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.
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.
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.
If the patient relationship to subscriber is other than ‘Self’, for most payers, only the guarantor’s first, middle, and last name will pull to electronic claims, except in the cases of certain payers.
Guarantor name, address, date of birth, sex and telephone number print on paper claims. If relationship to guarantor is set to Self, box 4 on paper claims prints Same.
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
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
Release of Info: The checkbox for Release of Info only prints on paper claims.
Insurance (Guarantor Screen)
Carrier Name: See Insurance Reference.
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
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
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
Patient Tab
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")
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
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.
Insurance Tab (Patient Screen)
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.
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.
Carrier: See Insurance Reference.
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
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
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
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
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
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.
Ledger
Continue reading below for ANSI specifications regarding items in the Ledger.
Ledger - Incident
Incident Tab
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".
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
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
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
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
Claims Tab
Claims Tab - Symptom Dates Sub-tab
Payers may require certain dates under varying circumstances. If a payer requests the following then they need to be entered in this section.
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.
Onset of Current Illness date will pull to an eClaim if a date is present in the 'First Symptom Date' field, regardless of what value is selected in the 'First Symptom Date Type' pop-up menu.
The actual First Symptom (Onset of Current Illness) Date appears on eClaims when populated.
ANSI Reference: 2300 Loop, DTP*431, DTP03
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.
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.
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.
ANSI Reference: 2300 Loop, DTP*454, DTP03
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.
ANSI Reference: 2300 Loop, DTP*304, DTP03
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.
ANSI Reference: 2300 Loop, DTP*090, DTP03
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.
ANSI Reference: 2300 Loop, DTP*091, DTP03
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.
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.
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.
In order to send this information on the electronic claim, the procedure needs to have Medically Necessary checked in the Fee Schedule. Go to References, select Fee Schedules in the sidebar, then select your fee schedule and your podiatry fee. Check the Medically Necessary checkbox towards the middle of the screen.
The Date Last Seen will need to be entered in the patient's ledger. Select the patient, go to their Ledger, select the appropriate Incident and click on the Claims tab. Enter the date the patient was last seen by the primary care provider in the Last Seen field.
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.
ANSI Reference: Service Line = 2400 Loop, DTP*472 Segment
Code: 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: 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: 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
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: 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: 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: 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: 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
Rx: 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
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
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
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
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.
Referral: 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
Facility: 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
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
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
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
Emergency: 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
Taxable: 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 > 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 Reference
Insurance Reference - Company Info Tab
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.
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.
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.
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.
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.
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.
ANSI Reference: 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
ANSI Reference: Billing Provider Name = 2010AA Loop, REF*EI
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 tab of the associated insurance reference.
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.
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.
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.
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.
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.
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.
ANSI Reference: Claim Information = 2300 Loop, REF*EW
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.
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.
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.
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.
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.
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.
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.
ANSI Reference: Billing Provider Name = 2000A Loop, PRV*BI*PXC
Office Reference - Mailing Address Tab
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.
Keep in mind that, for most addresses that appear on an eClaim, a 5-digit Zip Code is acceptable. However, the full, 9-digit Zip Code is required for the billing provider when sent on an eClaim. If a 5-digit Zip Code is used for the office reference, all eClaims sent with the office as the billing provider will reject for invalid Zip Code.
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)
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.
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)
Facility Reference
A Facility must be associated to a charge or set as a Default Facility in the Office reference in order to appear on claims.
A note on service facilities for eClaims: If the location and NPI of a service facility is the same as the office information on an eClaim, there is a strong likelihood that the payer will reject the claim. There are, however, occasions in which MacPractice needs to pull information that will only pull when there is a facility associated to the charges. In order to pull the necessary information, but to avoid pulling facility information that matches office information, MacPractice will strip facility information from an eClaim if the name of the facility matches the office name exactly. All other information that is needed to pull based on a facility being present in the charges will pull as needed to the electronic claim.
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.
ANSI Reference: Service Facility Location = 2310C Loop, NM1*77, NM103
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.
ANSI Reference: Service Facility Location Name = 2310C Loop, N301 (Address), N302 (Suite), N401 (City), N402 (State), N403 (Zip Code)
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.
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.
ANSI Reference: Service Facility Location Name = 2310C Loop, REF*LU, REF02
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
Laboratory Reference
Labs need to be submitted on claims when the office performs laboratory services such as blood work.
A note on labs for eClaims: If the location and NPI of a lab is the same as the office information on an eClaim, there is a strong likelihood that the payer will reject the claim. There are, however, occasions in which MacPractice needs to pull information that will only pull when there is a lab associated to the charges. In order to pull the necessary information, but to avoid pulling lab information that matches office information, MacPractice will strip facility information from an eClaim if the name of the lab matches the office name exactly. All other information that is needed to pull based on a lab being present in the charges will pull as needed to the electronic claim.
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.
ANSI Reference: Service Facility Location = 2310C Loop, NM1*77, NM103
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.
ANSI Reference: Service Facility Location Name = 2310C Loop, N301 (Address), N302 (Suite), N401 (City), N402 (State), N403 (Zip Code)
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.
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.
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.
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.
ANSI Reference: Service Line = 2400 Loop, REF*F4, REF02
Referrers Reference
Previously titled, "Referrals", this reference is used to store records of providers who refer patients to the office.
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.
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.
ANSI Reference: Referring Provider Name = 2310A Loop, NM102
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.
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.
ANSI Reference: Referring Provider Name = 2310A Loop, NM109
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.
ANSI Reference: Referring Provider Name = 2310A Loop, REF*0B, REF02
