The Third Party Billing module records billable services, billing insurance providers, records of staff providing billable services, generates the HCFA 1500 and 837p exports for billing health insurance claims, and creates service entry fields for tracking the length of time services are provided calculating the number of service units using that time. Third Party Billing utilizes a number of fields in annual review, service entry, and employee setup to complete the health insurance claim form. In the process of generating the data for these forms, CAREWare reports a number of quality check measures to ensure the required data elements are complete in the claims forms. Users are prompted to complete Demographics fields, Insurance Assessment fields, and service entry records when attempting to create a claim in Third Party Billing. These quality check messages can help to improve data quality and occur when creating a claims form. Users can also enable Required Data Elements so that users are prompted to complete those Demographics fields in advance of generating a claims form. Once data entry is complete, the claims forms can be generated and then exported in the HCFA 1500 and 837p format for billing.

 

To enable the Third Party Billing Module, follow these instructions:

 

1. Log into the Provider.

2. Click Administrative Options.

3. Click Third Party Billing.

4. Click General Settings.

 

 

5. Click General Settings.

 

 

6. Click Edit.

7. Check Active.

8. Click Save.

 

At this point, the Third Party Billing Module is activated. Activating Third Party Billing activates a number of fields in CAREWare that are part of the claims data sets used for reporting billing.

 

 

Service Tab

 

Once Third Party Billing is enabled, the fields Provided By, Start Time, and End Time are added to all services. The Start Time and End Time is used to calculate the number of units billed for the service provided by the service provider. That calculation only occurs if Calculate Units is checked under General Settings. Rounding Units under General Settings determines how many decimals are used for services. Typically there would be two decimals for a service cost, however users can customize that as needed. If Include Contract Info is checked, the contract the service is active form is included in the claims data set. The Provided By field is a list of staff that provide these billable services. Claims Data Sets can be created filtered by specific staff that provided services. The Provided By list is populated by adding service providers (In this case, these are staff that provide a service), to Employee Setup and setting those staff as service providers by checking Billable Service Provider.

 

 

Insurance Assessment Tab

 

In the Insurance Assessment tab, Third Party Billing uses the Insurer, Billing Provider ID, Billing Secondary ID, Billing Notes, Primary Diagnosis Code, and Primary Diagnosis Date fields for the claims data set. The insurer is an insurance provider that is billed for the provided service. The insurer is setup under Insurance Provider Setup in Third Party Billing. The Billing Primary ID and Billing Secondary ID are identification values for the insurer. The secondary ID is an option that needs to be enabled under Insurance Provider Setup if it is required for that insurer for billing purposes. Billing Notes are a memo field for explaining the patient's billing. The Primary Diagnosis Code uses the ICD10 code and can be set to specific services billable for clients with a specific diagnosis. The Primary Diagnosis Date is the date the client was diagnosed. An example may be a client has a diagnosis code of B20 due to an HIV diagnosis. In that case the client's HIV date is entered for the Primary Diagnosis Date.

 

 

Employee Setup Tab

 

Employee Setup is used to populate the Provided By field for services and lists staff as the service provider for claims data sets. For staff to be included in the Provided By drop down list in the services tab, the staff need to be entered as an employee, they need to be active, and they need to be set as a Billable Service Provider. There needs to be an Effective Date, which is the date they began providing billable services. The NPI is the National Provider Identifier. The N5 is the provider plan network identification number.

 

 

Once the General Settings are complete, the first step in setting up Third Party Billing is to add insurers under Insurance Provider Setup. The insurance provider setup lists the available insurance providers and gives billing administrators a way to activate/deactivate them using check boxes along with a way to configure settings for billing exports.

 

To add an Insurer under Insurance Provider Setup, follow these instructions:

 

1. Click Insurance Provider Setup.

 

 

2. Click Add.

 

 

3. Complete the form.

4. Click Save.

 

In order for an insurer to be included in Insurance Assessment records for clients, the insurer must be active. The CAREWare Insurance Category is generated from the list of insurance options set under Insurance Setup in Central Administration. The address fields are for the insurance company, which are included in the claims data sets. The N5 and NPI are optional values and are included in claims data sets if Use NPIs is checked. The PayerID is a number assigned to the insurance company for the purpose of billing. The Insurer initials are the first letters in the insurance companies name. Use secondary ID and Use Agency ID determine if those ID values are included in a billing claim.

 

Once the insurer is active for the provider, client records can have that insurer activated for their record by selecting the insurer in Insurance Assessment records. That is required for billable services to be included in a claims data set for a client.

 

The next step for setting up Third Party Billing is to establish which services these insurer are billing for and which diagnosis the billable services are applied to. The service setup gives billing administrators a way to mark subservices as billable, associate existing subservices with CPT codes and set other billing traits including the diagnosis code, modifier, and max units.

 

To activate a subservice for Third Party Billing, follow these instructions:

 

1. Click Billable Service Setup.

 

 

2. Click a subservice to highlight it.

 

Note: The subservice list is generated from the Subservice Manager under Service/Contract Setup.

 

3. Click Edit Service.

 

 

Note: A service needs to be active in order to edit it. If a service has a blank value under Active, click the service to highlight it and then click Activate, prior to clicking Edit Service to complete the Third Party Billing settings for that billable service.

 

 

4. Complete the form.

5. Click Save.

 

 

The diagnosis code is the ICD10 code for the client's primary diagnosis. The CPT code is the billing code assigned to that type of service for billing. The Modifier is a two letter code providing an additional attribute to the service. Example: If XS is entered in the Modifier field, then the service was provided in a structure separate from the building the provider practices from. That may be the case for providing Covid testing during the pandemic, where testing was done in the parking lot instead of inside the building. The Max Units is a limit to the number of service units that can be billed for that client at a time. Service units are calculated in increments of 15 minutes so a 32 would set a limit of 8 hours for that service.

 

Once the field are complete, the service is activated, and a client has the insurer listed under at least one Insurance Assessment record, adding that service to a client triggers a claim, which populates a claims data set. The claims data set can be used to generate reports and export the HCFA 1500 and 837p files for billing.

 

 

The next step for completing the billing process is to generate a Claims Data Set. Billing operators can use the Claims File Generator to generate new claims data set files for specific date ranges and specify a directory to store them. Each Claims Data Set is created using a date span and optional filters for specific insurers and/or case managers (service providers).

 

To create a Claims Data Set, follow these instructions:

 

1. Click Claims Data Sets.

 

 

2. Click Create New Claim.

 

 

Note: In this example, the claim is for a single day, it is filtered for a single provider, and it is filtered for a single case manager. The date span is required and if the insurer and case manager filters were left blank, the claims data set would include billable claims for all insurers and case managers during that date span.

 

3. Complete the form.

4. Click Create Claim.

 

 

 

When creating a claim, there are options to Change Insurer and Change Case Manager. Those options allow users to select one or more insurers or case managers as a filter to limit the claim file to just services billed by that/those insurer(s) and/or provided by that/those case manager(s).

 

Change Insurer:

 

 

This list of insurers comes from the active insurers under Insurance Provider Setup.

 

Change Case Managers:

 

 

This list of Case Managers are the same staff that appear in the Provided By field when adding a service, which is generated by setting those employees up for Third Party Billing under Employee Setup.

 

Once a Claims Data Set is created, that file can be used to review insurance and service records as well as create the HCFA 1500 and 837p claims files used for billing. Clicking the Billing Report Generation button will open a new dialog from which Billing Operators can generate and work with claims data sets. Billing operators can review the insurance status of clients, review detailed service information, include/exclude individual service records, and generate billing reports.

 

To review a claims data set, follow these instructions:

 

1. Click the claim to highlight it.

 

 

2. Click Manage Claim.

 

 

The Insurance Status Review, Service Data Review, and Remittance Report are tools that can be used to check the completeness and quality of the 837p file and HCFA 1500 Report prior to downloading them.

 

Insurance Status Review

 

Each Insurance Assessment record for clients included in the claim are listed here. Users can use this list to verify the insurance fields are filled in correctly before submitting a billing claim.

 

 

Service Data Review

 

Each service record for clients included in the claim are listed here. Users can use this list to verify the service fields are filled in correctly before submitting a billing claim.

 

 

Note: Records with Yes under selected are included in the exported files. Clicking a service and then clicking Change Selection deselects the service and excludes it from the billing claim file exported.

 

Remittance Report

 

The Remittance Report is a consolidated list of clients that are included in the claim as well as the insurer from the insurance assessment, the service date, and the total cost of that billed service.

 

 

Once the records are reviewed and the report is ready to be exported, users can click one of the three options for exporting the claims data set.

 

Create and Download 837p Files – This exports the 837p file for submission for billing.

Create and Download Test 837p Files – This exports a test file for the 837p file, which cna be used to test the submission process without completing a submission.

HCFA 1500 Report – This exports the HCFA 1500 Report for submission for billing.

 

For more information regarding the 837p file or the HCFA 1500 Report go to CMS.gov or click here.