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1. Click on Master Files on the left side of the screen. This displays several sub-categories.
2. Click on Payors/Plans. The Payors tab will display by default.
3. Click .
4. Enter the payor information.
● Receiver ID — Select the desired option from the drop-down according to which receiver users will be sending claims to for this payor. The fiscal intermediary for Medicare A should be listed (PGBA, NGS, CGS,etc.), along with any clearinghouse that is used (ZirMed, Availity, etc.)
● Send Electronic 837 Bill — This should be checked if submitting batch claim files electronically for this payor.
● Payor ID — This must be the payor ID specified by the clearinghouse for agencies billing electronically through a clearinghouse such as ZirMed or Availity. For Medicare as a payor, this should be “MA”. For any payors being billed on paper, anything can be entered in this field as long as it doesn’t include special characters.
● Name — This must be 23 characters or less (including spaces and withoutapostrophes). *Once set, do NOT make changes to this without first contacting HEALTHCAREfirst.
● Address — This is what will pull to the paper bill, but is not necessary if the payoris being billed batch files electronically. For Medicare A, do NOT include periods, dashes, or anyspecial characters, as this will result in errors when electronically billing.
● Financial Class — This is an editable list designed to help users categorize and compile claim batches. If the desired item does not display, it must be added in the Reference Files.
● Payment Source— Payment Source should indicate who is signing the reimbursement check. This list is not editable and includes the following options:
1. Medicare A — Should only be chosen for the true Medicare payor (Medicare, PGBA, NGS, CGS, etc.).
2. Medicaid — Select for all traditional and waiver Medicaid payors. *Do NOT select for Room & Board.
3. Medicaid Room & Board— Select only for Medicaid Room & Board payors when submitting claims directly to the state Medicaid (not using clearinghouse).
4. Private Insurance — Should be chosen for all commercial payors (includingMedicare Advantage for private insurances like Humana, AETNA, etc.).*If submitting electronic claim files through a clearinghouse for Room & Board payor, users must choose Private Insuranceas the PaymentSource instead of Medicaid Room & Board.
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If submitting electronic claim files through a clearinghouse for Room & Board payor, users must choose Private Insurance as the Payment Source instead of Medicaid Room & Board. |
5. Self-Pay
6. Other — Do not use.
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Failure to follow these guidelines for Payment Source will cause errors on the claim creator screen for payors billed electronically or will not populate the appropriate fields of the claim form for those billed on paper. Additionally, the OASIS will extract based on how the plan question is answered within the OASIS document. |
5. Select the appropriate office or folder from the drop-down menu. By default, no offices are selected.
6. Choose the appropriate line of business.
7. Click 
at the top of the page.
8. Make sure the correct item is highlighted in the payor listing grid.
9. Highlight New in the Phones/Email section of the screen.
10. Enter the phone number in the field above.
11. Select the appropriate phone type from the drop-down menu (e.g. Office, Home, Cellular, etc.).
12. Click 
to save the phone number.
13. Repeat steps 9-12 for each phone/fax number that should be listed.
14. Click at the top of the page.
15. Electronic Remittance Advice: Select only if receiving the Remittance electronically from the Payor.
● ERA Adj Threshold is the amount the system will automatically adjust off the balance.
● Code is the adjustment code that is assigned to that amount.
16. Include multiple service type codes in 270 — If the payor accepts more than one service type code (STC) in eligibility verification, enter the maximum amount of STCs on request form 270. Refer to the “Payor Setup Guide” for more information on this.
● If the Payor does NOT support multiple STC codes in each 270 file, uncheck Include multiple service type codes box to the bottom-right.
● If the Payor DOES support multiple STC codes in each 270 file, check this box and enter the number of different STC codes that are allowed in a single 270 file in the Max per 270 field.
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