. The State License Number field is only used for electronic claims to specific payers.

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• ANSI Reference: Rendering Provider Name = 2310B Loop, REF*0B, REF02

Trading Partner Number: This field is used for UHIN Submitter IDs. For Capario claims, this will pull for payer ID: MACSIS.

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• ANSI Reference: Submitter Name = 1000A Loop, NM109 (UHIN) Billing Provider Name = 2010AA Loop, REF*1G, REF02 (MACSIS)

Mammography Certification: The Mammography Certification field is only available in MacPractice versions 3.5.3 or higher. If using anything previous to that version, the Mammography Certification number can be entered in the Unique field.

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• ANSI Reference: Claim Information = 2300 Loop, REF*EW

User Reference - Provider Tab - Additional Credentials Sub-tab

UPIN: UPIN numbers were assigned to providers and used for referrals. The UPIN Number in the Users reference is not used on any claims, but instead for reference. The UPIN Number should be entered in the Referral reference if needed for claims. See Referrers Reference for more information. After the NPI Only date, May 23rd 2008, CMS stopped assigning UPIN numbers to many providers. UPIN numbers are rarely used anymore.

DEA: DEA or Drug Enforcement Administration numbers are assigned to providers that write prescriptions. The DEA Number is not used on claims.

Is Employed by Hospice: If the place of service is set to anything but Office (11), and Is Employed by Hospice is checked, or if the place of service is set to Hospice (34) then the information is sent on the electronic claim.

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• ANSI Reference: Service Line = 2400 Loop, CRC*70

Unique: The Unique field has been used for Mammography Certification Numbers in the past. This is replaced by the Mammography Certification field in version 3.5.3.

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• ANSI Reference: Claim Information = 2300 Loop, REF*EW

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All other fields in the user reference are not used on claims.

Office Reference

Office Name: The office name is used in electronic claims. If Bill as Individual is checked, the office name is replaced by the rendering provider's name in the 2010AA loop. See Bill as Individual for more information.

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• ANSI Reference: Submitter Name = 1000A Loop, NM103 and Billing Provider Name = 2010AA Loop, NM103

Office Name refers to an individual: When Office Name Refers to an Individual is checked, all claims created for this office reference will be set to Bill as Individual. See Bill as Individual for more information.

Phone: The phone number does pull into eClaims.

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• ANSI Reference: Submitter Name = 1000A Loop, PER04

Default Facility: The Default Facility can be set per Office reference if the office always wants a facility to appear on claims. The Default Facility will be overridden by any Facility or Lab associated to a charge in the Charge window.

Default Template: This sets the eClaim template to be used by default per office reference. Selecting the default template in the office reference will override the setting in Preferences > Forms. However, the default template set in the insurance reference, under the Claims tab will override the office reference setting.

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• If more than one office reference is used, and each office submits on a different template, it is recommended to set the correct eClaims template per office in the office reference and to leave the default template in the insurance reference set to "None". This will ensure that eClaims will automatically be created on the correct template at the time of claim creation.

Federal Tax ID: If there is no tax ID indicated in the provider’s user reference, the office Federal Tax ID will populate the claim. See Tax ID on Claims in the User Reference for more information.

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• ANSI Reference: Billing Provider Name = 2010AA Loop, REF02

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. The group NPI entered in the office reference can be overridden by the Group NPI in the Users reference. The group NPI prints in box 33a on paper claims. If Bill as Individual is checked in the Insurance reference, no group information is submitted on claims. See Bill as individual for more information.

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• ANSI Reference: Billing Provider Name = 2010AA Loop, NM109

Type of Bill: Type of Bill populates on Institutional electronic claims only. It is also known as a Facility Type Code.

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• ANSI Reference: Claim Information = 2300 Loop, CLM05

Group Taxonomy Code: The Group Taxonomy code is the specialty code for 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

Office Reference - Mailing Address Tab

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Office Address: The Street Address, Suite, City, State, and Zip Code will go onto claims. These items will populate eClaims as well, but the location of this information on the claim is dependent on whether “Use Physical Location” is checked in the Physical Location tab of the office reference.

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• ANSI Reference: (If Physical Location is not checked) Billing Provider Name = 2010AA Loop, N301 (Address), N302 (Suite), N401 (City), N402 (State), and N403 (Zip Code)

• ANSI Reference: (If Physical Location is checked) Pay-to Provider Name = 2010AB Loop, N301 (Address), N302 (Suite), N401 (City), N402 (State), and N403 (Zip Code)

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Office Reference - Physical Location Tab

Office Address: The Street Address, Suite, City, State, and Zip Code will go onto claims, only if “Use Physical Location” is checked in the Physical Location Tab.

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• ANSI Reference: (Only if Physical Location is checked) Billing Provider Name = 2010AA Loop, N301 (Address), N302 (Suite), N401 (City), N402 (State), and N403 (Zip Code)

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Facility Reference

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A Facility must be associated to a charge or set as a Default Facility in the Office reference in order to appear on claims.

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Facility Name: The facility's name is printed in box 32 for paper claims. The Facility Name does appear on electronic claims when a facility is associated to the charge, or when there is a default facility set in the office reference.

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• ANSI Reference: Service Facility Location = 2310C Loop, NM1*77, NM103

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Facility Address Information: The facility’s address information pulls into Box 32 of CMS-1500 (HCFA) claims. The address information also pulls to electronic claims when a facility is associated to the charges, or when there is a default facility set in the office reference.

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• ANSI Reference: Service Facility Location Name = 2310C Loop, N301 (Address), N302 (Suite), N401 (City), N402 (State), N403 (Zip Code)

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Facility Tax ID: The Facility Tax ID will print on paper claims in box 32b if using the Only Legacy or NPI and Legacy forms. The Tax ID is no longer sent on electronic claims as of ANSI 5010.Image Removed

Secondary Facility ID: The Secondary Facility ID is only used for one payer, MC036 for electronic claims. The ID will pull onto paper claims in box 32b if no Facility Tax ID is present and if the office is using the NPI and Legacy or Only Legacy forms.

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• ANSI Reference: Service Facility Location Name = 2310C Loop, REF*LU, REF02

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National Provider ID (NPI): The Facility NPI should be entered if the facility is being submitted on claims. The NPI will pull into box 32a for paper claims. Facility NPI numbers are typically group, or Type-2 (organizational), NPIs

• ANSI Reference: Service Facility Location = 2310C Loop, NM109

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Laboratory Reference

Labs need to be submitted on claims when the office performs laboratory services such as blood work.

Laboratory Name: The Laboratory name will print on paper claims in box 32 if the Laboratory is associated to the charge and the Type of Service is set to Diagnostic Lab (Pathology)(5) in the charge window. The Type of Service does not matter for electronic claims, but there cannot be both a Lab and a Facility tied to the charge. If there is both a Lab and a Facility selected in a charge, the Lab information will override the Facility information.

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• ANSI Reference: Service Facility Location = 2310C Loop, NM1*77, NM103

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Laboratory Address: The Laboratory address will print on paper claims in box 32 if the Laboratory is associated to the charge and the Type of Service is set to Diagnostic Lab (Pathology)(5) in the charge window. The Type of Service does not matter for electronic claims, but there cannot be both a Lab and a Facility tied to the charge. If there is both a Lab and a Facility selected in a charge, the Lab information will override the Facility information.

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• ANSI Reference: Service Facility Location Name = 2310C Loop, N301 (Address), N302 (Suite), N401 (City), N402 (State), N403 (Zip Code)

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Lab ID #: The Laboratory ID number is typically the Lab's Tax ID number. This will print in box 32b if using the Only Legacy or NPI and Legacy forms. This is not used for electronic claims.

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Secondary Lab ID #: This number is used when a secondary lab identifier is needed. This will print in box 32b if using the Only Legacy or NPI and Legacy forms and no Lab ID # is filled out. Not used for electronic claims.

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National Provider ID: The Laboratory NPI should be entered if the Lab is being submitted on claims. The NPI will pull into box 32a for paper claims. Laboratory NPI numbers are typically group, or Type-2 (organizational), NPIs.

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• ANSI Reference: Service Facility Location = 2310C Loop, NM109

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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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ANSI Reference: Service Line = 2400 Loop, REF*F4, REF02

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Referrers Reference

Previously titled, "Referrals", this reference is used to store records of providers who refer patients to the office.

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Referrer Reference - Referrer Info Tab

In order for referral information to show on a claim, the Referral must be tied to the charge and Use on Claim must be checked in the Referral reference.

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Is Person: Is Person should be checked if the referring entity is a person. Any other referral, such as a referring hospital or clinic, should not have Is Person checked and should only include the referral name in the Last Name field.

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• ANSI Reference: Referring Provider Name = 2310A Loop, NM102

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Taxonomy Code: The Referral Taxonomy Code is the specialty of the referring provider. Taxonomy codes are not printed on paper claims or eClaims as of ANSI 5010.Image Removed

Referrers Reference - Provider IDs Tab

National Provider ID (NPI): The Referral NPI number should be entered in this field. Referral NPI numbers are typically individual, or Type-1, NPIs. In cases where the Referral is a non-person entity, the Referral NPI would then typically be a group NPI. The NPI number will print in box 17b of a paper claim.

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• ANSI Reference: Referring Provider Name = 2310A Loop, NM109

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All other fields will pull onto claims based on what the Plan Type is set to in the Insurance reference. For paper claims they will only print in box 17a if using the NPI and Legacy or Only Legacy forms. The provider can control which box the number is pulled from by changing the Legacy Referral ID Number override in the Insurance reference. The Qualifier Code can also be overridden as needed by changing the Legacy Referral Qualifier Code. These are set to Automatic by default and should only be changed if the provider is getting denials for their paper claims. The Qualifier Code overrides to not affect electronic claims. The numbers in these fields are not sent if the clearinghouse is sending NPI only.

For electronic claims, the only field to pull is State License. This will only pull for workers compensation payers when the rendering provider's office is in the state of Texas.

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• ANSI Reference: Referring Provider Name = 2310A Loop, REF*0B, REF02

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