Setup Customers with Confidence

Introduction The customer record in ediInsight, along with its associated provider records, is the most important file

in the application for accurate claims processing.

This documentation, along with the Webinar, will give you the critical information required to ensure

both types of records are correctly configured.

Customer Record

The customer record is the main structure around which you define the specific configuration for each

of the practices, groups, labs and facilities you support. The customer record contains information

relevant to the specific requirements of that customer. The flexibility of the records allows you to have

a different configuration for every customer.

Details in the customer record are global settings for all provider records. However, when an exception

occurs, you will be able to set provider-specific data as needed at the provider level.

Customer Information Tab

All information entered here applies to all providers in the customer record, unless exceptions are

entered into a particular provider’s record. Much of the information here defaults into each provider

record you create, saving you data entry.

Column 1

Name: Enter the name of the practice or provider

Alias: Enter an alternate name that can be used to identify the customer. This can be used to look up a

customer on the Customer Search screen.

EDI Status: Click the Radio button of the appropriate status for this customer

Active- customer and provider records are completed; claims are ready to be sent and

responses, including ERAs, are ready to be received

Test/Demo- Allows claim files to be loaded for testing or demoing to your customer; claims

cannot be set to READY while in this status

Inactive- Customer is no longer considered active in ediInsight and claims cannot be set to

Ready

CBO/ Bill To: A Central Billing Office (CBO) is a customer that manages multiple customers within

ediInsight. Assigning a CBO/Bill To to a customer allows users within that CBO access to that customer

within ediInsight.

Tax Type: Enter “24” for Employee Identification Number (EIN). In the rare occasion that the customer is

identified by their Social Security Number select “34”. This will be the default that will be used when

setting up the Provider Record.

Tax ID: Enter the Tax ID or Social Security Number. If the customer has multiple Tax ID or SSN numbers

enter MIXED.

Monthly Fees

Monthly fees are created by the re-seller to reflect the pricing structure for all providers. Fees allow

Practice Insight to bill you, and to create the Vendor Billing report. Enter the fees you charge your

customer, so you can use the Customer Month End Invoice.

Staff Members

In order for staff members to login to the practice, staff members need to be setup in ediInsight. They

may work claims, upload claim files and download responses. In order for them to login, you will create

staff records which include logins, passwords, permissions and menus they will see displayed

Column 2

Address: Complete the full address information here to allow it to copy down into each provider record

you create. This will save you time when you are setting up the provider records. When the ZIP code is

entered the City, State will auto-populate.

Phone Number: Enter the customer phone number. This number is used in the PER segment of the ANSI

837 file.

Column 3

Class: The class determines how the customer record will be processed.

Provider- Select this class for customer representing providers filing claims.

CB0- Select this class for customer that is a billing service or central billing office and is managing

multiple customers within ediInsight. The CBO must be setup before the providers

Support Vendor: Defaults to the vendor number of the person creating the record.

Software Package: The name of the practice management software used by the provider. This field is

required for customers that are integrating with ediInsight.

Previous Clearinghouse: Select the previous clearinghouse that the customer was sending claims to.

This setting ties to the Alternate Payer Table and can be used to map Other Clearinghouse Payer Ids to

the Practice Insight Payer List.

Notes: This field can be used to enter Notes specific to this patient. We recommend using this field to

enter in Billing Notes.

Setup Specifications Tab The fields in this tab relate to specific technical data for configuring the input and output for this

customer. These setup fields are global across all providers in this customer record, and there are no

provider-level equivalents.

Column 1- Claims Filing

Claim Format: Select the format that matches the inbound file from the Practice Management System.

Claim Format does not affect functionality of Practice Insight; it is used for customer sorting and listing

purposes only.

Claim Loader: This field is only required if Practice Insight is unable to identify the type of file being

uploaded.

Pre Loader: If a non-standard ANSI, print image, or NSF will be loaded into Practice Insight, this field is

used to assign a custom script that will convert the file to the standard format. This field is set by

Practice Insight and should not be set by a Vendor.

Post Loader: If a customer needs additional data not being inbound on a claim (i.e. ordering provider for

DMERC), a script can be assigned to the claim to add the additional data. These scripts are created and

this field is set only by Practice Insight.

AutoAdd Providers: This feature is targeted to new customers and when selected, it will create provider

and provider id records automatically from the inbound claim file. Billing Providers will be created from

Loop 2010AA and providers in Loop 2310B of an ANSI claim will be created as Rendering Providers. Once

claim files for all providers and payers have been uploaded and providers created, this feature should be

set back to No.

Req Rend Doc: (Require rendering doctor) This flag indicates that claims will always have a Loop 2310B

(Rendering Provider) Loop. If this loop is missing claims will be marked Invalid and rendering provider is

required to be added before claims can be marked Ready.

Response Format: This is the format that the Response Report will be returned to the customer in. Only

customers who have integration with their Practice Management Software will use the “File” option.

Report- Displays Responses in their original format

File- Reformats responses as a flat file for use by the PMS

ERA Format: This is the format that the ERA file is made available to the customer in. This setting does

not affect the “View EOB” functionality.

ANSI- 835 format for uploading into practice management system

NSF- NSF format for uploading into the practice management system

Multiple File Download: Identifies how files are downloaded from the Transfer Files screen to a user-

designated drive.

Individual- All selected files will be downloaded individually as a separate file;

Zipped- All selected files are compressed into one zip file; that file is then downloaded. The

individual files have to be unzipped locally. This option allows you to download many or large

size files at one time.

Column 2- Clinical Claim Scrubbing and Statements

Clinical Scrub

Submitter ID: The Submitter ID created by user to identify this customer for Clinical Claim Scrubbing;

must match the submitter id registered with MEGAS.

Status: The customer’s Clinical Claim Scrubbing Status:

Live- Customer is currently actively scrubbing

Demo- Approximately 100 claims can be sent to MEGAS for scrubbing. MEGAS will retain the

response(s) and contact the reseller to arrange a demonstration for your prospective customer.

They will review the edits and discuss the relevance of those edits to your customer.

Trial- A period of 30 days during which the client may use the scrubbing functionality for free,

allowing the customer to use live claims to determine if they believe the scrubbing function adds

value to their practice.

Terminated- Customer is no longer an active Clinical Claim Scrubbing customer

Provider Count: Enter the number of providers who will be doing Clinical Claim Scrubbing

Specialty: Enter the clinical specialty of the Customer. This is used to configure Clinical Claim Scrubbing

edits for their particular patient types.

Contact Name: Enter the name of the customer contact for Clinical Claim Scrubbing. This is required for

the contract and cannot be either Practice Insight or the reseller’s information.

Statements

Bill Loader: Select the type of statement file that will be loaded

Bill Paper Type: Select the Type of Statement that will be sent to the customer

Credit Cards: Select the Credit Card options that your office will accept

MC-MasterCard

Visa-Visa

Dscvr- Discover

AMEX- American Express

Column 3 Integration and Misc Info

Integration

SFTP/HTTPS: Required if your practice management system will be automatically sending files to

Practice Insight. Please contact Practice Insight for assistance in configuring integration.

Reference ID: This field is for customers who are doing automated customer registration with Practice

Insight and will typically be blank.

Vendor Account#: This is in field is available on the Search Customer window at the Vendor Level. This

field is designed to contain the unique id number that a vendor or billing service uses to identify their

customer.

Vendor Password: This field is used for automated registration integration and should be left blank for

most customers.

Exclusive Receiver: This field should be left blank for most customers.

Misc Info

Patient Act Prefix: This is the Patient Account prefix from the Practice Management software. This is

helpful when splitting ERA files for NPI or TAX ID maybe in multiple customers.

CLIA Number: This field is necessary for Print Image only and will help Practice Insight know if Box 23 is a

Referral Number or CLIA number.

Est Provider Count: This field is not currently in use but will be used in future billing enhancements.

Enter the estimated Provider count.

Auto Load NPI: Use this option if NPI numbers for ancillary providers (i.e. referring, supervising, and/or

ordering) will not be sent on an inbound 837 file. Practice Insight will use the UPIN to find the matching

NPI in NPPES database.

Provider Record Setup You have the ability to configure each provider record as needed for each payer they submit to. The

flexibility of the provider record allows a provider to file one way for one payer and a completely

different way for another payer. By designing this record as payer-centric, it can accommodate any

combination of payer requirements.

We cannot stress enough the importance of correctly configuring the provider records within your

customer record. Claims may not load, match to the wrong provider record, be sent without the

required payer data, and they may be rejected/denied, if the provider information is not correct.

Your provider will give you the payer-specific information or you may be able to get it from the practice

management system. For new customers and providers, you are encouraged to verify with each payer

that the payer ids from the practice are indeed correct.

Global Provider Fields The top section of the provider record contains data fields for this provider. The information here is not

payer-specific, so this information can be used for all claims for this provider.

An important note: Our programs use the information in a provider record when we outbound claims.

This means the outbound claim will use, for example, the practice and provider names in the provider

record for the various loops in the outbound 837 ANSI file. So, if you entered the master information

into the customer record, it will default into these fields of every provider record. Complete and

accurate information in provider records ensures clean claims for your customer.

Entity Type: ANSI designation of a provider as:

Person- In ANSI, this is entity type 1. It identifies the record as an actual human being/person

capable of rendering hands-on clinical services to patients.

Non-Person- Use this entity type when referring to a non-human, group or legal structure such

as an LLC, Corporation, etc. In ANSI, this is entity type 2.

Provider Type: Identifies the entity to be paid vs. the entity rendering services.

Billing- Identifies the group or legal entity requesting payment for services

Rendering- This is the provider of services who treats patients, thus rendering service, but may

not directly receive payment.

A rendering provider can be a billing provider when he/she both performs/renders the hands-on

care and also receives the payment.

Practice Name: Required if Entity Type is Non-Person. Typically defaults to the customer name.

Last Name: Enter the last Name of the provider. Name should include NO PUNCTUATION and must

match what will be sent on the claim.

First Name: Enter the provider’s first name.

Middle Name: Enter the middle name of the provider. This is only required if it will be sent on the

inbound claim.

Initials: Enter the Provider’s Initials. This is used for identifying the provider in listings and reports.

Sig Name: Enter the Signature Name that will appear on printed HCFAs, reports, letters.

Specialty: 10-Digit Taxonomy Code used to further detail the provider’s clinical abilities. Required on all

Medicaid Claims

NPI: 10-Digit National Provider Identifier.

Default Tax Type: This is the code, or qualifier, for the identification number entered in the “Tax ID”

field.

Tax ID: The primary number identifying this provider to payers; this id will be to be sent on all claims,

unless another ID is indicated on a doctor id record.

The Tax ID entered identifies the provider to each carrier using this number, which must match the id

the provider used to enroll with this payer. It must be the number associated with the provider’s NPI.

If a provider needs to be identified to a particular payer using a different number, it can be setup under

the provider id record.

24- Federal Tax ID/Employer Identification Number

34 - Social Security Number

XX - NPI/National Provider Identifier

Social Sec: Enter the Social Security number of the Provider. This number is only required if the provider

bills claims under their social Security number.

UPIN: Enter the Universal Provider Identification Number (UPIN). This number may be sent on claims to

payer who are not yet NPI Ready.

State Lic#: Enter the number the state assigned to this provider.

Address: Enter the Address of the Provider. This address will be sent in the billing loop on claims. It

needs to match the address the provider enrolled with, because some payers do verify this and reject if

the addresses differ.

WD Contact: Enter the Contact Name of the person to receive watch dog alerts and audit notices.

Bill Method: Enter the Billing Method for the provider.

Billing Start: The date the provider began sending live, production claims in ediInsight.

Billing End: Enter the date the date the provider terminated their contract. If the provider actively

sending this date should be blank.

Claim Scrub: Identify how this provider will be charged for Clinical Scrubbing, when it is implemented

Doctor ID Record Prior to the implementation of the National Provider Identifier (NPI), payers often assigned their own

specific identification numbers to the provider. If a provider billed as part of a group, the group would

also be assigned a group number. These id numbers are often called legacy PINs.

Other payers, typically commercial, would use the tax id/EIN or social security number as their way of

identifying their doctors.

When setting up provider ids, we encourage you to enter any prior Medicare, Medicaid and Blue Shield

ids. These numbers are still used to identify the provider in certain circumstances.

Above is a view of the bottom section of the provider record. This screen displays the values in the key

fields of the Doctor Ids as assigned by each payer.

Doctor ID Record

From the exhibit above, you can see where the column headers come from. This Doctor Id Record

details the payer-specific settings for all payers which have assigned PINs to this provider.

ID Type: Abbreviation for the Payer assigning the PIN. Typically the format is MCR (Medicare), MCD

Medicaid), and BS or BCBS (Blue Cross Blue Shield) followed by the 2-character state code.

PIN Number: Payer Assigned Provider Identification Number. This is referred to as the Legacy PIN.

Practice Type: Use this option to select how the provider bills to the insurance company.

Group- Select this option if the provider bills as a group for this insurance company.

Solo- Select this option if the provider bills under their own identification to the insurance

payer.

NPI Only: Clarifies which key ids will or will not be sent to the payer in the outbound claim. By default,

ediInsight will send the NPI in the NM109 of the billing, rendering, Pay To provider record.

Yes- Send NPI only and strip out any legacy ids.

No- Will allow legacy ids to be sent along with the NPI to this insurance payer.

Require PIN- Will send NPI and Legacy ID; claim will be Invalid if it is missing the legacy PIN.

Tax ID Type Override: Allows provider to send a different Tax ID than the one shown in “Default Tax

Type” in the customer record.

Reference ID: This field is for integrated automated registration only should be left blank for most

customers.

Configuring Customer/ Provider/ PIN Exceptions

Provider has more than 1 Payer-assigned Legacy PIN If a provider has more than 1 Payer-assigned Legacy PIN, then two person/rendering provider records

need to be created in the customer record. Each instance of the provider record should only have 1

instance of the Legacy Provider PIN, and both need the NPI and Tax ID.

Leave the Bill Start Date blank to ensure you are not billed for these multiple records.

Customer Bills for Multiple Locations If provider bills for claims under multiple locations, then a Non-Person Billing Record needs to be

created for each location.

Leave the Bill Start Date blank to ensure you are not billed for these multiple records.

Practice has more than 1 NPI A Practice may be assigned more than 1 NPI number if they have multiple locations. In an instance

where a provider has multiple NPI numbers, then a Billing Non-Person record for each NPI needs to be

created.

In the first billing/non-person record, enter one of the NPIs, the tax id, and any doctor ids related to this

NPI. In each additional billing/non-person record, enter the other NPI(s), the tax id, and any doctor ids

related to this other NPI. Leave the Bill Start Date blank to ensure you are not billed for these multiple

records.

Provider Bills under Multiple Taxonomy Codes If a provider needs to bill under multiple taxonomy codes, then multiple person/rendering provider

records need to be created within the customer record. Each provider must include the tax id, NPI,

unique Taxonomy/Specialty code and all associated doc id records.

Leave the Bill Start Date blank to ensure you are not billed for these multiple records.