Rendering Providers

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

The Rendering Providers menu item on the Accounting menu launches the Rendering Providers screen. This screen is used to store Rendering Provider data in Methasoft for medical billing functionality. Once entered on this screen, Rendering Providers are then associated with specific Billable Services on the Billable Services screen. A Billable Service can be associated with one specific Rendering Provider by selecting 'Specific Provider' in the 'Rendering Provider Type' field, or can be associated with multiple potential Rendering Providers by selecting 'Entered By' in the 'Rendering Provider Type' field and associating users with Rendering Providers on the Employee Profile screen. This screen is used by facilities either using Methasoft to track medical billing claim data, or by those using Methasoft's full medical billing functionality to export EDI billing files for claim submission. The Rendering Providers screen provides the necessary fields for collecting the data necessary for exporting valid EDI billing files for claims submission. Rendering Providers entered on this screen appear available for selection in the 'Rendering Provider' field on the Billable Services screen when using the 'Specific Provider' type, and on the Third Party Billing Association pop-up window accessed on the Employee Profile screen when using Billable Services configured to use the 'Entered By' type. By associating a user with a Rendering Provider record, Methasoft knows which Rendering Provider provided an applicable 'Entered By' Billable Service based on the user who is logged in and enters data for the service rendered. Billable Services configured to use the 'Specific Provider' type will always be associated with the specific provider selected on the Billable Services screen regardless of the user who is logged in and enters data for the service rendered. We have commonly seen only one record on this screen, which is the facility itself and is associated with one or more Dosing billable services. This is one of several reasons we install a 'Site Rendering Provider' record by default. We have also commonly seen a facility's Doctor as the only Rendering Provider record being used, generally associated with one or more Dosing billable services. For facilities generating and/or exporting billing claims for service types beyond Dosing services, we have commonly seen many records entered on this screen and heavier use of the 'Entered By' 'Rendering Provider Type' functionality available on the Billable Services screen. For Self-Pay-Only facilities, this screen is essentially irrelevant because the default 'Site Rendering Provider' record will always be used for setting up necessary Billable Services. See the 'Considerations' section below, as some Payers have specific requirements regarding the submission of Rendering Provider data on electronic billing claims.

Field Descriptions

Entity Type

This field is used for selecting the Entity ID Code/type of the rendering provider. The value selected in this field is exported to the data element NM101 (Entity ID Code) in the NM1 (Rendering Provider Name) segment of either Loop 2310B or Loop 2420A on billing export files (see 'Considerations' section below), and is mandatory in order for the file to be accepted.

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 rendering provider. If '1 - Person' is selected in the 'Entity Type' field above, then this field is used for entering the Last Name of the rendering provider. The text entered in this field is exported to the data element NM103 (Name Last/Org Name) in the NM1 (Rendering Provider Name) segment of either Loop 2310B or Loop 2420A on billing export files (see 'Considerations' section below), in which case this data is mandatory in order for the file to be accepted.

First Name

In the case that '1 - Person' is selected in the 'Entity Type' field above, then this field is used for entering the First Name of the rendering provider. The text entered in this field is exported to the data element NM104 (Name First) in the NM1 (Rendering Provider Name) segment of either Loop 2310B or Loop 2420A on billing export files (see 'Considerations' section below), in which case this data is mandatory in order for the file to be accepted.

Middle Name/Initial

Generally this field is not used. In the 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 rendering provider. The text entered in this field is exported to the data element NM105 (Name Middle) in the NM1 (Rendering Provider Name) segment of either Loop 2310B or Loop 2420A on billing export files (see 'Considerations' section below), and may not be mandatory in order for the file to be accepted, depending on the clearinghouse and/or payer(s) involved.

Suffix

Generally this field is not used. In the 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 (Rendering Provider Name) segment of either Loop 2310B or Loop 2420A on billing export files (see 'Considerations' section below), and may not be mandatory in order for the file to be accepted, depending on the clearinghouse and/or payer(s) involved.

Primary ID Code Type

This field is a required field because the data is mandatory in order for a billing export file to be accepted. The value 'XX - National Provider Identifier (NPI)' is selected by default when adding a rendering 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). The value selected in this field is exported to the data element NM108 (ID Code Qualifier) in the NM1 (Rendering Provider Name) segment of either Loop 2310B or Loop 2420A on billing export files (see 'Considerations' section below).

Primary ID Code

This field is a required field because the data is mandatory in order for a billing export file to be accepted. The 10-digit NPI number entered in this field is exported to the data element NM109 (ID Code) in the NM1 (Rendering Provider Name) segment of either Loop 2310B or Loop 2420A on billing export files (see 'Considerations' section below).

Secondary ID Code Type

Generally this field is not used. This field should only be used if a payer and/or clearinghouse requires submission of rendering provider Secondary ID data on billing export files. If used, the value selected in this field is exported to the data element REF01 (Reference ID Qualifier) in the REF (Rendering Provider Secondary ID) segment of either Loop 2310B or Loop 2420A on billing export files (see 'Considerations' section below).

Secondary ID Code

Generally this field is not used. This field should only be used if a payer and/or clearinghouse requires submission of rendering provider Secondary ID data on billing export files. If used, the value selected in this field is exported to the data element REF02 (Reference ID) in the REF (Rendering Provider Secondary ID) segment of either Loop 2310B or Loop 2420A on billing export files (see 'Considerations' section below).

Taxonomy Code

This field is only used if required by a payer and/or clearinghouse for claim adjudication. When used, a rendering provider's taxonomy code is entered in this field, and this value is exported to the data element PRV03 (Rendering Provider Taxonomy Code / Reference ID) in the PRV (Rendering Provider Specialty Information) segment of either Loop 2310B or Loop 2420A on billing export files (see 'Considerations' section below).

Address 1

This field is used for entering the first Address line, the street address, of the rendering provider's address. This field is not required because this data is not exported for either 4010 or 5010 EDI billing export files (no data element exists).

Address 2

This field is optional and used for entering a second Address line of the rendering provider's address if needed, such as a Suite number or letter. This field is not required because this data is not exported for either 4010 or 5010 EDI billing export files (no data element exists).

City

This field is used for entering the City of the rendering provider's address. This field is not required because this data is not exported for either 4010 or 5010 EDI billing export files (no data element exists).

State/Province

This field is used for entering the 2-letter State abbreviation of the rendering provider's address. This field is not required because this data is not exported for either 4010 or 5010 EDI billing export files (no data element exists).

Postal Code

This field is used for entering the 5-9-digit Postal/Zip Code of the rendering provider's address. This field is not required because this data is not exported for either 4010 or 5010 EDI billing export files (no data element exists).

Country

This field is used for selecting the Country of the rendering 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 is not being exported to any billing export files.

Grid Columns

Rendering Provider Name

This column displays the Organization Name entered for each Non-Person Rendering Provider in the 'Last/Organization Name' field. If the Rendering Provider is a Person, then this column displays the Last Name, First Name of the Rendering Provider.

Primary ID

This column displays the Primary ID Code entered for each Rendering Provider in the 'Primary ID Code' field.

Secondary ID

This column displays the Secondary ID Code entered for each Rendering Provider in the 'Secondary ID Code' field.

Taxonomy Code

This column displays the Taxonomy Code entered for each Rendering Provider in the 'Taxonomy Code' field.

Procedures

How to Add a Rendering Provider
1.) Press the New button. 2.) Select the 'Entity Type' of the Rendering Provider. If the Rendering Provider is a person, select '1 - Person'. If the Rendering Provider is a facility selected '2 - Non-Person'. 3.) If '2 - Non-Person' is selected in the 'Entity Type' field, enter the Organization Name of the Rendering Provider in the 'Last/Organization Name' field. If '1 - Person' is selected in the 'Entity Type' field, enter the Last Name of the Rendering 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 Rendering 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 Rendering 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 Rendering Provider, if applicable, in the 'Suffix' field. 7.) Select the Primary ID Code Type of the Rendering 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, and the only acceptable 837P 5010 format value. 8.) Enter the 10-digit NPI code of the Rendering 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 Rendering Provider's Secondary ID Code in the 'Secondary ID Code' field, for the appropriate type of code selected in Step 9. 11.) (Optional) If required by a payer and/or clearinghouse, enter the Rendering Provider's Taxonomy Code in the 'Taxonomy Code' field. 12.) (Optional) Enter the 1st line of the Rendering Provider's Street Address in the 'Address 1' field. 13.) (Optional) When applicable, enter the 2nd line of the Rendering Provider's Street Address in the 'Address 2' field. 14.) (Optional) Enter the name of the City of the Rendering Provider's address in the 'City' field. 15.) (Optional) Enter the 2-character capitalized abbreviation for the State of the Rendering Provider's address in the 'State/Province' field. 16.) (Optional) Enter the 5 or 9-digit zip code of the Rendering Provider's address in the 'Postal Code' field. 17.) (Optional) Select the Country of the Rendering Provider's address in the 'Country' field. The 'US - United States' is selected by default. 18.) Press the Save button. The Rendering Provider is now saved and appears on the grid.

How to Edit a Rendering Provider
***Note: See 'Considerations' section below regarding Editing or Deleting a Rendering Provider. 1.) Select the Rendering 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 Associate a Rendering Provider with a Methasoft User for 'Entered By' Billable Services
1.) Open the Employee Profile screen. 2.) Select the Methasoft User with whom you wish to associate a Rendering Provider on the grid. 3.) Press the Billing Assoc. button to launch the Third Party Billing Association pop-up window. 4.) On the Third Party Billing Association pop-up window, select the Rendering Provider you wish to associate with the selected Methasoft User in the 'Associated Provider' field. 5.) Press the SAVE button. The 'Successful Association' confirmation message will appear, confirming your association has been saved. 6.) Press the OK button. The Methasoft User is now associated with the Rendering Provider selected.

How to Delete a Rendering Provider
***Note: See 'Considerations' section below regarding Editing or Deleting a Rendering Provider. 1.) Select the Rendering 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

Self-Pay-Only Facilities Do Not Need to Use This Screen

If your facility does not track any third party billing data, or does not track such for Rendering Providers, then your facility should never need to access this screen. Instead, when configuring your Billable Services, always select 'Specific Provider' as the 'Rendering Provider Type', and then the default 'Site Rendering Provider' selection.

You Must Associate Rendering Providers (Persons) With Methasoft Users for 'Entered By' Billable Services to Function Properly

If the entered Rendering Provider is a Person and will be entered data for rendered billable services configured to use the 'Entered By' 'Rendering Provider Type', then you must access the Employee Profile screen and press the Billing Assoc. button to launch the Third Party Billing Association pop-up window to associate the Rendering Provider with a Methasoft User in order for all billing/claim/export file functionality to work properly.

Editing or Deleting Rendering Provider and/or Methasoft Users - Be Careful

Methasoft attempts to cover as many scenarios as possible to prevent users from creating bad data, or losing data, by inadvertently deleting a Rendering Provider that is currently in use, or has previously been associated with rendered billable services. However users should exercise caution when editing or deleting a Rendering Provider record on this screen to prevent the possibility of losing data necessary for third party billing functionality, whether past or present. It is recommended that you do not delete a Rendering Provider record unless it is absolutely necessary and you are certain that the provider being deleted has not been used to enter rendered service data. Editing a Rendering Provider is less dangerous, provided that you do not change the name of the Rendering Provider in a harmful manner - for example, changing the first and last name of a Rendering Provider to another person.

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

Related to the Consideration above this one, when editing a Rendering 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 Rendering 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. Similar examples apply to the timing of claim generation, along with the timing of export file generation and/or submission. And all of these principles apply when deleting a Rendering Provider, even more than when editing a service.

Specific / Unique Payer Requirements for Rendering Provider Data - Inclusion or Exclusion (Related to Loop 2010AA)

According to the 5010 837P format mandate, if the Rendering Provider is the same as your facility's Billing Provider, then Rendering Provider data should not be submitted. However, we have encountered cases where a payer and/or clearinghouse defies this mandate and requires both to be submitted. We have also encountered cases where the Rendering Provider was not the same as the Billing Provider, but the clearinghouse and/or payer would not accept files with any Rendering Provider data. The payer always wins, so proceed accordingly. And the clearinghouse always wins, if your facility's clearinghouse is the gatekeeper for adjudicating claims to one or more payers. Methasoft Billing functionality is flexible enough to handle these intricacies, but the configuration changes needed to change export behavior may require the help of a Methasoft Support Specialist.

Specific / Unique Payer Requirements for Rendering Provider Data - Loop 2310B or Loop 2420A

According to the 5010 837P format mandate, Rendering Provider data should be exported to Loop 2310B and applies to each service line of a claim, provided that only one Rendering Provider rendered each of the services (contained in service lines) within the claim. If more than one Rendering Provider is involved, then one provider should be exported to Loop 2310B, and any additional providers should be exported to Loop 2420A, but only for the services (service lines) each provider rendered. Generally this standard formula works out, however we have observed cases where a clearinghouse and/or payer overrides this standard and creates their own requirements. Methasoft Billing functionality is flexible enough to handle these intricacies, but the configuration changes needed to change export behavior may require the help of a Methasoft Support Specialist.

Specific / Unique Payer Requirements for Rendering Provider Data - Number of Service Lines per Claim Allowed

Some clearinghouses and/or payers (typically payers) have specific requirements related to the number of service lines per claim they allow to be submitted. In Methasoft this is controlled by the 'Lines Per Claim' value on the Payer/Rate Groups screen, which by default is set to 50. However if a clearinghouse and/or payer requires this value to be changed, it can impact the 2 considerations above this one significantly. Methasoft Billing functionality is flexible enough to handle these intricacies, but the configuration changes needed to change export behavior may require the help of a Methasoft Support Specialist.

Rendering Provider Data can be Edited on the Service Line Management Window

Note that on the Claims Generator screen, pressing the Edit Service Line button will launch the Service Line Management window for editing some service line data, including Rendering Provider data. Using this functionality is not recommended because the resulting data can be confusing later based on established Billable Service and Rendering Provider configuration(s), however it is an available option to accommodate unusual scenarios.

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.