Healthy U Home Health Utah

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Make separate claims (with totals) for claims.

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Suppress dots & dashes in ICD codes, dates and insured information.

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Print upper case letters only.

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Print middle initials only.

Locator

Print Variation

Box 1

Checks box 7 for Other

Box 11

Prints the Insurance ID

Box 12

Prints 'Signature on File' and date

Box 13

Prints 'Signature on File'

Box 17A

Prints the Attending Physician's UPIN

Box 19

Prints 'VOID' for voided claims

Box 23

Prints prior authorization number

Box 24

Prints net charges on the claim

Box 24K

Prints Service Provider's UPIN

Locator 27

Prints X in "Yes"

Box 29

Does not include payments from Medicare

Locator 31

Prints Authorized Signature and Date

Locator 33

Prints provider number after PIN #

Prints the agency name, address and phone number

Field

Description

Insurance Type Code

Administration>Financial>Insurance Codes and/or Insurance Company: In the Insurance Type Code field, select the appropriate code identifying the type of insurance policy within a specific insurance program.

National Provider ID/Provider Taxonomy Code

For the patient's attending/referring physician, enter the doctor's (MD#1 field in Patient>General>Admissions & Status) National Provider ID in the UPINfield in Resource>General>Roles for this doctor.

In addition, HIPAA also requires that you provide the Tax ID (or SSN) and Provider Taxonomy Code for the physician, both of which can be entered in Resource>General>Roles as well.

Pay Source, HIPAA tab

Assign Benefits (Assignment of Benefits): currently defaulted to Y for each carrier. Change to N where applicable.

Rel Infor (Release of Information): currently defaulted to Y for each carrier. Change to N where applicable.

Patient Sign (Patient Signature Code): If the Release of Information field is set to Y, then select the appropriate Patient Signature Code if different from the system set default of B (Signed authorization form for HCFA-1500, Block 12/13 on file).

Medicare Assign (Medicare Assignment Code): currently defaulted to A (Assigned). Change to other value as needed.

Provider ID

Enter your organization's Healthy U assigned provider number in the Provider ID field in Administration>Financial>Insurance Companies>Company.

Receiver ID (Payer)

Enter HT000179-002 with the hyphen in the Receiver ID (Payer) field in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter U of U HEALTH PLAN into the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter the submitter ID assigned to you by Healthy U in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.

Locator

Setup

FL 1

Select the Check box 7 for Other print variation.

FL 11

Select the Print the Insurance ID print variation.

FL 12

Select the Print 'Signature on File' and date print variation.

FL 13

Select the Print 'Signature on File' print variation.

FL 17/17a

The attending physician name prints in FL 17. The legacy number and qualifier prints in FL 17a and is set to the UPIN code by default. FL 17b is for the NPI number of the physician. The values in FL 17a and FL 17b depend on the agency's selection in Administration>Financial>Insurance Codes>NPI for Legacy ID, NPI, or both.

FL 19

Select the Prints 'VOID' for voided claims print variation.

FL 23

Select the Print prior authorization number print variation.

FL 24

Select the Print net charges on the claim print variation.

FL 27

Select the Prints 'X' in 'Yes' print variation.

FL 29

Select the Do not include payments from Medicare print variation.

FL 31

Select the Print Authorized Signature and date print variation.

FL 33

Select the Print the agency name, address and phone number print variation.

Print or type the NPI number of the billing provider in the unshaded area.

Field

Description

Insurance Type Code

Select the appropriate code identifying the type of insurance policy within a specific insurance program in the Insurance Type Code field in Administration>Financial>Insurance Codes>General and/or Administration>Financial>Insurance Companies>Company.

National Provider ID/ Provider Taxonomy Code

For the patient's attending or referring physician, enter the doctor's (the MD#1 field in Patient>General>Admissions & Status) national provider ID in the UPIN field in Resource>General>Roles.

In addition, HIPAA also requires providing the tax ID (or SSN) and provider taxonomy code for the physician that can be entered in Resource>General>Roles.

Assignment of Benefits

and

Release of Information

In Patient>General>Payers>HIPAA, the Assign Benefits (Assignment of Benefits) and Rel Infor (Release of Information) fields are currently set to Y by default for each carrier. Change to N where applicable.

Patient Sign (Patient Signature Code)

If the Rel Infor (Release of Information) field in Patient>General>Payers>HIPAA is set to Y, select the appropriate patient signature code, if different from the default code of B (Signed authorization form for CMS-1500 (08/05), Block 12/13 on file).

Medicare Assign (Medicare Assignment Code)

If needed, select the value other than the default A in the Medicare Assign field in Patient>General>Payers>Pay Source>HIPAA.

Provider ID

Enter the organization's provider number assigned by Healthy U in the Provider ID field in Administration>Financial>Insurance Companies>Company.

Receiver ID (Payer)

Enter HT000179-002 (with the hyphen) in the Receiver ID (Payer) field in Administration>Financial>Insurance Codes>EMC.

Receiver Name (Payer)

Enter U of U HEALTH PLAN in the Receiver Name (Payer) field in Administration>Financial>Insurance Codes>EMC.

Submitter ID

Enter the submitter ID assigned by Healthy U in the Submitter ID field in Administration>Financial>Insurance Codes>EMC.

Test Submission Indicator

Select the Test Submission Indicator check box in Administration>Financial>Insurance Codes>EMC to indicate if this is a test file being sent.