Hipaamagic has the ability to fill in the ANSI required provider data from a lookup table. The table is called the Provider table. It can be found and maintained by clicking on the DATA menu option of the main menu. There should be an entry in the Provider table for each billing entity whose claims will be translated as well as an entry in the table for each rendering provider who is a member of the billing entity. A billing entity is something like Marcus Welby MD LLC. A rendering provider is Dr Marcus Welby. Even a solo practitioner will have TWO entries in the provider table. A larger group practice will have an entry in the provider table for the billing entity and each rendering provider will have an individual entry in the table.

The national standard format lists the billing provider data in the BA0 and BA1 records. The information which is used to find the BILLING PROVIDER is in the BA0 record of the NSF in positions 4 through 20. (You may view an NSF file by selecting the View NSF File option of the DATA menu option.) This field is referred to as the BA0_02 field. It is also called the EMC, electronic media claims, identifier. The claim level referring provider is normally found in the EA0 record in an NSF file. The rendering providers are found in the FA0 and FB1 records. There is a detailed explanation of where this data is found in the NSF file and how it is mapped in HIPAAMagic below:

Billing and Pay to Provider: All billing and pay to provider loops are filled with data from the NSF file first and overwritten with data from the provider lookup tables if the Slam It button is checked. The key field for lookup is the BA0_02 field in the NSF file. The BA0_02 field is the first field on the provider table form from the data menu. First page frame, upper left, and when the mouse is placed on it you see a tool tip that says BA0_02. The billing provider entry in the Provider table should have the billing provider specialty code filled in as well as the group or practice employer?s tax id, with a ?24? qualifier. The contact field and the contact phone number are also required. Use no punctuation in the phone number.

If you want the payments to go to a different location than the place where services are performed, such as a lock box, then you can fill in the data for the Pay To Provider in the provider lookup table. The translator will still use the BA0_02 field as a key to find the billing provider and it will substitute the data under the Pay to Provider tabs to replace the pay to provider data in the BA1 record, as long as the Slam It radio button is selected. The only time you need to have any data in the Pay to Provider screens is for billing provider entities. Pay to provider data will be ignored for all other types of providers, referring, rendering, supervising, and so on.

Rendering Provider: Claim Level or 2310B loop. The first detail service line in the NSF is searched for the existence of either FA0_23 or FB1_14 or FB1_17. These fields in the NSF are Rendering provider NPI, Rendering Provider last name or Company Name and Rendering Provider UPIN respectively. If you don?t have any of these fields then you do not get a rendering provider loop in the ANSI file at either the claim level or the detail level, 2310B or 2420A loops.

If you have one or more of the FA0_23, FB1_14 or FB1_17 fields we will try to find the provider in the provider table as follows:

First we will use the FA0_23, rendering provider NPI field to look up the provider in the provider table. This is the Provider Medicare ID in the Provider table. It is on the second page frame of the provider maintenance form under the Billing Provider ID?s tab. Remember FA0_23 = Medicare ID in Provider table. None of the other ID numbers in the table are used in this search.

Second, if the FA0_23 field is blank we will use the FB1_17 rendering provider UPIN number to search the provider table. This is the Provider UPIN in the provider table. It is on the second page frame of the provider maintenance form under the Billing Provider ID?s tab. Remember FB1_17 = Provider UPIN ID in Provider table. None of the other ID numbers in the table are used in this search.

Once the correct provider record is found, the NM1 segment and any applicable ref segments are filled in, in the ANSI file.

If there are subsequent entries in the rendering provider fields on detail records other than the first detail record, FA0 sequence 02 or higher, they will be used and included in the ANSI file only if they are different than the first detail record. All of the above searching and replacement of data for rendering providers will be done only if the Rendering Provider checkbox is checked at the bottom of the provider record screen.

Referring provider: Claim level 2310A loop.
For the claim level referring provider we look first in the EA0_21 field for a UPIN number and then in the EA0_20 for the referring provider NPI or Medicare ID. The Provider table is searched using the Provider UPIN as the key field or the Provider Medicare ID in the event that the first search is unsuccessful. If there is no entry in the EA0 record for referring provider we will use the entry in the first detail line or FA0 record to apply to the entire claim. If there are subsequent entries in the detail records for referring provider, they will be included in the ANSI output file only if they are different than the first detail record entry. All of the above searching and replacement of data for Referring Providers will be done only if the Referring Provider checkbox is checked at the bottom of the provider record screen.

Referring Provider: Detail level 2420F loop.
For the detail level referring provider we use the FA0_24 field first and then the FB1_13 field second to search for the provider record in the provider table. If there is an FA0_24 entry and we get a hit on the provider table using the Medicare ID as the key field we will then ignore the FB1_13 information if we have the referring provider radio button checked and Slam It checked also. All of the above searching and replacement of data for Referring Providers will be done only if the Referring Provider checkbox is checked at the bottom of the provider record screen.

Supervising, Ordering and Other Providers in 2400 level detail loops.
These lookups will be handled in essentially the same way as the detail rendering and referring providers. The system will use either their UPIN or NSF defined NPI / Medicare numbers to find the records in the provider table and will substitute the data from the provider record if the provider is found and has the appropriate provider type checkbox checked in the provider form, supervising, Ordering etc. All of the above searching and replacement of data for Referring Providers will be done only if the appropriate type of provider checkbox is checked at the bottom of the provider record screen.

A note about the Information, Use It and Slam It radio buttons: These buttons determine how the data entered into the form above them will be used. If the Information button is selected, the system will not use the data in the provider record at all. It becomes a convenient place to store the data, but it won?t get used. If the Use It button is selected, the system will use the data from the provider record to fill in blanks in the data from the NSF file. If data is in the NSF file, it will not be overwritten. If the Slam It button is checked, the system will overwrite data in the NSF file with data from the provider record. If the data from the NSF record is filled in and the data in the provider record is blank for a particular field, the NSF data will prevail. The system will not overwrite non-blank data with blank spaces.

Empire Medical Review Services, Inc
11357 North Port Washington Road
Phone: 262.240.9700
Mequon, Wisconsin 53092