| Prompt | Response | Req | Len |
|---|---|---|---|
| Insurance Carrier Code | Type the code you want or click the magnifying glass to search the table. This code cannot begin with a zero. |  |
5 |
| Insurance Carrier Name | Type the insurance carrier name. | |
60 |
| Address Line One | Type the address for the insurance carrier. | 40 | |
| Address Line Two | Type any additional address information. | 40 | |
| Zip | Type the five digit zip code or the zip-plus-four. If you type the zip-plus-four CGM webPRACTICE will automatically insert the dash before the last four numbers. | 10 | |
| City | Type the city for the insurance carrier. | 25 | |
| State Code | The state automatically populates based on the Zip Code entered, or you can type a valid state code or select one from the list. A Validate Address button is provided to the right of the State Code field. | |
2 |
| Country Code | Type a valid country code or select one from the list. | 2 | |
| Subdivision | Type the country subdivision code, or select one from the list, when the country in the address is outside the United States, its territories, or Canada and has country subdivision codes. | 3 | |
| Payer Tax ID # | Type the Tax ID number for this carrier, if applicable. | 20 | |
| Contact Individual | Type the name of the contact person for this insurance carrier. | 30 | |
| Telephone Number | Type the phone number for this insurance carrier. | 20 | |
| Fax | Type the fax number for this insurance carrier. | 15 | |
| E-mail Address | Type the e-mail address of the contact person for this insurance carrier. | 49 | |
| Website | Type the website of the carrier. | 51 | |
| Insurance Form | Select the applicable insurance form type from the list. | |
2 |
| Default PCP Dr for Ref Dr | If you want the Primary Care Doctor on the patient's account to default into the Ref Dr field in Procedure Entry instead of the Referral Source code, select this check box. | 1 | |
| Electronic Form Number | Select the applicable electronic form number from the list for this carrier. If current claims exist - change to this field is not allowed. | |
2 |
| UB Payer | If this insurance carrier requires facility charges to be filed on a UB form, select this check box. | 1 | |
| Default Insurance Type | For Medicare and Medicaid policies only. Select the Insurance Type you want to default into the Insurance Type field on the patient's insurance policy information screen for this carrier. | 2 | |
| Force UB Claim to Paper | If this insurance carrier's UB claims are to be forced to paper, select this check box. | 1 | |
| Claim Filing Indicator | Select the type of claim for this carrier. This code allows you to select a more specific type of claim indicator for 5010 claims. This value is sent in Loop 2000B and Loop 2320 SBR09 segment or Box 1 on the CMS form. If this field is not populated, the 'Insurance Form' selected for this carrier is used to determine the type of claim. One example why this field is necessary would be for Medicare Advantage/Commercial Medicare plans. If you have the Insurance Form set to Medicare (C), then 'MB' would be sent in the SBR09 segment or if the Insurance Form is set to Commercial (F), then 'CI' would be sent. Either of these values would cause the claim to reject if you do not also have '16-HMO Medicare Risk' selected for the Claim Filing Indicator. |
2 | |
| E-Secondary | If secondary claims can be filed electronically for this insurance carrier, select this check box. If you select this option, all secondary claims will automatically be included in the electronic claims file and will not print on paper claim forms. The prerequisites for this are that the secondary insurance policy on the patient's insurance information screen must be marked as Secondary and 'Y' must be selected in the Bill this Carrier field. | 1 | |
| Equivalent Ins. Code | Type the code you want or select from the list. This list contains insurance names as stored in the Equivalent Insurance Name fields in CGM webPRACTICE Integration Options (System, Database Maintenance Menu). For additional information see the Equivalent Code help section under Introduction, System Processes. | |
1 |
| EPSDT Carrier | If this carrier is an EPSDT carrier, select this check box. | 1 | |
| Insurance Class Code | Type the code you want or select from the Insurance Class list. The fee schedule in the Fee Schedule field must match the Fee Schedule stored with the selected Insurance Class code in the Insurance Class Table. | 5 | |
| Do not Bill to Insurance | If this carrier's claims are not to be billed to them, select this check box. If Do not Bill to Insurance is selected, that selection overrides any other selections for this carrier (for example, Force UB Claim to Paper), which means that no claims will be sent for this carrier. | 1 | |
| Fee Schedule (Allowable) | Type the code you want or select from the Fee Schedule list. If you want to automatically calculate write-off adjustments for this carrier during payment entry, you must select a fee schedule. If you select an Insurance Class code, this fee schedule must match the fee schedule stored with the selected Insurance Class in the Insurance Class Table. | 5 | |
| Auto Post Sec Adj | If you want secondary adjustments from the Electronic Remit to post automatically, select this check box. | 1 | |
| Plan Code | Type the code you want or select from the Plan Code list. | 3 | |
| Default Payment Code | Type the code you want to default for this insurance carrier during payment entry or click the magnifying glass to search the table. | 5 | |
| Policy # Format | Enter the correct number format that staff members should use when completing the Policy Number field in the patient's Insurance Policy Information screen. Multiple policy number formats can be entered as long as they are separated by a comma (for example, NNAAEEPA,NNEE,AAPNE). You need to use the following characters to indicate the correct format: A = Alphabetical N = Numeric E = Any type of character P = Punctuation Whenever a number is typed in the Policy Number field, it is compared to this format to make sure it is correct. For example, if the policy number should be in the format of NNAAEEPA, then a policy number of 12AB3D-A would be accepted. |
250 | |
| Auth Required | If this insurance carrier requires an authorization, select this check box. | 1 | |
| Expected Pmt Days | If your practice uses the Insurance Collection module, type the number of days you must typically wait until you can expect to receive a payment from this insurance carrier. | 3 | |
| Anesthesia Minutes per Unit | This field will default to the value stored in the Anesthesia Minutes per Unit field in the Insurance Billing section of the CGM webPRACTICE Default Values function; otherwise the field will be left blank. You can change the value as needed for individual insurance carriers. The hierarchy for determining the Anesthesia Minutes per Unit value when a claim is created: 1. If a value has been stored in the Anesthesia Minutes per Unit field for the Insurance Carrier Code, it will be used. 2. If a value has been stored in the Anesthesia Minutes per Unit field in the CGM webPRACTICE Default Values function, it will be used. 3. The system standard of 15 minutes will be used. |
3 | |
| Medigap Provider # | Type the Medigap Provider number for this carrier, if applicable. | 15 | |
| Timely Filing Limit | If your practice uses the Insurance Collections module, type the number of days from the date of service that this insurance requires you to file a claim. | 3 | |
| Add Physical Status Base Units | If you want the Anesthesia Physical Status Base units automatically added for this carrier, select this check box. | 1 | |
| Electronic ID# | Type the electronic identification number for this carrier, if applicable. The Electronic ID # is also commonly known as the 'Payer ID.' | 80 | |
| Follow Up Letter | If your practice uses the Insurance Collections module, type the number of days since the insurance claim was filed for a follow up letter to be sent to the insurance carrier. | 3 | |
| Liability/Default Pmt % | Type the default insurance liability percentage followed by a forward slash '/' and then the default payment percentage for this carrier. This field is used for the default value for the Ins Liability/Default Pmt % field when entering a patient's insurance information. This is actually a two-part question. The first part - Liability determines what portion of a procedure should go in the insurance balance. If the entire balance is to remain in the insurance balance until the insurance pays, then the response should be 100. If you are collecting a portion at the time of service, the entry should be the portion that will remain in insurance balance. For example: if you are collecting 20% up front, the liability should be 80. The second portion - Default Pmt % is what percentage the carrier actually pays. These two responses should be separated by a forward slash '/'. For example, if this carrier was Medicare, and you do not collect any money at the time of visit, your entry should be '100/80'. If you leave this field blank, the system treats it as if '100' was entered, which means the entire balance would remain in the insurance balance until the insurance pays. |
7 | |
| UB Electronic ID# | Type the electronic identification number for this carrier, if applicable. | 80 | |
| DME Place of Service | Select the Place of Service code to include on claims for Take Home Supply items. When insurance claims are generated for a carrier that has a DME Place of Service selected, any procedures that have the Take Home Supply check box selected in the Procedure Code Table will be split out into a separate claim. | 3 | |
| Additional Payer ID# | Type the additional payer identification number for this carrier, if applicable. | 80 | |
| Default Billing Group | Type the code you want or click the magnifying glass to search the table. Whenever an insurance policy is added or changed on a patient's account, you will be asked if you want the Billing Group on the account changed to this value. | 8 | |
| HPID | Health Plan ID. This field is informational only at this time and will be activated in a future release. | 10 | |
| Assignment Default | Select the Assignment Default option you want. This field sets the default value for the Accept Assignment field on the patient's Insurance Policy Information screen when registering patients with this insurance carrier. For more information see the Accept Assignment Protocol help section under Introduction, System Processes. | |
2 |
| Comment | Type any necessary comment text. | 45 | |
| Comment | Type any necessary comment text. | 45 | |
| CGM webVERIFY Payer ID | If your practice uses CGM webVERIFY, select the applicable payer from the CGM webVERIFY Payer ID list, then select which identifier to send on the eligibility request - Individual NPI, Group NPI, Tax ID, or Provider ID. | 15 | |
| Eligibility Verification Frequency | If your practice uses CGM webVERIFY, you can select how often you want to run batch eligibility verification for this carrier. If you leave this field blank, 30 days is assumed. You can still run individual verifications as normal. When eligibility is checked for appointments on a schedule date, if a patient account has a policy with Eligibility Verification Frequency set to "Every visit", the policy won't be verified if it has already been verified using the Schedule > Verify Eligibility > Verify Eligibility within the last 60 days. |
2 | |
| Verify when Payer is Secondary | If your practice uses CGM webVERIFY, you can enable eligibility to be checked for secondary policies in batches by selecting this check box. | 1 | |
| Allows Verification of Future Dates | If your practice uses CGM webVERIFY, select this check box to allow eligibility to be verified for future dates of service. | 1 | |
| Managed Care Plan | Community Health Centers only - if this carrier is a managed care plan, select this check box. | 1 | |
| Public Insurance | Community Health Centers only - if this carrier is a Public Insurance Program, select this check box. | 1 | |
| PCCM Program | Community Health Centers only - If the insurance carrier is a 'Public Carrier, Managed Care Plan' or a 'Primary Care Case Management Program (PCCM)', select this check box. | 1 | |
| Typology Code | Community Health Centers only - select the applicable typology code from the list. | 5 | |
| 5010 Format | This will display what items are being sent in the 5010 format, i.e. claims/remits, etc. | 100 | |
| ICD-10 Activation | Displays the effective date when the carrier will require claims to be submitted with ICD-10 diagnosis codes. This field can be changed to a later date if needed. | |
10 |
| Use CMS-1500 (02/12) | This field is only available if the database has been set up to print PDF paper insurance claims. When you select this field, all claims for the selected insurance carrier will be generated in the CMS-1500 (02/12) format. | 1 |
Copyright and Trademark Notice. Copyright © 2019 CompuGroup Medical, Inc. CGM®, CompuGroup Medical® and the CGM logo are registered trademarks and CGM webPRACTICE™ and CGM webTOOLS™ are trademarks of CompuGroup Medical AG in the United States and/or other countries. Any rights not expressly granted herein are reserved.
