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Module 1: Setting Up Insurers, Billing Codes & Billing Info

As a US Biller, there are 5 learning modules for you to walk through before you get up and running with Jane’s insurance features:

Learning Modules Complete
1. Setting up insurers, billing codes, and billing info ✍️
2. Claim submissions & management
3. Modifiers, creating a custom billing code, changing and adding billing codes
4. Remittances
5. A/R tracking (aging claims)

 

💡Jane Tip: We recommend heading over to Jane’s Demo Clinic to practice as you learn! Log in as the ‘owner’ profile for Full Access to the features we’ll be talking about. You can find the login password to access the Demo Clinic by heading to the Jane Community Group on Facebook and clicking the ‘Featured’ tab. If you’re having any trouble, you can also request the password by email ([email protected]).


In this module, we’ll be covering the 3 steps that are required to get the account ready before using Jane’s Insurance features. Those include:


Step 1: Setting up insurers

Adding Insurers

Note: Speed up or slow down the video speed using the ⚙️ button inside the video player!

The first step is to add in all the insurance companies the clinic needs to bill. You’ll start by creating the list of insurance companies you’ll be billing before you can start entering patient insurance information, assigning the clinic’s rates to CPT codes, and insuring the actual visits.

It’s a good thing to note here that we can skip a ton of manual work in these initial set-up steps by importing both insurers and patient policies. You can find out more about that process by heading to our guide, ‘Importing Your Insurers and Policies to Jane’.

Even if you’re coming into an account with all of this information already set up, it’s always a good idea to know where to look in case you need to make changes or add in new insurers.

You will need an account with Full Access permissions to see this page in the Settings.

Creating the Insurer

Starting from the Settings tab, scroll down to the Insurers section on the left-hand side.

Select ”New Insurer” from the top right, and then fill out the insurer’s information as required in the form.

Important Note: If you’d like to bill using our EDI generation/download tool for submission, you’ll need to add the following fields to the insurer:

  • Insurer Name
  • Payer ID and/or Full Insurer Address
  • Insurance Program

Saving the Insurer

Once you’ve finished entering the insurer details, click “Create Insurer” to finish. Continue setting up each insurance company the clinic will be billing. There’s no need to set up all possible insurers from the get-go, as you can always come back to this area and create a new insurer later (i.e. if the clinic is treating a client with insurance coverage you’ve never billed before).

If you’d like to read a more detailed guide on each of the fields, and how they interact with other sections of Jane you can head to Step 1 of our US Insurance Set-Up Guide.

Practice Drill 🏈

Let’s now head into the Demo Clinic and try adding an Insurer!

Instructions:

  • Start by heading to the Settings tab and into the Insurers section on the left-hand side.
  • Select New Insurer from the top right, and then fill out the following insurer’s information:
    • Insurer Name - Aetna, Medicare, etc.
    • Payer ID and/or Full Insurer Address - Choose an option from the Payer ID dropdown menu or type in a custom Payer ID.
    • Insurance Program - Select any of the choices from the dropdown menu.
  • Once you’ve finished entering the insurer details, click Create Insurer to finish.

Touchdown! 📣


Step 2: Assigning rates to the clinic’s billing codes (CPT & ICD10)

 

CPT codes are essential to submit insurance using Jane, so let’s take a look at where clinics can set up their fees.

Assigning Rates to CPT Codes

To get started, head over to Settings, and then scroll down to the Billing Codes tab. Jane will opt you into our library of CPT code sets and ICD-10 code sets by default.

To set up the clinic CPT fees, scroll down to find our database search bar. Search to find a CPT code you use, and assign it to the appropriate fee schedules.

Here’s how it works:

  1. Use the search bar to find a CPT code.
  2. Click “Assign Rate” to enter the Default Billed Amount for this CPT code in the Billed Amount box.
  3. Enter the Insurer’s Allowed Amounts associated with this procedure code.
  4. Click “Create Billing Code” to save this new code to the clinic’s list.

When setting up clinic billing code fees, you can also set up some handy defaults to save time, prevent billing mistakes, and make insurer Accounts Receivable more realistic.

These defaults include insurer-specific Allowed Amounts and procedure-specific Modifiers. This allows the clinic to account for any Contracted Rates or Fee Schedules that they might have with an insurer.

💡Pro Tip: A Procedure’s Allowed Amount is not sent to the insurer (the default Billed Amount is!) when billing the insurer through Jane’s Electronic Submission (EDI) feature. Allowed Amounts are only used as the basis for Co-insurance % calculations and internal invoicing.

Practice Drill 🏈

Hope you didn’t close the Demo Clinic because we’re going to assign a rate to a CPT Code!

Instructions:

  • Start by heading to the Settings tab and into the Billing Codes section on the left-hand side.
  • Scroll down to the code database search bar, and type in the billing code of your choice i.e. 90837, 87350, or 97810:
    • You can also type keywords such as “chiropractic” or initial visit” to find the codes you need, try it out yourself!
  • Once you’ve found the code you’d like, click Assign Rate on the right-hand side.
  • Enter a $ amount under the Billed Amount text box and then Create Billing Code.

Touchdown! 📣


Default Allowed Amounts & Modifiers

What is an Allowed Amount?

An Allowed Amount refers to the price an insurance company allows for a particular procedural (CPT) code. Sometimes Allowed Amounts are referred to as insurer ‘Contract Rates’ or ‘Fee Schedules’.

If entered at the time of service, Allowed Amounts can be used to help calculate patient Coinsurance as well as make your clinic Accounts Receivable more realistic. For example, if you know the insurer is going to allow less than your clinic fee for a particular billing code (and you are contractually obligated to adjust off the difference between what is billed and what is allowed), then you can add in an Allowed Amount at the time of service before filing the claim.

Note that entering Allowed Amounts at the time of service won’t affect your claim submissions! Jane does not include Allowed Amounts in your submissions (only your clinic billing code fees are used).

Why Set Up Default Allowed Amounts?

If you are in-network with an insurance company or you are just aware of what an insurance company allows, then you can add these known Allowed Amounts as defaults when setting up your clinic billing codes instead of manually adding them to each patient visit.

Note that you can set up unique Allow Amounts for each insurance company your clinic bills as well as all procedure codes billed by your clinic!

If you aren’t aware of a particular insurance company’s Allowed Amounts (or ‘Fee Schedule’), then there is no need to set up Allowed Amounts for that insurer.

How Do I Set Up Default Allowed Amounts?

First, head into Settings > Billing Codes, and either create a new billing code or edit an existing billing code as needed.

You’ll then be brought to a screen that looks this:

Every billing code will have a separate Allowed Amount box for all insurers set up on your Jane account. Once you’ve entered your insurer-specific Allowed Amounts, you’ll just need to save your billing code!

Why Set Up Default Modifiers?

If you bill a particular code that always needs to be accompanied by a specific Modifier or Modifiers, then you can have Jane automatically add those Modifiers whenever that billing code is added to a visit. Likewise, if only one or two of your insurers require that you include a Modifier when billing a specific procedure, you can set up default insurer-specific modifiers so you never need to worry about forgetting to add it to the claim!

How Do I Set Up Default Modifiers?

First, head into Settings > Billing Codes, and either create a new billing code or edit an existing billing code as needed.

You’ll then be brought to a screen that looks this:

You’ll notice there is an overall default box, as well as default boxes for each insurance company in your account. The overall default box will be used if the insurer-specific box is empty, but the insurer-specific box will be favored if it has modifiers. The insurer-specific boxes are there in cases some insurers you bill have different requirements for the same procedure code.

If you’d like to add multiple Default Modifiers (i.e. if the insurer requires a code to be billed with two different modifiers), you just need to separate those modifiers with a space.

As always, if you’d like to do some further reading on any of the above we’ve got got a slew of great guides you can refer to:


Step 3: Location & Staff Billing Info

 

We’re almost ready to start billing! Let’s explore one more area of Jane which has some important ties to insurance submissions in Jane, the Location and Staff Billing Info For paper (CMS-1500) and electronic (EDI Files) claim submissions, clinics need to add some identifying information for their business, locations, and staff members.

Location Info

There are two areas in Jane where we need to add some claim-related information:

  1. Location(s).
    • Settings > Clinic Info & Locations
  2. Staff Profile(s).
    • Staff Profile > Billing

This information can be entered by heading into Settings > Clinic Info & Locations > Edit Location.

The following information is required for all claim submissions. Note: If you have multiple Locations, you’ll need to add this information to each:

  • Location Name & Address (Box 32 on the CMS-1500)
  • Location Billing Name & Address (Box 33** on the CMS-1500)
  • Location/Service Facility NPI (Box 32a and Box 33a** on the CMS-1500)
  • Place of Service Code (Box 24B on the CMS-1500)
  • This box can be determined by the information in a Staff Member’s Billing settings instead of the location if needed. See the Overriding Location Claim Info With Staff Billing Settings section below for more details.*


Setting Up Claim Information in Staff Profile(s)

This information can be entered by heading to Staff > Staff Profile > Billing.

The following information is required for claim submissions. It should be entered into the Default Claim Information section for each Staff Member who bills insurance.

  • Rendering Provider Identifier - typically a Rendering Provider NPI (Box 24i and Box 24j on the CMS-1500)
  • Tax ID & ID Type (Box 25 on the CMS-1500)

The following information is optional for claim submissions. This information only needs to be set if a staff member has been advised to do so by an insurance company, or if it is known to affect an insurance company’s adjudication process.

  • Billing Provider Taxonomy Code (Box 33b on the CMS-1500)

Once again, if you’d like to read a little bit more on the different areas of the Staff & Location Billing Numbers head over to Step 3 of our US Insurance Set-Up Guide

Got questions about how to populate a certain box on a CMS1500 form? Or maybe you just want to see where certain areas of Jane relate to your submissions, we’ve compiled all of this in our CMS Reference Sheet.

Practice Drill 🏈

Let’s enter some basic claim information for a staff member on the Demo Clinic.

Instructions:

  • Start by heading to the Staff tab and into the Billing section on the tab within a profile of your choice.
  • Scroll down to the Default Claim Information section and click View.
  • Enter a new Rendering Provider NPI & Tax ID Number.
  • Finish by clicking Save.

Touchdown! 📣


Great! Now that we’re all set up and ready to submit insurance, let’s head to Module 2: Claim Submissions and Management to learn about actually submitting these claims!