Whether you're just getting started with medical claims in CareStack or need a quick refresher, this guide walks you through everything, from setting up medical codes to submitting claims. Let’s dive in!
Topics Covered
- Set Up a Medical Code
- Set Up a Medical Plan
- Manage Medical Claim Submissions
- Set Up Medical Claim Form Defaults
- Add a Medical Insurance Plan
- Add & Manage Medical Codes
- Manage Medical Claims/Pre-Authorizations
- CDT Codes to Medical Codes Cross-Coding
Set Up a Medical Code
Please follow the guide listed here to add a medical code: Add, View, and Edit Procedure Codes.
A few key points to note:
- Medical codes would have ‘Code Type’ as ‘Medical’.
- Medical codes are not offered out-of-the-box, but are brought over during data conversion and can be added manually from the system.
Set Up a Medical Plan
Important points to take note of:
- Medical plans would have ‘Insurance Type’ as ‘Medical’.
- Claim Form Type would be ‘CMS1500’.
- To handle differing Carrier IDs or Claim Submission addresses, create a separate 'Address' under Carrier > Address Detail for use with Medical plans.
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Note: If you notice rejections due to the group number being present for Medicare claims, CareStack can skip sending the group number for all Medical plans with plan type ‘Medicare’. Please contact support@carestack.com to enable this. You would still need to enter a dummy group number value at the plan level, but this will not be sent along with the electronic claim. |
Manage Medical Claim Submissions
CareStack supports both paper and electronic channels for Medical Claims submission and only the paper channel for Pre-Authorizations.
Paper Claims
CareStack presently only supports the ‘CMS 1500’ form type for Paper Medical claims.
Electronic Claims
CareStack has partnered with the clearinghouse Availity to help with the electronic transmission of medical claims. Please contact support@carestack.com to get more information on the pricing and steps to get this feature enabled in your environment. Please note that some clients may be required to sign an additional Addendum to their CareStack Agreement before this feature can be activated.
| Note: CareStack presently does not support electronic attachments for medical claims. |
The list of insurance carriers supported by Availity can be found in the Payer List. Please filter by:
- Transaction Type: Professional Claims (837P).
Next, let's explore Payor Enrollment:
- Certain Payors require additional enrollment before a claim can be processed. Enrollment requires an Availity account: Availity Registration Link.
- Location-specific Availity accounts are not required since multiple locations (and providers) can be managed with a single account.
- To view payors that need enrollment, navigate to the Payer List and apply the 'Enrollment Required' filter.
- For certain payor enrollments, an additional Paid EDI plan is required. Payors that require this are indicated with a ‘Get EDI Plan’ tag:
- To upgrade your plan, click on the ‘Get EDI Plan’ link and follow the steps to completion.
- Since multiple locations/providers can be managed within a single account, activating the paid plan at the account level would suffice, even for enrollments across multiple locations/providers.
- All claim submissions would still go through CareStack. The paid plan is required purely for enrollment purposes and can be discontinued after enrollment(s) are done.
Set Up Medical Claim Form Defaults
CareStack allows you to choose the default values (at the account level) for certain fields inside a medical claim. This can be configured in Practice Settings > select Payments & Billing > Claim Form Defaults > Medical.
The different options are:
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Print CMS 1500 Claim Form
- Yes: Prints the entire CMS1500 claim form template along with the values
- No: Prints just the values and skips the CMS1500 template
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Is Patient's Condition Related To Employment?
- Field in CMS1500: 10.a
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Is Patient's Condition Related To Auto Accident?
- Field inside CMS1500: 10.b
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Is Patient's Condition Related To Other Accident?
- Field inside CMS1500: 10.c
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Patient's or Authorized Person's Signature
- Field inside CMS1500: 12
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Insured's or Authorized Person's Signature
- Field inside CMS1500:13
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Outside Lab?
- Field inside CMS1500: 20
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ICD Indicator
- The default value is ICD-10 and this is non-editable
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Place of Service
- Field inside CMS1500: 24.B
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Emergency
- Field inside CMS1500: 24.C
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Accept Assignment
- Field inside CMS1500: 27
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Qualifier for Date of Current Illness, Injury, or Pregnancy
- Field inside CMS1500: 14
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Date of Current Illness, Injury, or Pregnancy
- Field inside CMS1500: 14
Add a Medical Insurance Plan
a. At a patient level, a medical insurance plan can be added similar to how a dental insurance plan would be added.
b. A patient can have a Primary and a Secondary Medical Insurance plan. Please use the following guide for assigning and changing the hierarchy: Insurance Plan Hierarchy
Add & Manage Medical Codes
Medical codes can be added/managed similarly to how dental or custom codes are added/managed. Please use the following guide for workflows related to adding a medical code: Adding a code.
a. The billing order of a code is determined by the patient's active medical insurance(s) and the code-level 'Default Billing Order' setting. Based on these factors, the billing order can be:
- N: If the patient does not have an active Medical Insurance.
- M: If the patient has an active Primary Medical Insurance.
- MM: If the patient has a Primary and Secondary active Medical Insurance.
b. If the patient has Dental Insurance(s), the Billing order can factor in the ‘D’ billing order as well. The billing order would be a combination of the ‘D’ and ‘M’ billing orders, up to 3 characters. The ordering of the codes defines the order in which the system bills the insurance. For example:
- MD: Bill the Primary Medical first and then the Primary Dental.
- DM: Bill the Primary Dental first and then the Primary Dental.
- MDD: Bill the Primary Medical first, then the Primary Dental, followed by Secondary Dental.
- MMD: Bill the Primary Medical first, then the Secondary Medical, followed by Primary Dental.
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Note:
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Manage Medical Claims/Pre-Authorizations
Pre-Authorizations
A Medical Pre-Authorization can be created using the workflows mentioned in the following article: Pre-Auth Creation. Please note that the Pre-Auth makes use of a generic template with all relevant patient, provider, location, treatment information.
| Note: CareStack presently does not support electronic transmission of Medical Pre-Authorizations. |
Claims
A medical claim can be created for codes similar to how claims are created for dental codes. Please refer to the following guide: Claim creation workflow: Batch Claim Creation
- Generated claims can be viewed at the patient level (Billing > Claims) and inside the Claims module (System Menu > Claims).
- To filter for medical claims, use the filtering option and select ‘Medical’.
When you click on a claim, the Claim Details slide-out opens with 3 tabs:
Details : Shows a summarized version of the claim-related details.
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Form:
- Shows the relevant claims details inside the CMS1500 claim form template.
- Any field that is not greyed out can be edited.
- These edits are only at a claim level and it will not write back to the relevant areas.
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CDT-Medical Code CrossWalk
- Shows the default crosswalk logic used for mapping CDT codes to Medical codes. This is presently not editable.
CDT Codes to Medical Codes Cross-Coding
Watch this video for a quick overview.
CareStack allows you to map CDT codes to Medical codes before it is submitted to the Carrier. Before starting with the cross-coding workflow, please ensure relevant Medical Codes have already been added to the system via Practice Settings.
- To cross-code from CDT to Medical codes, click into the required claim.
- Then, navigate to the Form tab > click Take Action button (Field 24).
Clicking on the ‘Take Action’ button opens the Cross Coding workflow and this has 2 steps.
Step 1: Cross Code Codes
It lists the different codes that are presently inside the claim and the cross-coded Medical code(s) based on the mapping inside the CDT-Medical Codes CrossWalk tab.
For each code in the claim, you can select the cross-coded medical code that's listed or click on ‘+Add Medical Code’ and add a different medical code.
- After the required medical codes have been selected, you can either choose to:
- Apply & Close: This skips ‘Step 2: Merge Codes’ and adds the selected medical codes to the claim form.
- Apply & Proceed: Takes you to ‘Step 2: Merge Codes’.
Step 2: Merge Codes
- This step allows you to merge codes if similar medical codes were selected for the CDT codes in Step 1.
For eg:- Code 1 -> Medical Code 1 and Medical Code 2.
- Code 2 -> Medical Code 1 and Medical Code 2.
- Rather than having 4 separate line items (Medical Code 1 and Medical Code 2 twice) in the claim, Step 2 allows you to merge these into just 2 line items but each with the Quantity (Field 24.G) being 2.
Final result inside the claim form, Field 24:
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Note:
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Practices can use this simple guide to learn all about medical claims.