Insurance

To Update/Maintain Insurance Information:

EVV Aggregator: check this box if MCG+ is the Aggregator (i.e. submits the claim data) for your State (e.g. FL, GA, KY, NE), otherwise leave unchecked. Only enabled if EVV Required option is selected.

Insurance Type: payers are grouped by type if they use the same Revenue/HCPCS/Modifiers on claim output. Select from the drop-down (Insurance Types are created in File > File Maintenance > Category). For example, if the insurance uses the same codes revenue & HCPCS as Medicare, select the Medicare Rev Type here. When assigning revenue/HCPCS/modifiers to charge codes, they are added based on Insurance Type.

Financial Class: (Insurance Class) groups payers for purposes of running the billing process, claim generation and reports. (Classes are created in File > File Maintenance > Category, Insurance Class Type).

Bill Type: Select the claim format to be used for claim generation. This setting can be bypassed at the claim level if 'Any Form Type' is checked. The payer designates which form type they accept.

Provider #: Enter the provider number assigned to your agency by the insurance company. Optional.

Payer/Submitter #: Enter the 5-digit electronic claim payer ID assigned to the insurance based on the Clearinghouse or claim receiver designation.

GL A/R Account #: Enter the Accounts Receivable account number for your agency's General Ledger. Obtain this number from your Accounting department.

GL Revenue Account #:  Enter the Revenue account number for your agency's General Ledger. Obtain this number from your Accounting department.

GL Discount Account #: Enter the Allowance account number for your agency's General Ledger. Obtain this number from your Accounting department.

PPS Billing: check this box if the payer reimburses based on Medicare PDGM billing rules.

Bill Method: For Medicare Home Health and Medicare Advantage payers who reimburse the same as Medicare, set to 'Medicare.' For Medicare Hospice and payers who reimburse the same as Medicare, set to 'Hospice.' For NY Medicaid EPS, set to 'NY Caid.' Otherwise set to 'Normal.'

Payor Type: Determines the value for element SBR09 Claim Filing indicator in electronic claim files. (i.e. MA for Medicare, MC for Medicaid and Title Programs, CI for Private Insurance and Unknown (Commercial), VA for Other Gov't,  BL for Blue Cross.. Also used to determine if insurance is Medicare to allow for Real-Time Eligibility functions.

EVV Required: check this box if using Netsmart Electronic Visit Verification functionality for this payer. Only enabled if EVV is configured for the agency.

Timely Filing: enter the number of days the insurance allows for claim submission. The Charge Detail List can show the timely filing indicator on the report.

EVV ID: setup for this item will be completed during EVV implementation. This information comes from the Clinical Insurane Library and is a combination of the Payer and Plan ID, seperated by a colon (ex: CRM2:732F5858-5C2B-4220-07E6-4D1825297702). Obtain these values from MCG+. Only enabled if EVV is configured for the agency.

Billing Unit Overrides: overrides the Itemizations chosen in the billing Option Sets so multiple payers can share one Option Set even if their unit requirements are different. Modalities 1-40 are available for unit overrides.

N/A This is the default option and means no payer override has been selected. The system will use Units set at the Option Set level instead.

Units: Units on the claim is equal to visit quantity (e.g., 1 visit = 1 unit, regardless of visit time)

Hours: Units on the claim is based on actual visit time (e.g. 1 minute visit = 1/60 = .02 units)

*1/2 Hrs: Revenue and units will be based on visit time (rounded to 30 minutes) and uses the Insurance Rate (if present) or Charge Code Rate (see Colorado Medicaid FAQ).

1/4 Hrs: Units on the cliam will be based on visit time rounded to the 15 minute increment.

1/2 Units: Units on the claim will be based on visit quantity multiplied by 2 (e.g. 1 visit = 2 units)

1/4 Units: Units on the claim will be based on visit quantity multiplied by 4 (e.g. 1 visit = 4 units)

1/x Units Units on the claim will be based on visit quantity multiplied by x (value of x can be entered in electronic Option Set locator 2390.22 or will default to 8 (e.g. 1 visit = 8 units)

Charge Gross: Units on the claim will show visit quantity multipled by charge code gross amount (File > File Maintenance > Charge Codes, Bill Rate tab).

*1/4 Hrs: Units on the claim will show visit time rounded to the 15 minute increment. Revenue will be based on visit time and will use the Insurance Rate if present or Charge Code rate. (see Indiana Medicaid FAQ).

*Hrs Rounded: Units will be based on visit time. Revenue will be based on visit time and use the Insurance rate if present or Charge Code rate. Note, time less than the first 30 minutes is still rounded to 1 unit but after that partial units of service 29 minutes or less round to the next lowest unit and 30 minutes or more rounds up to the next highest unit. If electronic claim Option Set locator 2390.12 is set to Revenue Code/Date Consolidation, time for the day will be totaled and then units calculated (see Indiana Medicaid FAQ or Colorado Medicaid FAQ).

*Hrs Round Up: Units will be based on visit time. Time is calculated up to the next hour (see Colorado Medicaid FAQ).

*OH Medicaid: Used for Ohio Medicaid billing (see OH Medicaid FAQ).

*FL PPEC: Used for FL Medicaid PPEC Nursing and CMS Therapy billing (see FL Medicaid and CMS Therpay Billing FAQ).

Ins-Rate tab

To Add an Insurance Rate:

Press Add to add a new row.

Charge-Description/Charge-Code: Select a charge description or code from the drop-down.

Start-Date: Enter the effective date for the rate amount.

End-Date: Enter the ending date for the rate amount or leave blank if unknown..

Type: Select 'F' if entering a flat dollar rate amount or 'P' if billing a percentage of the agency's Usual & Customary rate for the charge code.

Rate: Enter the dollar or percentage amount for this charge (based on Type selected).

Allow: If checked, when the billing audit is generated, any amount not covered by the payer will be written off to an Allowance account. If unchecked, the system will send the non covered dollars to the next active payer for the patient instead. If no additional payers are found, the non covered amount will be written of to an Allowance account.

EVV: check this box for each visit that needs to be tracked by Electronic Visit Verification for this payer. Only displayed if EVV Required is checked on the Insurance tab.

HCPC: view only field that displays the insurance HCPCS and modifiers for each service code. To change a HCPCS, go to File > File Maintenance > Charge Code.

Clone button: This routine copies the active insurance rates from the user specified insurance to the currently selected one. All rates active on the Start Date specified will be copied from the specified insurance to the current record. Any rates already present and active will be end dated one day prior to the selected date. Select a insurance and press Clone to begin the process or Abort to cancel. After rates have been cloned, they can be edited or adjusted as needed. Note: the EVV setting will not be copied over during the clone process due the fact that insurance may have the same billing rates but do not necessarily share EVV requirements.

Contact Tab

Go to the Clinical Insurance library to add or change the business phone if needed. A fax number, email address and contact name can be added in the Billing Module if desired.Optional.

Notes tab

Enter any notes associated with the payer. Optional.

Click Print to preview or print a complete Insurance List.

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