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The Plan Maintenance - Claims tab maintains claims control information about a plan.
Claim Breaks
A claim is made up of the charges on a visit and will never be made up of charges on more than one visit. However, in some circumstances, more that one claim may be generated from a single visit. A claim "break" will always occur for each combination of physician and facility on a visit. However, breaks for different diagnosis codes, different dates of service, and separate claims for anesthetists are not normally mode unless specifically asked for by the user:
Date of Service
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Indicates if claims will break for each date of service within a Visit.
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Anesthetist
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Indicates if a separate claim will be created for the anesthetist.
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Claim Control
Payer Type
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Type of payor (Medicare, Medicaid, etc.) for controlling special claims logic.
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Pmt Source
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HCFA (CMS) Source of Payment for electronic claims
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Editing Ind
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HCFA (CMS) Claims Editing Indicator. Note - If this is a Medigap payor, both this field and the Plan Type field on the General Tab of the Plan Maintenance form must be set to Medicare or Medigap for electronic processing to function properly.
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HPSA Modifier
HPSA Modifier
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Enter/Select the Modifer to be billed for this plan for Health Provider Shortage Areas. The standard CMS Modifier is AQ.
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Claim Audit Options
Enforce Group No
Present
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Checking this "On" will enforce an edit in the Claims Audit that will generate an error if the Provider's Group Number cannot be found.
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Enforce Indiv No
Present
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Checking this "On" will enforce an edit in the Claims Audit that will generate an error if the Provider's Individual Number cannot be found.
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Staff ID Qualifiers
Group No
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Select the ANSI Claim qualifier to report on paper claims for combined Legacy/NPI mode
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Indiv No
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Select the ANSI Claim qualifier to report on paper claims for combined Legacy/NPI mode
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Claims Control by Level
There are a number of fields that control how and when claims are to be filed and refiled. MedSuite supports up to three levels of insurance on a patient. As a result, the claim control fields are repeated for each of the three levels; primary, secondary and tertiary. It should be understood that the fields in this section repeat for each of the applicable levels.
Valid for Level
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Indicates that the plan is valid for the level. For example Medicare Supplement plans may be valid for secondary and tertiary insurance, but not appropriate for primary insurance.
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Wait for Payment
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Indicates if the billing cycle will bill this plan and wait at the level until the claim is paid or denied. If the plan does not wait for payment, the next level of insurance (or self if there is no next level of insurance) will be billed.
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File Claims
File Claims
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Indicates whether or not claims should be filed and if claims are filed, how they are handled based on the following fields.
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Hold Days
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Number of days after charge is posted to hold claims from being filed. May be overridden in Visit Entry. This applies only to Primary claims. Secondary and Tertiary claims are not Held.
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Type
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Indicates how claims are to be generated:
| • | Electronic/Paper (Based on Carrier) |
| • | Test (Paper and Electronic) |
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Paper Format
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Paper claim format
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EMC Format
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Electronic Claims Format
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Refile Claims
Refile Claims
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Indicates whether or not claims should be refiled and if claims are refiled, how they are handled based on the following fields.
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Refile After Days
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Number of days after initial submission to refile claims
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Force Refile to Paper
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Indicates if system-generated refiles will be forced to paper or if they will be sent in the same manner as the original claim
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