Referring Providers

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

The Referring Providers menu item on the Accounting menu launches the Referring Providers screen, which is used to enter Referring Provider information allowing users to associate a Referring Provider with a specific patient on the Billing Episodes screen. If a patient's Billing Episode is not associated with a Referring Provider, then no Referring Provider data is exported on EDI billing export files. Generally this screen is only used by facilities using Methasoft's third party billing functionality including exporting 837P EDI export files, and need Referring Provider data to be exported at the Claim level (in Loop 2310A) for submitted claims. Submitting Referring Provider data at the Service Line level (in Loop 2420F) is not currently supported. This screen can also be used to simply track Referring Provider data without associating Referring Providers to specific patients on the Billing Episodes screen.

Field Descriptions

Last Name

This field is used for entering the Last Name of a Referring Provider. The data entered in this field is exported to data element NM103 (Name Last) in the NM1 segment (Referring Provider Name) of Loop 2310A (Claim-level Referring Provider Name) on 837P billing export files.

First Name

This field is used for entering the First Name of a Referring Provider. The data entered in this field is exported to data element NM104 (Name First) in the NM1 segment (Referring Provider Name) of Loop 2310A (Claim-level Referring Provider Name) on 837P billing export files.

Middle Name / Initial

This field is used for entering the Middle Name or Middle Name Initial of a Referring Provider. The data entered in this field is exported to data element NM105 (Name Middle) in the NM1 segment (Referring Provider Name) of Loop 2310A (Claim-level Referring Provider Name) on 837P billing export files.

Suffix

If applicable, this field is used for entering the Suffix of a Referring Provider's name. The data entered in this field is exported to data element NM107 (Name Suffix) in the NM1 segment (Referring Provider Name) of Loop 2310A (Claim-level Referring Provider Name) on 837P billing export files.

Primary ID Code Type

This field is used for selecting the type of Primary ID Code used to identify a Referring Provider. The value selected in this field is currently limited to only one possible value 'XX - National Provider Identifier (NPI)' because that is the only value allowed for the 5010 837P export file format. The value selected in this field is exported to data element NM108 (Identification Code Qualifier) in the NM1 segment (Referring Provider Name) of Loop 2310A (Claim-level Referring Provider Name) on 837P billing export files.

Primary ID Code

The field is used for entering a Referring Provider's Primary ID Code, which currently is the Referring Provider's assigned 10-digit NPI number. The data entered in this field is exported to data element NM109 (Identification Code) in the NM1 segment (Referring Provider Name) of Loop 2310A (Claim-level Referring Provider Name) on 837P billing export files.

Secondary ID Code Type

When required by a Clearinghouse and/or Payer, this field is used to select the type of Secondary ID Code used to identify a Referring Provider. The value selected in this field is exported to data element REF01 (Reference Identification Qualifier) in the REF segment (Referring Provider Secondary Identification) of Loop 2310A (Claim-level Referring Provider Name) on 837P billing export files. When not required by a Clearinghouse and/or Payer, this field should be left blank.

Secondary ID Code

When required by a Clearinghouse and/or Payer, this field is used to enter the Secondary ID Code used to identify a Referring Provider. The data entered in this field is exported to data element REF02 (Reference Identification) in the REF segment (Referring Provider Secondary Identification) of Loop 2310A (Claim-level Referring Provider Name) on 837P billing export files. When not required by a Clearinghouse and/or Payer, this field should be left blank.

Grid Columns

Last Name

This column displays the Last Name of each Referring Provider as entered in the 'Last Name' field.

First Name

This column displays the First Name of each Referring Provider as entered in the 'First Name' field.

Middle Name

This column displays the Middle Name or Middle Name Initial of each Referring Provider as entered in the 'Middle Name / Initial' field.

Suffix

This column displays the Suffix of each Referring Provider's name, when applicable, as entered in the 'Suffix' field.

Primary ID

This column displays each Referring Provider's concatenated Primary ID Code Type and Primary ID Code as selected / entered in the corresponding 'Primary ID Code Type' and 'Primary ID Code' fields.

Secondary ID

This column displays each Referring Provider's concatenated Secondary ID Code Type and Secondary ID Code as selected / entered in the corresponding 'Secondary ID Code Type' and 'Secondary ID Code' fields.

Procedures

How to Add a Referring Provider
1.) Press the New button. 2.) Enter the Last Name of the Referring Provider in the 'Last Name' field. 3.) (Optional) Enter the First Name of the Referring Provider in the 'First Name' field. 4.) (Optional) Enter the Middle Name or Middle Name Initial of the Referring Provider's name in the 'Middle Name / Initial' field. 5.) (Optional) When applicable, enter the Suffix of the Referring Provider's name in the 'Suffix' field. 6.) Select the type of Primary ID Code used to identify the Referring Provider in the 'Primary ID Code Type' field (currently 'NPI' is the only available/allowed selection in this field). 7.) Enter the Primary ID Code used to identify the Referring Provider in the 'Primary ID Code' field. Currently this must be the Referring Provider's 10-digit assigned NPI (National Provider Identifier) number. 8.) (Optional) When requested by a Clearinghouse and/or Payer, select the type of Secondary ID Code used to identify the Referring Provider in the 'Secondary ID Code Type' field. 9.) (Optional) When requested by a Clearinghouse and/or Payer, enter the Referring Provider's Secondary ID Code in the 'Secondary ID Code' field. 10.) Press the Save button. The Referring Provider is now saved and appears on the grid.

How to Edit a Referring Provider
1.) Select the Referring Provider to be edited on the grid. 2.) Press the Edit button. 3.) Make changes as needed to data in the detail fields for the selected Referring Provider. 4.) Press the Save button. Any change(s) made are now saved and reflected on the grid.

How to Delete a Referring Provider
1.) Select the Referring Provider to be deleted on the grid. 2.) Press the Delete button. A 'Delete this Record?' application message will appear, confirming you wish to delete the selected Referring Provider. 3.) Press the Yes button to delete the selected Referring Provider or No to cancel. If the selected Referring Provider is deleted, the grid will refresh and no longer display the selected Referring Provider.

Considerations

Leaving the Referring Provider Field Blank on Billing Episodes Results in No Referring Provider Data Exported on EDI Billing Export Files

It is rare that Methasoft users use the Referring Providers screen, and generally the Referring Provider field is left blank for each patient on the Billing Episodes screen. Regardless of whether or not Referring Providers are entered on the Referring Providers screen, as long as the 'Referring Provider' field is left blank for each patient's Billing Episode, no Referring Data will be exported for Claims on 837P 5010 EDI export files. If a Referring Provider is selected for a patient's Billing Episode and Claims are generated based on that Billing Episode, then if those Claims are exported, the selected Referring Provider's data will be exported to Loop 2310A (at the Claim level) for every exported for that patient. Exported Referring Provider data is currently only patient-specific and is exported at the Claim level for all rendered Billable Services being claimed.

Export Functionality for Referring Provider Data is Currently Limited to the Claim Level

The 837P 5010 EDI format supports exporting Referring Provider data at both the Claim (Loop 2310A) and Service Line (Loop 2420F) levels. Methasoft currently only supports exporting Referring Data at the Claim level in Loop 2310A, which is why a Referring Provider is currently associated with a patient on the Billing Episodes screen - i.e., Referring Provider data is not currently Service-specific. This functionality will not change in the future unless it is determined that exporting Referring Provider data at the Service Line level in Loop 2420F needs to be implemented.

A Referring Provider Must be Associated with a Patient's Billing Episode Prior to Claim Generation in Order for Referring Provider Data to be Exported

If Claims have been generated for a patient, and then a user edit's the patient's current, effective Billing Episode and associates it with a Referring Provider, the selected Referring Provider's data will not be exported unless the previously generated Claims are deleted and re-generated. This is by design, because when Claims are generated, they are associated with a specific instance of the patient's associated Billing Episode. Once a Billing Episode is edited, a new instance of the edited Billing Episode is created.

Currently Only One Iteration of the Referring Provider Loop is Exported, and Thus Only 'DN' is Exported as the Entity Identifier Code Qualifier

For the 837P 5010 EDI format standard, the Referring Provider Segments can repeat up to twice per Loop (either Loop 2310A or Loop 2420F). Currently when exported from Methasoft, only one iteration of Referring Provider Segments will export to Loop 2310A at the Claim level. Because of this, 'DN' (Referring Providers) will always be exported to the data element NM101 (Entity Identifier Code) value in the NM1 segment (Referring Provider Name) of Loop 2310A (Claim-level Referring Provider Name) on 837P billing export files. The only other possible value, 'P3' (Primary Care Provider) that can be exported to this data element is only allowed if the NM1 segment repeats, which is currently unsupported in Methasoft.

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.