Electronic Claims Direct to Payer Runbook

Creating HIPAA Compliance

With the HIPAA Professional format (new 837 format), all Insurance Codes are required to have Payer Codes and a Claim Receiver Type.  Perform the following steps to update your data for HIPAA-compliance.

STEP A:  Maintain Insurances

1. Obtain a current Payer ID List containing the Payer IDs to be assigned during Insurance Maintenance.  To obtain a list, call WebMD/Envoy's Fax-on-Demand phone number at 1-800-760-2804 and follow these instructions.

   1. Press 1, to place an order.

   2. Press 2, to order a document.

   3. Enter the document number - 11.

   4. Press #, to complete the order.

   5. Enter your Fax Number.

   6. Press 1, if your entries are correct.

   7. Enter your phone number, then press #, to complete the call.

   Note:  Keep WebMD/Envoy's Fax-on-Demand phone number handy because the Payer IDs change periodically.

2. Obtain an updated list of Medicare Medigap Numbers to be assigned during Insurance Maintenance.  You can download the list by clicking this internet address:
   www.medicarenhic.com/download.

3. Perform Insurance Maintenance.

1. Open Insurance Maintenance to edit the insurance carriers.

2. Maintain the Contact field by entering the Payer Codes here.

   • For Medicare Insurance Codes, enter the Payer Code of 31142 in the Contact field.

   • If an Insurance does not have a Payer Code, enter OTHER in the Contact field.

3. Maintain the Medigap # field by entering Medicare's Medigap Number.  Refer to Medicare's list.

4. Maintain the EMC Claim Receiver Type field.  Valid entries are:

   • C = Medicare

   • D = Medicaid

   • G = Blue Cross

   • F = Commercial

   • Z = The insurance does not have a Payer Code

5. Maintain the Insurance Set ID Code field.  
   Note:  For your Medicare Insurance Codes, enter M in the Insurance Set ID Code field.

6. Click Save to save your changes.

STEP C:  Maintain Providers

1. Obtain a TAXONOMY/SPECIALITY Code List to use during Provider Set Maintenance.  You can either have NDS fax you the list or download it  by going to this address:  www.wpc-edi.com/codes.

2. Perform Provider Maintenance.

1. Open Provider Maintenance to edit the Providers.

2. Make sure that the Provider Form Type Print Code for the Medicare Form Type is only 6 digits long and does not include any hyphens (-).  (Years ago the Provider numbers began with the first two letters of the Physician's last name).

3. Make sure entries in the Federal ID Number field do not contain hyphens (-).

4. Click Save to save your changes.

3. Perform Miscellaneous Provider Information Maintenance.

1. Open Miscellaneous Provider Information Maintenance by clicking Additional on the Provider Maintenance Menu Bar.

2. Verify that the Provider's Last Name, First Name and Middle Initial fields are filled in.

3. Verify that the Suffix field is filled in correctly with the abbreviation for the provider's professional degree (for example, MD, DO, or PA).  Note:  This field is required.

4. Set the Prevent Autobill field to NO.

5. Click Save to save your changes.

4. Perform Provider Set Maintenance.

1. Open Provider Set Maintenance by clicking Additional on the Provider Maintenance Menu Bar.

2. Make the Location and Department fields blank, so they default to ALL.

3. To set the Insurance Set field, enter M for Medicare.

4. Tab to the Specialty field and enter the Taxonomy Code. All providers require a Taxonomy Code.
   Note:  You can either have NDS fax you the list or download the list by going to this internet address:  www.wpc-edi.com/codes.

5. Click Save to save your changes.

STEP D:  Additional File Maintenance Notes

• When entering Policy Holder information during Patient Entry, if the Policy Holder is the patient (self), the patient name displays.  Press [TAB] past the name fields to accept.  If the Policy Holder is not the patient, make sure the correct guarantor name and account is entered.

• Caution:  Patient Policy Holder information must be agree with the Patient's Relationship Code.

• Run the Medicare update.  

• When the update is complete, contact NDS Technical Support to have them run a Just Ask report to make sure that all data in the patient insurance policy holder fields is valid.  

• Use Patient Entry to make corrections to any invalid Patient Insurance policy holder information before continuing.