Add new Insurance Companies, Edit existing Insurance Companies and Associate Providers to Insurance Companies when submitting Insurance Claims.

1. Add a new Insurance Company.

2. Edit an existing Insurance Company.

3. Delete an Insurance Company.

4. Click inside the blank grid directly below column headers and begin typing to search by name, City, State, etc.

1. Click Add New Company icon to open Edit Insurance Company dialog.

2. Insurance Company Information: Add Insurance Company Name, mailing address, phone and fax (optional)

NPI: Payer NPI, if required.

Type: This will be used to determine which box to check in Block 1. on the CMS 1500 form.

Eligibility ID Qualifier: This will be used to identify the type of Receiver ID used for checking insurance eligibility for patients. Payers that require a legacy ID need to have the ‘Prior Identifier Number - Q4’ option selected in the Eligibility ID Qualifier drop down on the Insurance Company dialog. Payers that require a tax ID need to have the ‘Federal Taxpayer Identification Number  TJ’ option selected; the field can be left empty for all other payers. There are several other options in the drop down but they’re currently not used. If the tax ID option is selected then the Receiver ID field is automatically populated from the group’s tax ID info.

Group Provider (Legacy)- If the Insurance Company requires a Legacy number in addition to a NPI number, Type the Group/Pay To number here.

Fee Schedule (Legacy)- This is for information purposes only, any Legacy Fee Schedules previously assigned to this Payer.

Fee Schedule- Use the Drop Down option to select a Fee Schedule from the list in Fee Schedule Maintenance, or leave blank and it will use the Default fee schedule

3. Check the box if applicable:

Active This box will default to active. Click to remove check mark if the Company becomes inactive/no longer a valid Insurance Company.

Show Legacy ID If checked, the Legacy numbers entered in the Company information will be included on all claims.

Default Electronic Check box if claims for this insurance company will go to the payer electronically. If not checked, claims will be printed on a CMS 1500 form.

Note: If a Payer/Insurance Company normally accepts only paper claims, but claims will be sent to GatewayEDI to drop to paper and forward to the Payer, see next step for setup information.

4. Electronic Submission Info is inserted into the Electronic Insurance files to identify Payer, Clearinghouse and Type of claim. To automatically populate some of this information, it is recommended that the Claims Options  section be completed prior to setting up the Insurance companies.

Note:  All fields are required when submitting electronic claims. Payer ID and Receiver ID.will be provided by your Clearinghouse.

Payer Qualifier-Identifies type of Payer ID. (For most Payers, this will be ZZ-Mutually Defined)

Payer ID-Identifies the Payer of claims submitted for this Insurance Company. (GatewayEDI will provide a list of your Payer IDs)

Note: All payers that will be sent electronically to GatewayEDI and then dropped to paper claim by Gateway, will be Payer ID 00010

Clearinghouse Name-Identifies the Clearinghouse  (Info entered in Claims Options )

Clearinghouse ID-Identifies the Clearinghouse.  (Info entered in Claims Options)

Type - Identifies the Type of Claim

Receiver Qualifier-Identies the Receiver ID.  (Info entered in Claims Options)

Receiver ID-Identifies the Receiver of the Electronic file submitted.  (Info entered in Claims Options)

5. Enter additional ID numbers if necessary for the claim processor to identify the entity. Leave blank unless the payer requests this information.

EIN: Payer EIN

Claim Office #: Payer Claim Office Number

NAIC Code: Payer National Association of Insurance Commissioners Code

The information in Provider Setup section is required when filing claims, and is used to file to identify the Rendering Provider of Service, The Pay To Group/Provider and other identifiers.

6. Click the New Provider Mapping button (Green +) to add Providers of Service to this Insurance Company.

7.  Click to highlight a Provider and Click the Add button to open the Edit Billing Information dialog.

Edit Billing Information dialog is used to identify Billing/Pay To information (top portion) and Rendering Provider of service (bottom portion). This information will be included on all claims submitted to this Insurance Company.  

8. Insurance Payment To: This section is populated with data used when setting up Manage Groups. Verify that this is the correct Pay To information. To edit information or add additional IDs required for this payer, click to place a check mark in the Override Group Values box.

9. Tax ID: If the Pay To provider is an individual and payments are reported to his Social Security number, Click SSN and type social security (Block 25)

10. Legacy ID for paper claims: When filing paper claims, if payer requires a Billing legacy number in addition to the Billing NPI, select legacy qualifier from the drop down list and enter the legacy ID.

11. Electronic Claims-Additional IDs: Add additional ID numbers, if required for selected payer. Submitter ID is required. Other IDs should be left blank unless the payer requests them.

12. Pay-To Address: If Pay-To address is different than Billing Provider street address, enter that information here.

13. Eligibility Request Info: Some payers require a Tax ID or a legacy ID to be sent with an eligibility request. If a payer does not require one, this section can be left blank. Below is a list of some that do require this information:

Payers requiring Legacy ID                        

• BCBS of Arkansas
• BCBS Michigan
• California Medicaid
• Maine Medicaid
• Mercy Health Plan of Arizona
• Ohio Medicaid
• University Family Care of Maricopa
• Wisconsin Medicaid Well Woman Program

Payers requiring Tax ID

• AFTRA
• American Postal Workers Union
• American Republic Insurance
• Amerigroup, Carefirst BCBS
• Cariten Healthcare
• Cariten Senior Healthcare
• Fallon Health Plan
• Keystone Mercy Health
• Kaiser Foundation Health Plan of Northwest
• Lovelace Health Plan
• Mayo Management Services
• Mega Life
• Midwest National Life
• Physicians Mutual Insurance
• Preferred Health Systems
• Significa Benefit Services
• Texas CHIP
• Trustmark Insurance
• Writers Guild

14. Provider Information: This section is populated with data used when setting up Provider Manager . If this insurance requires a Rendering Provider Legacy number in addition to the NPI, use the drop down arrow to select an identifier for the ID and then type the ID into the field. (Block 24j)

15. Electronic: Enter any additional IDs to be included on electronic claims, if required by this payer for Rendering Provider.

16. Click Save.

Tools -> Insurance Companies

1. Click on the Insurance Company to be deleted.  

2. Click on the Remove Company Icon (Red X). You will be prompted to verify that you want to remove the selected insurance company.

3.  You will be prompted to verify that you want to remove the selected insurance company. Yes to delete, No to cancel

Note: Users must have security privileges to delete an Insurance company. Insurance demographics will have to be updated for any patients that  have the deleted insurance company in their information.