Billing (X12) Setup This session includes Community Setup, Payor Setup, Procedure Codes, Place of Service, X12 codes for Transaction Types and Service Types. Note: Before using Eldermark Software for X12 Billing, the customer is responsible for the following items: Have current provider information setup with the State Department of Health. Have up-to-date residents’ state service agreements, effective dates and authorization numbers to ensure proper resident setup. Determine procedure codes and modifiers needed. Community Setup: To setup the community billing information, click on File – Setup – Community. Double click on your community to open. Click on the ‘AR Options’ tab.
This field listed below in res must be activated by Eldermark Staff.
Complete the fields for Billing Contact, Federal Tax ID, MA Provider ID and Provider NPI. All fields require completion; this information is used in the electronic file to identify your community.
Enter the name and phone number of the billing contact for your community. Billing Contact:
Enter your community identification numbers. Community Identification Numbers:
Federal Tax ID: A Federal Tax ID, also known as an Employer Identification Number (EIN), is a nine-digit number issued by the Internal Revenue Service for banking, tax filing, and other business purposes. MA Provider ID: The MA Provider ID is the legacy identifier that was used prior to the change to the NPI in 2008. Provider NPI: National Provider Identifier or NPI is a unique 10-digit identification number issued to health care providers in the United States by the Centers for Medicare and Medicaid Services (CMS).
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EIN (Employers Identification Number): Employers Identification Number should be 9 numeric digits. This number is usually the same as the Federal Tax ID number. Mark this box below to pull the resident’s primary diagnosis into all claims. Diagnosis in Claims:
Payor Setup: For each organization that you wish to submit electronic claims for, you will need to complete the X-12 Payor setup. To select the payor organizations, click on File – Payors. This will open up the list of payors.
Find the appropriate payor(s). Double click on the payor to open the record.
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Confirm the address is correct.
Click on the ‘Electronic billing (X12)’ tab. The following screen will open.
Check the box below for X12 Payor.
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ISA Interchange Control: All fields are required. Details about each field are to follow. Click on the blue question mark by each field for help with that field.
ISA Status: For your initial submission, this needs to be a ‘T’ for test. Keep the ISA Status at ‘T’ for testing mode until DHS approves you for production status. Once it is accepted by the State and you have authorization to send production files, then you change this field to a ‘P’. Note: to test the 5010 file layout, you will need to change this field to a ‘T’. Sender ID Code: The Sender ID Code is a 2-character code that indicates what kind of value the Sender ID Value is. Sender ID Value: The Sender ID Value identifies the Sender in an X12 transaction. Sender ID Value = NPI assigned by the Dept. of Human Services. Note: The community is the sender. Receiver ID Code: The Receiver ID Code is a 2-character code that indicates what kind of value the Receiver ID Value is. Receiver ID Value: The Receiver ID Value identifies the Receiver in an X12 transaction. Note: Medical Assistance (Medicaid, Elderly Waiver) is the receiver. Billing Company NPI: If the billing company is not the same as the providing community, you may need to state the NPI of the billing company. If you do NOT populate this entry, then the Company Provider NPI will be used, or the Company Federal Tax ID. Output file with CR/LF: If this option is selected, then the output file has carriage return + line feeds in the file, to make it somewhat more readable. This option may not be supported by all providers.
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Setup Example for Minnesota Elderly Waiver: These are examples. Each community is responsible for obtaining the correct data from their state.
Signatures:
Provider Signature: This is used to indicate if the provider signature is on file. Valid values are 'Y' for Yes, or 'N' for No. M A Assignment: This is used to indicate whether the provider accepts Medicare Assignment. Benefits Assignment: This is used to indicate an assignment of benefits. A ‘Y’ value indicates the insured or responsible person authorizes the resident benefits to be assigned to the provider (facility); a ‘N’ value indicates benefits have not been assigned to the provider and the resident will be reimbursed. Release of Information Code: Code indicating whether or not the provider has a signed statement by the patient authorizing the release of medical data to other organizations on file.
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Patient Signature Code: Code indicating how the patient or subscriber authorization signatures were obtained and how they are being retained by the provider. These are examples. Each community is responsible for obtaining the correct data from their state. Setup Example for Minnesota Elderly Waiver:
Other X12 Setup:
Procedure Code System: HC - Health Care Financing Administration Common Procedural Coding System (HCPCS) Codes 1297. Because the AMA’s CPT codes are also level 1 HCPCS codes, they are reported under HC. CODE SOURCE 130: Health Care Financing Administration Common Procedural Coding System. Click on the question mark for additional types. Place of Service: The 'Place of Service' is a code identifying the type of community where services were performed; the first and second positions of the Uniform Bill Type code or the Place of Service code from the Electronic Media Claims National Standard Format. 12= Home 13= Assisted Living Community Click on the question mark for additional values.
Mark ‘Use this code for ALL claims’ if you always use the same place of service on claims.
Provider Taxonomy Code: Code indicating group or category of provider. For valid values, go to http://www.wpcedi.com/reference/ for a complete listing of codes.
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Examples: Home Health = 251E00000X, Assisted Living Facility = 310400000X, Assisted Living, Behavioral Disturbances = 3104A0603X. You will need to verify you are using the correct number for your community. Charges Output:
Line Item Detail: Select this option if you need to submit detailed charges. As Summary: Select this option if you can submit a summary of charges.
File Export Location: You will create a file in Service Minder to send to your state. The export location is where you will be saving the file you create.
To set the Export Location for the data file, click on ‘Export Location’ and create a file folder that will be easy to locate when you are ready to submit the file. Browse to the location you want to save the file. Click on ‘Make New Folder’. Name the folder X12 Billing or something similar. Click ‘Ok’ to save your changes and close this window. Then click ‘Save’ to return to the Payor listing.
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Place of Service: Note: If you have marked: anything in this table.
in the X12 payor setup, you do not need to enter
To access, click on File – Setup – Place of Service. This table is shared between all communities if you are a multicommunity company.
Click new to enter codes you require that are not in the table.
Most communities have one Place of Service; some may have two. The Place of Service will be assigned to charges at the resident level on the monthly recurring transaction and/or the resident services.
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Procedure Codes: In most instances, these will be HCPCS codes. HCPCS Codes, Healthcare Common Procedure Coding System numbers, are the codes used by Medicare and monitored by CMS, the Centers for Medicare and Medicaid Services. They are based on the CPT Codes (Current Procedural Technology codes) developed by the American Medical Association. HCPCS Codes are numbers assigned to every task and service a medical practitioner may provide to a Medicare patient including medical, surgical and diagnostic services. Since everyone uses the same codes to mean the same thing, they ensure uniformity. You should be able to obtain a valid listing from your state agency. In some states the Procedure code and any required modifier can be found on the state service agreement. To access, click on File – Setup – Procedure Code. This table is shared between all communities. Click ‘New’ to enter codes you require that are not in the table.
Set-up procedure codes with:
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Code: Required Code and Description, as set by the State. (Make description its own section to match software fields) Unit: Type of unit minutes, daily, each, monthly, etc., as set by the State. Quantity: Standard quantity which makes a unit – Program will take ‘confirmed’ schedule to calculate total number of units to bill. Procedure Codes will be assigned to Transaction Types and Service Types along with any modifier needed. Transaction Type X12 Setup: To add procedure codes and modifiers to Transaction Types, click on File – Setup – Transaction Types. Enter the Procedure Code and/or Modifier Code associated with each Transaction that may be billed to Medical Assistance/waivered programs. Find the Transaction Type that you need to assign a procedure code to and double click to open the Transaction type record.
Service Type X12 Setup: To add procedure codes and modifiers to Service Types, click on File – Setup – Service Types. This will bring up a listing of Service Types. Enter the Procedure Code and/or Modifier Code associated with each service that may be billed to Medical Assistance/waivered programs. Find the Service Type that you need to assign a procedure code to and double click to open the Service Type record.
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Enter the Procedure code and X12 modifier if appropriate.
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