Billing provider information

A billing provider can be either a group of service providers or one service provider that is the same as the billing provider. The billing provider will receive payments for services provided by its service providers. The billing provider file is the basis for maintaining service providers as well as the means of issuing 1099's at the end of the year. It’s imperative that this information be carefully updated.

As billing providers are added, they are automatically created as service providers of themselves.

Before additional service providers are added, determine whether these providers will be added based on an actual individual ID number or based on system created incremental numbers.

Using a provider's actual ID# will improve your ability to identify service providers and reference data.
Service providers can be added through Add/Update Provider or during Claim Entry. Decide which method is best for your site and develop a process and train the appropriate individuals. See Add billing and service providers.
- Be sure they are clear on PPO and Discount arrangements and how they are maintained on the service provider level. Also remember to set up the provider as a PCP A physician who serves as a group member's primary contact within the health plan. In a managed care plan, the primary care physician provides basic medical services, coordinates and, if required by the plan, authorizes referrals to specialists and hospitals. if you're using Point of Service A Point of Service (POS) plan is an "HMO/PPO" hybrid; sometimes referred to as an "open-ended" HMO when offered by an HMO. POS plans resemble HMOs for in-network services. Services received outside of the network are usually reimbursed in a manner similar to conventional indemnity plans (e.g., provider reimbursement based on a fee schedule or usual, customary and reasonable charges)./referral tracking Tracking process that allows administrators to manage health care costs with a Primary Care Physician is the "gatekeeper" for participants' health care needs..

Note: Remember that a service provider may exist under multiple billing providers and each service provider may have multiple PPO and/or discount arrangements.

Billing Provider Information has three subtabs—Demographics, Tax Information, and Billing Provider PPO Matching.

Demographics tab

The Demographics tab displays the billing provider's name and alternate billing names along with some billing provider options, such as if members receive an EOB when the billing provider is paid.

Billing provider field descriptions

* indicates a required field

Name
Group/Individual	Select either `Group` or `Individual` to indicate the provider type.
Alpha	Auto-updated, read-only field based on the group or individual information entered, used to sort the provider's name in reference lists.
Group	The provider group's name.
Individual	When the provider isn't in a group these fields apply. `Last Name`*—The individual's last name. `First Name`—The individual's first name. `Middle Name`—The individual's middle name. You can enter a middle initial rather than a full name. `Prefix`—A title that displays at the beginning of a person's name to indicate marital status and gender, education, or occupation, (e.g., Dr., Mrs., PhD, etc.) `Generation`—Suffix to distinguish persons that share the same name in a family, (e.g. Jr., II, Sr, etc.)Select a generation from the list. The list only displays if the System Administrator Control (SAC) is set to perform a data validation on the Generation field. `Title`—A professional or some other designation that comes at the end of a name, for example, CPA, MD, ESQ, etc. Select a title from the list. The list only displays if the System Administrator Control (SAC) is set to perform a data validation on the Title field.
Additional Information
Receive 1099 Misc	Indicates the 1099-MISC form will be sent to the billing provider when it's issued.
Prevent Benefits Assignment	Prevent operators from assigning services and benefits to the billing provider.
Suppress Member EOB	Prevent generating member EOBs EOBs are sent to members and payees to inform them of the disposition of claims. Typically an EOB identifies the date and type of service, the billed amount, deductibles, co-insurance, and an explanation of any ineligible charges. An EOB can also be a helpful tool in identifying fraudulent claims, as the member receives notification even when payment is made to the provider. An EOB isn't a bill. when the billing provider is paid.
Suppress Pend Statement	Prevent a pend statement being generated for the billing provider.
Allow Batched Checks	Indicates that batch multiple claims payable to the billing provider are on one check.
Suppress PPA	Indicates that the PPA window won't display in claims entry or claims processing when the associated service provider is on the claim. Your system might be configured to display suppress the PPA window if the claim is zero. This field won’t display for the first service provider associated with this billing provider. If an operator isn't allowed to take PPA (security settings), the PPA window will be suppressed. If the provider or member has a PPA, pend code P28 will be applied to the claim so that an operator who has the ability to determine whether to take PPA or not can complete the claim. Note: Contact your basys representative to set or change SAC (System Administration Control) settings. Don't change SACs without first consulting basys as changing them can affect other functions and global system settings.
Take PPA at Billing Provider Level	If your system is configured to take prior payment adjustments at the service provider level, but this billing provider does not, use this option to have any prior payment adjustments taken at the billing level for any associated service providers. If this option isn’t selected and your system is configured to take the prior payment adjustments at the service provider level, the PPA will apply to the service provider and not the billing provider. Note: Contact your basys representative to set or change SAC (System Administration Control) settings. Don't change SACs without first consulting basys as changing them can affect other functions and global system settings.
Suppress Checks/EOBs	Indicates that checks and EOBs are suppressed for the billing provider.
ProviderXG access enabled	Enables user access to the ProviderXG portal. You must select this check box to let Provider contacts access ProviderXG (see Add, update, or delete a provider contact). Note: If you restrict access to ProviderXG and then enable access again, the contacts previously set up to use the portal on the billing provider's Contacts screen keep their account credentials.
Correct ID	The ID to use for this billing provider. A billing provider with this ID must already be in the system. Use when bills were originally submitted under this provider ID and were later determined to be incorrect.
ID Format*	The provider ID format. `E`—EIN. `S`—SSN.
Alternate Billing Names	Names other than the billing provider or service provider associated with this billing provider.
Source/Other Billing Provider ID	Other billing provider identifiers along with the source of the ID. `Source`—The data source for the other ID. `Other Billing Provider ID`*—The ID.
Comment	Additional information associated with the provider. Include information that will help other users quickly respond to inquiries about the billing provider. The comment can be up to 50 characters long.
Effective From Effective Through	Start and end dates for provider alert messages. Click and select a date or enter a date in `MM/DD/YYYY` format. Alerts with effective dates only show on a claim when they are within the effective date range.
Alert	Important or critical information about the provider. The alert can be up to 150 characters long. The Claims or provider demographics data tile will show an alert icon next to the billing provider's name. The alert shows in the Provider Alerts window (if your office is configured that way) and in the Alerts tab when processing a claim associated with the provider. You can add an effective date range to limit the alerts.

Key information from this tab displays on the Provider session Demographics and Additional Information data tiles.

Tax Information tab

The Tax Information tab shows W-9 tax information for the billing provider. See Update W-9 information.

Tax information field descriptions

* indicates a required field

Field	Description
W9 Last Review Date	The last date an operator reviewed the W-9 information on file. Click and select a date or enter a date in `MM/DD/YYYY` format.
Pend All Claims	Select the check box to pend all claims from this Tax ID and then select the pend code that will be assigned to this provider's claims. P31 is the default pend code. For example, if a billing provider fails to respond to a W-9 request, you may wish to pend all claims from the billing provider.
W9—Name
Group/Individual	The name information as per the W-9 form. Select either `Group` or `Individual` to indicate the federal tax classification. Note: If you switch an existing group to an individual, you may have to rearrange the names that display in the Last, First, and Middle Name boxes.
Name Control	A four-digit IRS control number. See the 1099-MISC Information booklet for more information. If `Name Control` is blank, its value is defaulted as you enter or update information in the Line 1 field. For a Group, the value defaults to the first four characters of Line 1, with quotation marks, spaces, and the word "THE" removed. For an Individual, the value defaults to the four characters of the Last Name.
Line 1	The group's name. This corresponds to the spaces allowed by the IRS on the W-9 form. Use Line 2 if additional space is needed for the name.
Line 2	The second line of the group's name.
W9—Name (Individual)	Individual demographic fields. `Last Name`*— The individual's last name. `First Name`— The individual's first name. `Middle Name`— The individual's middle name. You can enter a middle initial rather than a full name. `Prefix`— A title that displays at the beginning of a person's name to indicate marital status and gender, education, or occupation, (e.g., Dr., Mrs., PhD, etc.) `Generation`— Suffix to distinguish persons that share the same name in a family, (e.g. Jr., II, Sr, etc.) Select a generation from the list. `Title`— A professional or some other designation that comes at the end of a name, for example, CPA, MD, ESQ, etc. Select a title from the list.
W9—Address (The address information as per the W-9 form)
Foreign Country	Select either `Yes` or `No` to indicate whether the country is a foreign country (not USA).
Invalid Address	`Invalid Address`- Check box indicating the address isn't valid.
Street Address or P.O. Box	Second line of the provider's address. Note: The address does NOT use the POSTNET validation process.
City, State, Zip	Third line of the provider's address.

W9 request history table fields

Field	Description
Requested Date	The date the fund office requested a W-9 from the billing provider.
Requested Operator	The operator that updated the Requested Date.
Requested System Date	The date the operator updated the Requested Date.
Received Date	The date the fund office received the W-9 form from the billing provider.
Received Operator	The operator that updated the Received Date.
Received System Date	The date the operator updated the Received Date.

Billing Provider PPO Mapping tab

Use the PPO Mapping tab to match billing providers with a PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. based on specific criteria. See Map provider PPOs for more information.

PPO Mapping field descriptions

* indicates a required field

Field	Description
From Date*	The first date the PPO match is active.
Thru Date	The PPO term date, or the PPO match's end date.
Service Provider*	The service provider The actual provider who renders the services to an individual. to map. For service providers, the list includes any PPO codes listed under the service provider. For billing providers, the list includes all PPO codes in your system.
Unique ID	The provider's unique ID with the PPO. If a claim is submitted with this unique ID, it's matched to the related service provider.
PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. Code	The PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. code to map (includes all PPO codes listed in the system).
Claim Type	The claim type to map. `D`—Dental `I`—Institutional `P`—Professional
Modifier	The modifier Basis for determining the contract (contribution rates) applied to members. Modifier examples include: area, class, group, local, plan, shift, and status code. to map (includes all modifiers listed in the system).
Specialty	The service provider's specialty to map (includes all specialties listed in the system).
POS (Place of Service)	The place(s) of service to map.
Procedure Code (Range)	The procedure code A claim procedure code that identifies a specific service performed by a service provider. range to map. This field isn't validated, and only displays for you to reference.
Age (Range)	The patient age range to map. If a patient’s age is outside of this range, this provider will not be used for the matching process.