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: National Plan Identifier/Pay-To Plan secondary Identification (Not Implemented. Leave blank)

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

Eligibility ID Qualifier: This will identify the type of Receiver ID used for checking insurance eligibility for patients. Only a small list of payers require this information. If not required by the payer, leave blank. See step 13 for a list of payers requiring this information and adding the required numbers. For payers requiring a Legacy ID , use the drop down option and select ‘Prior Identifier Number - Q4’ For payers requiring a Tax ID , select ‘Federal Taxpayer Identification Number-TJ’. There are several other options in the drop down but they’re currently not used. If the tax ID option is selected, the Receiver ID field is automatically populated from the Group/Billing tax ID setup in Manage Groups. Add Eligibility ID in each provider's billing information (See Step 6)

Group Provider (Legacy)-  This is for information purposes only, any Legacy Fee Schedules previously assigned to this Payer from earlier versions of SOAPware.

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

Fee Schedule- Use the Drop Down option to select a Fee Schedule from the list in Fee Schedule Maintenance, or leave blank and charges will be the amount specified in 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 clearinghouse to drop to paper and forward to the Payer, see next step for setup

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. (TriZetto will provide a list of your Payer IDs)

Note: All payers that will be sent electronically to TriZetto and then dropped to paper claim by TriZetto, 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.

EIN: Payer EIN

Claim Office #: Payer Claim Office Number

NAIC Code: Payer National Association of Insurance Commissioners Code

Note: Most Payers will not require this info, and if it's added into the claim when not required, the claim will deny.

The information in Provider Setup section is required when filing claims, to identify the Rendering Provider of Service, The Pay To/Billing Provider and other identifiers as required by each payer.

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.

Note: If group information is edited for select payers, the check mark must remain in the check box before changes will be included on claims.

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. If not required, leave blank.

11. Electronic Claims-Additional IDs: Add additional ID numbers, if required for selected payer. Most payers will not require this information, and if it's added to this setup when not required, the claim will reject.

12. Pay-To Address: If Pay-To address is different than Billing Provider street address, enter that information here. If group does not have a P.O. or lock box, leave blank.

13. Eligibility Request Info: Some payers require a provider/group Tax ID or a Legacy ID be included when checking patient eligibility. If required by payer, you will get a message alerting you when checking eligibility. Enter those IDs in the Receiver ID field. The ID qualifier must also be completed if adding a Receiver ID. (See Eligibility ID Qualifier section in step 2.) If a payer does not require one, this section should be left blank. Below is a list of some payers that do require a Legacy ID or a Tax ID:

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. Select to check eligibility using the Group/Billing NPI or the Individual/Rendering provider ID, depending on how the provider is enrolled with the payer to check eligibility.

15. Provider Information Paper Claims Only: If this payer 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)

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

17. 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.