ServiceXG Basics

Update, add, delete, or associate PPO information

A Preferred Provider Organization (PPO) is a group of providers who contract with employers, insurers or administrators to provide services to employees for a negotiated amount. In some cases the benefit plan includes an incentive, such as lower deductibles and/or co-insurance, for employees who use providers in the PPO network.

You might need to add or delete Preferred Provider Organization (PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount.) information for service providers as they enter into new PPO arrangements or end existing ones. Other scenarios you might manually update PPO information are:

• The PPO information retained from an electronic claim was incorrect.
• The service provider no longer works under the billing provider Tax ID. In this case, it is a best practice to update the service provider's PPO so it's no longer in effect.
• The service provider could belong to a different PPO depending on the address where the service was performed.

Three areas are checked for a claim with a PPO and the same PPO must be found in each to use the schedule pricing for that PPO.

1. PPO linked to benefit plan.
2. PPO linked to service provider or PPO in the claim (if your system is set to retain PPO ). Retaining PPO is only available for electronic claims (HIPAA 837 transactions). Validations determine the correct service provider for the claim.
   • If the service provider name on claim matches the service provider in the system, the PPO linked to the service provider is used.
   • If the service provider name and address on the claim matches the service provider name and address in the system, the PPO linked to the service provider is used.
   • PPO linked to member/dependent—This is set up in Member Information.You must create the PPO and link it to a schedule and benefit plan. When a claim is processed, the member’s benefit eligibility is checked and if the service provider is part of the PPO network.
3. The schedule determines the pricing to use.

Access the service provider’s PPO information

1. Search the billing or service provider.
2. In the Provider session, select the Provider menu and then Service Provider Summary.
3. Double-click the provider to update.

4. Select the PPO tab.

   

   PPO field descriptions

   * indicates a required field

   Field	Description
   Effective From*	The date the PPO takes effect. Click and select a date or enter a date in MM/DD/YYYY format.
   Effective Through	The date after which the PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. is no longer in effect. Click and select a date or enter a date in MM/DD/YYYY format. Leave blank to indicate no end date.
   PPO Code*	A code that represents the provider's PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. affiliation.
   PCP Flag	Indicates whether the provider is a Primary Care Physician (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.) for the PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount..
   Inactive	Indicates whether the service provider PPO is active.
   Unique ID	A unique ID the PPO assigns to the provider.
   Service Address	The service provider’s active address associated with this provider PPO affiliation.
   RV Code	The relative value procedure source code (basic pricing fee schedule) to be used when this provider is paid using the PPO code. Note: This pricing will take precedence over the relative value procedure source code (basic fee schedule code) specified in the schedule or benefit plan.
   UCR Code	The UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills. procedure source code (major medical fee schedule code) to be used when this provider is paid using the PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. code. Select a code from the list. Note: This pricing will take precedence over the UCR procedure source code (major medical fee schedule) specified in the schedule or benefit plan.
   RV Market ID	The market ID code associated with the relative value procedure source code (PHCS network related).
   UCR Market ID	The market ID code associated with the UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills. procedure source code (PHCS network related).
   Network	The PPO's associated network.
   Last Update	The date the information was last updated in the system.

Add a PPO affiliation

If the PPO affiliation only applies when a provider at a particular location, go to Associate a PPO with a provider address.

1. On the PPO tab for the service provider, click to add PPO information.

2. Enter the effective From Date (when the PPO arrangement takes effect). Continue to move through the table columns and enter the required information.

3. Click to apply the update.

Associate a PPO with a provider address

If a PPO arrangement applies only when a provider provides service at a certain location, follow these steps to link the PPO to a particular address.

1. Search the billing or service provider.
2. In the Provider session, select the Provider menu and then Provider Addresses

3. Select the PPO and Address History tab.

4. In the Address list, select the address that the PPO applies to and click below the table.

5. In the PPO table enter the effective From Date (when the PPO arrangement takes effect). Continue to move through the table columns and enter the required information.

   PPO and address history field descriptions

   PPO field descriptions

   * indicates a required field

   Field	Description
   Effective From*	The date the PPO takes effect. Click and select a date or enter a date in MM/DD/YYYY format.
   Effective Through	The date after which the PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. is no longer in effect. Click and select a date or enter a date in MM/DD/YYYY format. Leave blank to indicate no end date.
   PPO Code*	A code that represents the provider's PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. affiliation.
   PCP Flag	Indicates whether the provider is a Primary Care Physician (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.) for the PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount..
   RV Code	The relative value procedure source code (basic pricing fee schedule) to be used when this provider is paid using the PPO code. Note: This pricing will take precedence over the relative value procedure source code (basic fee schedule code) specified in the schedule or benefit plan.
   UCR Code	The UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills. procedure source code (major medical fee schedule code) to be used when this provider is paid using the PPO A group of providers who contract with employers, insurers or administrators to provide services to individuals for a negotiated amount. code. Select a code from the list. Note: This pricing will take precedence over the UCR procedure source code (major medical fee schedule) specified in the schedule or benefit plan.
   RV Market ID	The market ID code associated with the relative value procedure source code (PHCS network related).
   UCR Market ID	The market ID code associated with the UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills. procedure source code (PHCS network related).
   Last Update	The date the information was last updated in the system.

   Address History field descriptions

   * indicates a required field

   Field	Description
   Address 1	The provider's apartment, suite, floor, etc. This is the first line in the provider's address that isn't a street address or PO box number.
   Address 2	The provider's street address or PO box information.
   Address 3	The provider's city, state, and ZIP code.
   Current	Indicates which address in the history list is the current address. Select the radio button to make an old address current.
   Effective Date	The date the address was in effect.
   Action Date	The date the row was last updated.

6. Click to apply your changes.

7. Click to apply the update.

SEE ALSO