Pay-to Providers

(Topic Last Updated On: 06/08/2015)

The Pay-to-Providers menu item on the Accounting menu launches the Pay-to-Providers screen. This screen is rarely used, because Pay-to-Provider data is only required when the Pay-to-Provider is a different entity from a facility's Billing Provider, which we have rarely seen amongst users of Methasoft. For facilities continuing to submit 4010 EDI billing export files, the difference between the Billing Provider and Pay-to Provider could include Name, Primary ID, and/or Address data. For facilities exporting 5010 EDI export files, the difference between the Billing Provider and Pay-to Provider is strictly limited to Address data (See 'Considerations' section below regarding the new 5010 Loop 2010AC). However, when necessary, this screen is used to enter the necessary data for one or more Pay-to Providers in facilities using Methasoft's Billing Export functionality to export electronic claims. Some facilities that don't use Methasoft's Billing Export functionality still use this screen to store Pay-to Provider data if managing Third Party balances and/or billing activity outside of Methasoft. Pay-to Providers entered on this screen appear available for selection on the Receiver Format screen, which associates a Pay-to Provider with essential Billing Export header data. Then when the associated Receiver Format is selected on the Billing Export window, Methasoft knows which Pay-to Provider's data to export along with the associated Receiver Format data. Most commonly a facility using the Billing Export screen to export EDI files does not have a Pay-to Provider record on this screen, because the Pay-to Provider is the same entity with the same physical address as the Billing Provider, in which case entering data on this screen will cause billing export file rejections.

Field Descriptions

Entity Type

This field is used for selecting the Entity ID Code/type of the pay-to provider. The value '2 - Non-Person' is selected by default in this field when adding a new pay-to provider, because it is highly unusual that the pay-to provider is a person (possible exception being when, as examples, a facility's parent company, owner, or Medical Director/Doctor is the pay-to provider). The value selected in this field is exported to the data element NM101 (Entity ID Code) in the NM1 (Pay-to Address Name) segment of Loop 2010AB on billing export files, and is mandatory in order for the file to be accepted. For 5010 EDI exports, this data is the only user-entered data exported.

Last/Organization Name

If the '2 - Non-Person' is entered as the 'Entity Type' in the field above, then this field is used for entering the name of the pay-to provider. In the rare case that '1 - Person' is selected in the 'Entity Type' field above, then this field is used for entering the Last Name of the pay-to provider. The text entered in this field is exported to the data element NM103 (Name Last/Org Name) in the NM1 (Pay-to Provider Name) segment of Loop 2010AB on 4010 billing export files, in which case this data is mandatory in order for the file to be accepted. For 5010 EDI files this data element is no longer used, and thus this data is not exported.

First Name

Generally this field is not used. In the rare case that '1 - Person' is selected in the 'Entity Type' field above, then this field is used for entering the First Name of the billing provider. The text entered in this field is exported to the data element NM104 (Name First) in the NM1 (Pay-to Provider Name) segment of Loop 2010AB on 4010 billing export files, in which case this data is mandatory in order for the file to be accepted. For 5010 EDI files this data element is no longer used, and thus this data is not exported.

Middle Name/Initial

Generally this field is not used. In the rare case that '1 - Person' is selected in the 'Entity Type' field above, then this field is used for entering the Middle Name or Middle Name Initial of the pay-to provider. The text entered in this field is exported to the data element NM105 (Name Middle) in the NM1 (Pay-to Provider Name) segment of Loop 2010AB on 4010 billing export files, and may not be mandatory in order for the file to be accepted, depending on the clearinghouse and/or payer(s) involved. For 5010 EDI files this data element is no longer used, and thus this data is never exported.

Suffix

Generally this field is not used. In the rare case that '1 - Person' is selected in the 'Entity Type' field above, then this field is used for entering the Suffix (when applicable) of the pay-to provider's name. The text entered in this field is exported to the data element NM107 (Name Suffix) in the NM1 (Pay-to Provider Name) segment of Loop 2010AB on 4010 billing export files, and may not be mandatory in order for the file to be accepted, depending on the clearinghouse and/or payer(s) involved. For 5010 EDI files this data element is no longer used, and thus this data is never exported.

Primary ID Code Type

This field is a required field because the data is mandatory in order for a 4010 billing export file to be accepted. For 5010 EDI files this data element is no longer used, and thus this data is never exported. The value 'XX - National Provider Identifier (NPI)' is selected by default when adding a pay-to provider, because this value is the most commonly used value, and also the only acceptable value allowed by the 5010 EDI standard (See 'Considerations' section below regarding Loop 2010AC). The value selected in this field is exported to the data element NM108 (ID Code Qualifier) in the NM1 (Pay-to Provider Name) segment of Loop 2010AB on 4010 billing export files.

Primary ID Code

This field is a required field because the data is mandatory in order for a 4010 billing export file to be accepted. For 5010 EDI files this data element is no longer used, and thus this data is never exported. The 10-digit NPI number entered in this field is exported to the data element NM109 (ID Code) in the NM1 (Pay-to Provider Name) segment of Loop 2010AB on 4010 billing export files, in which case it is mandatory in order for the file to be accepted.

Secondary ID Code Type

Generally this field is not used. This field should only be used by a facility that continues to submit 4010 EDI files to a Payer that requires Secondary ID data on billing export files. A value selected in this field is not exported for 5010 export files. See the 'Considerations' section below regarding Loop 2010AC.

Secondary ID Code

Generally this field is not used. This field should only be used by a facility that continues to submit 4010 EDI files to a Payer that requires Secondary ID data on billing export files. Data entered in this field is not exported for 5010 export files. See the 'Considerations' section below regarding Loop 2010AC.

Taxonomy Code

This field is used for informational purposes only if a pay-to provider has an assigned Taxonomy Code. This value is not exported to either 4010 or 5010 EDI export files, because neither format has a data element to which to export this value.

Address 1

This field is used for entering the first Address line, the street address, of the pay-to provider's address. This field is required because this data is mandatory in order for billing export files to be accepted for facilities submitting 4010 EDI files. The text entered in this field is exported to the data element N301 (Address Information) in the N3 segment (Pay-to Provider Address) of Loop 2010AB on 4010 billing export files. Data entered in this field is not exported for 5010 export files. See the 'Considerations' section below regarding Loop 2010AC.

Address 2

This field is optional and used for entering a second Address line of the pay-to provider's address if needed, such as a Suite number or letter. The text entered in this field is exported to the data element N302 (Address Information) in the N3 segment (Pay-to Provider Address) of Loop 2010AB on 4010 billing export files. Data entered in this field is not exported for 5010 export files. See the 'Considerations' section below regarding Loop 2010AC.

City

This field is required for 4010 EDI files and is used for entering the City of the pay-to provider's address. The text entered in this field is exported to the data element N401 (City Name) in the N4 segment (Pay-to Provider City, State, Zip Code) of Loop 2010AB on 4010 billing export files. Data entered in this field is not exported for 5010 export files. See the 'Considerations' section below regarding Loop 2010AC.

State/Province

This field is required for 4010 EDI files and is used for selecting the 2-letter State abbreviation of the pay-to provider's address. The value selected in this field is exported to the data element N402 (State or Prov. Code) in the N4 segment (Pay-to Provider City, State, Zip Code) of Loop 2010AB on 4010 billing export files. Data entered in this field is not exported for 5010 export files. See the 'Considerations' section below regarding Loop 2010AC.

Postal Code

This field is required for 4010 EDI files and is used for entering the 5-9-digit Postal/Zip Code of the pay-to provider's address, as specified by a clearinghouse or payer. The code entered in this field is exported to the data element N403 (Postal Code) in the N4 segment (Pay-to Provider City, State, Zip Code) of Loop 2010AB on 4010 billing export files. Data entered in this field is not exported for 5010 export files. See the 'Considerations' section below regarding Loop 2010AC.

Country

This field is used for selecting the Country of the pay-to provider's Address. The 'US - United States' value is selected by default in this field and can be left alone, because currently this value is unnecessary and not being exported to any billing export files.

Grid Columns

Name

This column displays the Name entered for each Pay-to Provider in the 'Last/Organization Name' field.

Primary ID Code Type

This column displays the Primary ID Code Type/Qualifier selected for each Pay-to Provider in the 'Primary ID Code Type' field.

Primary ID Code

This column displays the Primary ID Code entered for each Pay-to Provider in the 'Primary ID Code' field.

Secondary ID Code Type

This column displays the Secondary ID Code Type/Qualifier selected for each Pay-to Provider in the 'Secondary ID Code Type' field.

Secondary ID Code

This column displays the 'Secondary ID Code' entered for each Pay-to Provider in the 'Secondary ID Code' field.

Procedures

How to Add a Pay-to Provider
***Note: Only enter a Pay-to Provider if your facility's Pay-to Provider is a different entity or has a different address than your facility's Billing Provider. 1.) Press the New button. 2.) Select the 'Entity Type' of the Pay-to Provider. '2 - Non-Person' is selected by default because generally the Pay-to Provider is the service facility. 3.) If '2 - Non-Person' is selected in the 'Entity Type' field, enter the Organization Name of the Pay-to Provider in the 'Last/Organization Name' field. If '1 - Person' is selected in the 'Entity Type' field, enter the Last Name of the Pay-to Provider in the 'Last/Organization Name' field. 4.) (Optional) If '1 - Person' is selected in the 'Entity Type' field, enter the First Name of the Pay-to Provider in the 'First Name' field. 5.) (Optional) If '1 - Person' is selected in the 'Entity Type' field, enter the Middle Name or Middle Name Initial of the Pay-to Provider in the 'Middle Name/Initial' field. 6.) (Optional) If '1 - Person' is selected in the 'Entity Type' field, enter the Name Suffix of the Pay-to Provider, if applicable, in the 'Suffix' field. 7.) Select the Primary ID Code Type of the Pay-to Provider in the 'Primary ID Code Type' field. 'XX - National Provider Identifier (NPI)' is selected by default because it is the most common type of ID used. 8.) Enter the 10-digit NPI code of the Pay-to Provider in the 'Primary ID Code' field, provided that this is the type of Primary ID selected in Step 7. 9.) (Optional) Select a Secondary ID Code Type value in the 'Secondary ID Code Type' field. 10.) (Optional) Enter the Pay-to Provider's Secondary ID Code in the 'Secondary ID Code' field, for the appropriate type of code selected in Step 9. 11.) (Optional) Enter the Pay-to Provider's Taxonomy Code in the 'Taxonomy Code' field. 12.) Enter the 1st line of the Pay-to Provider's Street Address in the 'Address 1' field. 13.) (Optional) When applicable, enter the 2nd line of the Pay-to Provider's Street Address in the 'Address 2' field. 14.) Enter the name of the City of the Pay-to Provider's address in the 'City' field. 15.) Select the capitalized abbreviation for the State of the Pay-to Provider's address in the 'State/Province' field. 16.) Depending on your facility's clearinghouse or payer requirements, enter the 5 or 9-digit zip code of the Pay-to Provider's address in the 'Postal Code' field. 17.) (Optional) Select the Country of the Pay-to Provider's address in the 'Country' field. The 'US - United States' is selected by default. 18.) Press the Save button. The Pay-to Provider is now saved and appears on the grid.

How to Edit a Pay-to Provider
1.) Select the Pay-to Provider you wish to edit on the grid. 2.) Press the EDIT button. 3.) Make changes as needed in the detail section of the screen. 4.) Press the SAVE button.

How to Delete a Pay-to Provider
1.) Select the Pay-to Provider you wish to delete on the grid. 2.) Press the Delete button. An application message will appear, confirming you wish to delete the selected provider. 3.) Press the YES button to delete the selected provider or No to cancel.

Considerations

Why Would a Service Facility Ever Need More Than One Pay-to Provider?

Though it is rare to see even one Pay-to Provider record on this screen, highly unusual circumstances could require even more than one Pay-to Provider record on this screen in a given facility. It might be necessary due to unusual clearinghouse and/or payer requirements. For example, if a facility submits to 2 different payers, and one of them requires a 'Secondary ID Code Type' and 'Secondary ID Code' but the other doesn't, then there is no other option but to enter not only 2 separate Billing Provider and Pay-to Provider records, but also 2 separate Receiver Format records so that each can be associated properly for use on the Billing Export window.

Loop 2010AC - Pay-to Plan Name

This loop is new for the 5010 EDI format, and essentially replaces the data elements no longer used by the 5010 format in Loop 2010AB. We've never seen this loop needed by Methasoft users, thus this loop is not currently supported by Methasoft.

Editing or Deleting Pay-to Providers for Third Party Billing - Potential Timing/Workflow Issues Related to Billing Export

When editing a Pay-to Provider for whom claims are being exported, it is important to consider the timing of the edit. For example, some data entered on this screen is retrieved at the time of exporting generated Claims. Thus, if Claims have already been exported but not yet submitted to a Payer, it is generally a good rule of thumb to edit the Pay-to Provider data then re-export the unsubmitted Claims. All staff responsible for billing activities within a facility should make sure they understand the billing workflow within their facility, and communicate changes that are being made in Methasoft accordingly, in order to minimize billing export file rejection. The same principles above apply when deleting a Pay-to Provider.

Dropdown Selection Fields - (4010) and (5010) Value Indicators

In numerous dropdown selection fields used on various Billing-related screens, you will notice '(5010)', '(4010)', or nothing following each value. These indicators are there to allow Methasoft to continue to support customers submitting 4010 EDI files until the transition from 4010 to 5010 is fully complete, at which time deprecation of 4010 functionality is expected. If '(5010)' appears following a value, this means that the value is only valid for 5010 EDI file submissions. If '(4010)' appears following a value, this means that the value is only valid for 4010 EDI file submissions. If nothing appears following a value, this means that the value can be legitimately used for both 4010 or 5010 EDI file submissions (i.e., these values were carried over from 4010 to 5010).

Dynamic Enable / Disable, Cascading (Filtered) Dropdown Selections, and Required Field Functionality

This screen includes functionality that will automatically enable or disable fields, filter subsequent dropdown combo field selection lists, and/or require fields dynamically depending on the selections made in other related fields. For example, if no value is selected in a Secondary ID Code Type field, then the Secondary ID Code field will be disabled. But once a value is selected in the Secondary ID Code Type field, not only does the Secondary ID Code field become enabled, it also becomes required. An example of Cascading (Filtered) Dropdown functionality is when a value selected in one combo dropdown field determines which dropdown values are available for selection in another dropdown field by filtering out invalid selections. This functionality exists to minimize erroneous data entry, and particularly the generation / export of invalid EDI files such as the 837P, which will be rejected by either a clearinghouse and/or payer. This functionality is in addition to, and when applicable will override, initial required field functionality which operates when a New record is being entered, no data is entered in any field, and the Save button is pressed.