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Insurance Codes – General tab

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Path: Administration > Financial > Insurance Codes > General tab

Use this tab to enter general settings for insurance codes, such as type, state, and mode, based on which financial calculations are performed. Here, you can set split billing rules and select the appropriate billing form for the payer. Using this tab, you define General Ledger accounts for revenue, discount, and accounts receivable balances from an external accounting system. You also can enable printing address exception rules for claims, orders, and reports at the insurance code level.

Type

Select the insurance type from the dropdown list:

  • C – Commercial
  • K – Medicaid
  • M – Medicare
  • S – Self-Pay (patient share required on Patient Entry)
  • U – Uncollectible (indigent patients)

Mode

Select the appropriate billing mode from the dropdown list:

  • R: Regular (fee-for-service) – To bill for visits entered through Scheduling, TimeLog, or Contract Invoices.
  • B: Benefit (per-diem) – To bill for levels of care indicated for a patient in Patient > General > Admissions & Status.
  • H: Hybrid – To bill for a combination of per-diem and fee-for-service.
  • P: Episodic (EPS and PPS) – To bill according to the PPS and EPS rules as calculated from OASIS or entered:
  • For PPS, billing is based on the HIPPS and HHRG codes indicated in Patient > General > Admissions & Status > PPS Information.
  • For EPS, billing is based on the HHRG code indicated in Patient > General > Admissions & Status > EPS Information.

State

  • Select the state to which you submit the Medicaid claims.

Ins Co

  • Select the insurance company for this insurance code.

Cycle

  • Select the appropriate billing cycle code for this insurance code.

Legal Entity

  • Select the legal entity to which the given insurance code belongs.

Insurance Type Code

  • Select the type of insurance policy for the given insurance type.

Claim Filing Indicator Code

  • Select the claim filing indicator code for the patient’s primary payer for Medicare CSP claims.

HPCANYS Code

  • Select the category code defined by HPCANYS for this insurance code. Information entered in this field is exported only for HPCANYS (New York Hospice).

Financial Class Code

  • Select the appropriate financial class code option for this insurance code.

Form

  • Select the billing form for this pay source.
    Note: Discontinued forms are marked with the word 'discontinued' in red.

Max Lines

  • Enter the maximum line count for the claim for this pay source.

Payer Name

  • Enter the first and last names of the payer.

Provider No

  • Enter the provider number or select the ellipsis and select the provider number from the list.

Secondary No./Locator Code

  • Enter the secondary number or the locator code from the bill.

Cost Report Medicare CCN

  • The Medicare Cost report filters data based on the Medicare provider (CCN) number and CBSA code combination the patients fall within. Enter the Medicare provider (CCN) number for the payer/branch combination for the Medicare Cost report. This field is required for the cost record to be produced for this insurance code.
  • If this field is blank, a warning message appears during the report generation in Reports > Financial. See the Medicare Cost Report in Help for more information on this report.

Provider Taxonomy Code

  • Select the appropriate provider taxonomy code.

Authorized Signature

  • Enter the authorized signature for the specified form.

Totals Rev Code

  • Enter the revenue code for this pay source to appear on the grand total lines on claims.

Supplies Rev Code

  • Enter the supplies revenue code for this pay source to appear on the grand total lines on claims.

Category of Service

  • Enter the category of service for New York Form A.

Supplies Rev Code Description

  • Enter the description of the supplies revenue code.

Track Appointments with This Payer in Telephony

  • Select this checkbox to set up the appropriate insurance code for sending appointments to the Telephony vendor. When searching for new scheduled appointments to be sent to the vendor, the system checks whether the payer specified in the appointment is set up for Telephony. Appointments with payers that are not set up for Telephony are ignored. If the payer is not specified, the system checks the patient’s primary payer for Telephony setup.
  • You may also set up payers for Telephony on the insurance company level.
  • For more information on Telephony setup, refer to the Telephony Setup Guide.

Split at Recertification

Select this checkbox to split the bill when a recertification occurs in the middle of a cycle.

  • The Per Diem pay sources use the specified Hospice Recert schedule if this is the benefit insurance, and the Per Diem tab is available for setting up the Hospice Recert periods.
  • The sources that are free from service pay use the certification periods for physician orders. You can set this up in the Business Units/Settings window in the Administration component.

Do not Split Monthly Claims

  • Select this checkbox if you do not want to split monthly claims for this payer.

Allow Patient/Insurance Plan Negotiated Rates

  • Select this checkbox to allow the patient or insurance plan negotiated rates for this payer.

Eligible for Immediate Claim Cycles

  • Select this checkbox if the insurance code is eligible for an immediate claim cycle.

Default Insurance ID with SSN

  • Select to prefill the Insurance ID field in Patient > General > Payers > Pay Source with the patient’s Social Security Number (SSN). Otherwise, the insurance ID must be entered manually.
  • This option is available only for the Medicare insurance codes.

Allow Visit Negotiation

  • Select this checkbox to allow the bill rates negotiation for the selected payer.

Allow Split Billing

  • Select this checkbox to enable split billing rules for this payer in Patient > General > Split Billing Rules.

Post to Line Items

  • This option is available for payers with the R - Regular (Fee-for-Service) billing mode.
  • Select this checkbox to enable the payer to post payments and adjustments to individual claim detail lines. Select Rules to define the rules for posting the line items.

Allow Professional Services

  • This option is available for payers with the R - Regular (Fee-for-Service) billing mode and the Form Type field has a value of "CMS-1500 (02/12)". 
  • Select this option when it may be necessary for the agency to change the place of service value for the location of the service rendered than what is defined in the billing rate associated with the service. 

Medicare Advantage

  • Select this checkbox if the payer defined is identified as a Medicare Advantage payer.

Medicaid Managed Care

  • Select this checkbox if the payer defined is identified as a Medicaid Managed Care or MCO payer.

Generate New Orders and SOC Date

  • Select this checkbox to allow new orders and SOC date generating for the insurance codes.

Order Interval Type

Select the type of the order interval you want to use.

  • If all orders are generated using one order interval for all patients, you do not have to define the order interval for each insurance code. You only need to define specific order intervals for payers that require a specific order interval. If the last period repeats, you must not enter more than three certification periods. The order interval should be a single value for fee-for-service and PPS types of insurance. When no order interval is defined for an insurance code, Homecare uses the order interval specified in Administration > Configuration > Business Units > Settings.
  • The Order Interval Type field initially defaults using implied rules: 1-4=months, 5-13=weeks, else days. You can change this field as appropriate.

Order Interval

  • Enter how often physician orders are to be renewed. You can enter the values from 1 to 99. For example, enter 1 for one month or 12 for 12 weeks.

Hold Orders due to Physician Not PECOS Enrolled

  • If 'Hold Order due to Physician Not PECOS Enrolled' is selected in Administration > Financial > Insurance Code > General and the Administration > Financial > Insurance Code > General > Provider Taxonomy Code = 251E00000X:
    • The physician enrollment status for MD#1 is checked against the start date of the order. If Resource > General > PECOS Enrollment > HHA = No, the Order Status of 'P' is changed to 'H', and the order cannot be approved.
    • Once the enrollment status changes to either 'Yes' or 'Pending' or the checkbox is cleared, the order status reverts to 'P' status.
    • If this checkbox is cleared after the order has been generated with an 'H' status, the order needs to be regenerated to change the status from 'H' to 'P.'
  • The following edit is effective based on the HOSPICE_PECOS_EFFECTIVE_DATE set in the SYS_SETTINGS table.
    • If 'Hold Order due to Physician Not PECOS Enrolled' is selected in Administration > Financial > Insurance Code > General and the Administration > Financial > Insurance Code > General > Provider Taxonomy Code = 251G00000X:
      • The physician enrollment status for MD#1 is checked against the start date of the order. If Resource > General > PECOS Enrollment > HOS = 'No', the Order status of 'P' is changed to 'H', and the order cannot be approved.
      • Once the 'HOS' enrollment status changes to either 'Yes' or 'Pending' or the checkbox is cleared, if the Patient Classes type is not 'Y', the order status reverts to the 'P' status.
      • If this checkbox is unchecked after orders have been generated with an 'H' status, the orders need to be regenerated to change the status from 'H' to 'P'.

Therapy Visit Warning and Highlighting

  • Select this checkbox to set up selected insurance codes for the therapy services calculations. Only services paid by this insurance as a primary payer are included in the therapy services calculation and highlighting. This checkbox is active only when at least one of the settings on the Business Unit level (therapy visit warning or highlighting) is turned on (see Setting Scheduling for Business Unit). By default, this checkbox is selected for all Medicare PPS insurance.

General Ledger Accounts

In this section you can assign General Ledger accounts of the Revenue, Accounts Receivable, Allowance (Discount), Cash, and Expense groups to the insurance code. The external accounting systems use General Ledger accounts to record appropriate account balances for the pay source.

  • The values from the dropdown lists are pulled from the General Ledger Accounts window in Administration > Financial. For more information, see General Ledger Accounts.
  • For the Revenue, Accounts Receivable, and Allowance (Discount) groups, you can manually select values from the dropdown list or enter the necessary values. If you select a GL account from the dropdown menu and modify the description of that account in Administration > Financial > General Ledger Accounts, the description is not automatically changed in this window. Homecare requires these GL account boxes.
  • For Cash and Expense groups, you can only select values from the dropdown list. If the description of the GL account that you selected from the dropdown list is changed in Administration > Financial > General Ledger Accounts, it is also updated in this window.
  • These two groups are enabled only if the Allow Cash and Expense Accounts Insurance Definitions checkbox is selected in Administration > Configuration > Business Units > Basic > Settings > Financial.

Print Address Exceptions

  • Select this checkbox to allow address exception printing. Select Rules to define the printing rules, which become enabled after selecting the Print Address Exceptions checkbox. Selecting Rules opens the Address Print Control Options window where print address exceptions can be set for claims, orders, and reports on the insurance code level.