Pro Health Billing Setup Guide
Pro Health Billing Setup Guide
Pro Health Billing Setup Guide
Contents
Company Information......................................................................................................................................................................2
B.
Security ....................................................................................................................................................................................2
C.
Facility.................................................................................................................................................................................3
D.
Providers .............................................................................................................................................................................4
NPI Designations...........................................................................................................................................................................4
Rendering Provider .......................................................................................................................................................................4
Billing Provider..............................................................................................................................................................................5
Insurance ID Type Fields ...............................................................................................................................................................5
E.
Clearinghouse .........................................................................................................................................................................6
F.
Insurance ..................................................................................................................................................................................6
Options .........................................................................................................................................................................................7
Anesthesia ....................................................................................................................................................................................8
G.
Diagnosis..............................................................................................................................................................................9
H.
I.
J.
K.
L.
Printing Claims........................................................................................................................................................................... 18
M.
N.
Setup.......................................................................................................................................................................................... 20
Print Patient Statements ........................................................................................................................................................... 20
O.
Report Setup..................................................................................................................................................................... 21
P.
Q.
Backing Up ........................................................................................................................................................................ 22
Company Information
1. From the Top Navigational Menu, select
System, and then select Information.
2. Under Company Info, enter your
Company Name, Contact Name, Phone
Number, and Zip Code.
3. Proceed to enter your Companys Address
in the fields provided.
4. Click Save when done.
B. Security
HIPAA mandates that each user accessing Patient data have a unique user name and a password assigned
to them. In order to remain HIPAA compliant, you must
delete the default username and password and select both
a username and password that is unique to each
individual that will have access to the program and its
data.
The first user to be entered will be for the Program
Administrator (in a small office, this may very well be
yourself). The Program Administrator (known as the
Super User) will have all the necessary rights to create
and delete users as well as to grant certain privileges to
certain users individually. They can also assist users in
resetting usernames and passwords when forgotten by the
user.
1. From the Top Navigational Menu, select Security,
then Users.
2. Left click on to the word Demo (originally set as the
default master account) to highlight it, and then click
on the Edit button to open the new window
3. Edit User Info and Rights.
4. Enter the users Last Name, First Name, and Middle Name in the fields provided.
5. Have the user select a Username and Password that only they will know and have them enter it in the
fields provided.
6. Select each of the settings that will apply to the user from the available boxes. For Program
Administrators, click both Super User and Access Security. For all other users, select the box next
to each access option applicable to them.
7. Access to Security: Ability to Add Data, Delete Data, or Edit Data on all records, Run Reports, and can
add, delete, or lock another person out of the software entirely. This option is only modifiable by users
who have been given Super User status.
8. Available Providers: For each user, choose the name of the provider that the user will be allowed access
to the providers data and their Patients data. Program Administrators should be given access to All
Providers.
9. Click Save when done.
C. Facility
This section will allow you to configure the information for each Facility (Hospital, Nursing Home,
Assisted Living Facility, etc.), location where services are rendered by the provider. From the Top
Navigational Menu, select Set Up, then Facility.
1. Click on the Add button at the bottom of the
Facility Data screen to open a blank Edit New
Facility Data screen
2. ID Code: Create a code name or number for this
Facility, which will allow you to identify this
Facility when this code appears on various
screens and reports. For example: St. Marys
Medical Center would be coded as SMMC or
SMH.
3. Facility: Enter the name of the Facility. This
number will appear in box 32 of the
HCFA/CMS 1500 Claim Form.
4. NPI: Enter the Facilitys NPI number. This
number will appear in box 32A of the
HCFA/CMS 1500 Claim Form.
5. Commercial ID: Enter the Facilitys
Commercial ID number (this is usually their
Tax ID number). This number will appear in
box 32B of the HCFA/CMS 1500 Claim Form.
6. Medicaid ID: Enter the Facilitys Medicaid ID
number. This number will appear in box 32B of the HCFA/CMS 1500 Claim Form.
7. Medicare ID: Enter the Facilitys Medicare ID number. This number will appear in box 32B of the
HCFA/CMS 1500 Claim Form.
8. Blue Shield ID: Enter the Facilitys Blue Shield ID. This number will appear in box 32B of the
HCFA/CMS 1500 Claim Form.
9. Place of Service: From the menu provided, select the code number indicating the Place of Service
(Office, Home, Hospital, etc.) that best describes what type of Facility this is. This number will appear in
box 24B of the HCFA/CMS 1500 Claim Form.
10. Enter the Address, Zip, City, State, Phone, and Fax numbers in the fields provided. This information will
appear in box 32 of the HCFA/CMS 1500 Claim Form.
Click Save when done.
D. Providers
Click on the Add From the Top Navigational Menu, select Set Up, and then Providers.
RENDERING NPI
Go to Setup, Select Provider; fill out the NPI on the upper part of the form
BILLING/GROUP NPI
Go to Setup, Select Provider; fill out the NPI on the lower part of the form
FACILITY NPI
Go to Setup, Select Facility; fill out the field labeled: NPI
REFERRING NPI
Go to Setup, Select Other Provider; fill out the field labeled: NPI
1. In the ID Code field, create a code name or number for this Provider, which will allow you to identify
whom the provider is when the code appears on various screens and reports. (For example: John Smith,
MD would be coded as SMIJO or SMITH.)
2. In the Last Name field, enter the Providers Last Name, which will print in Box 31 of the HCFA/CMS
1500 Claim Form.
3. In the First Name field, enter the Providers First Name, which will print in Box 31 of the HCFA/CMS
1500 Claim Form.
4. In the MI field, enter the Providers Middle Initial, which will appear in Box 31 of the HCFA/CMS 1500
Claim Form.
5. In the Title field, enter the Providers title or degree (M.D., Ph. D., etc.).
6. In the Tax ID field, enter the Providers Tax Identification number, which may be either their Social
Security Number (SSN) or their Employer Identification Number (EIN) also known as a Federal Tax ID
or Corporate Tax ID number Click in the appropriate circle to specify which type of Tax ID number is
being used. This will print in Box 25 of the HCFA/CMS 1500 Claim Form.
7. In the NPI field, enter the providers NPI number, which will appear in Box 24J or 33B of the
HCFA/CMS 1500 Claim Form.
8. In the Anes. Cash Rate field enter
base rate per unit dollar amount your
Anesthesia Provider charges for
anesthesia services when rendered to
Cash Patients (Patients with no
Insurance). Enter the dollar amount
with no $ sign. If your Provider is
not an Anesthesiologist, leave this
field blank.
9. The % Percent field is inactive and is
not to be used. Please leave blank.
10. In the License #field, enter the
Providers State License number.
11. In the Type of Service field from the
drop-down menu that appears, select
the type of business entity that best
describes your provider (i.e.: Solo
Practice, Partnership, Professional
Org., etc.). This information will print in Box 24C of the HCFA 1500 Claim Form, but is not required
on the CMS 1500 Claim Form.
12. In the UPIN field, enter the Providers Unique Provider Id Number. This will print in Box 24J of the
CMS 1500 Claim Form, or 33B of the HCFA 1500 Claim Form.
13. In the FACILITY field, enter the Facility or Location that the Provider performs their services the most
amount of times. For example, if it is in the office, select the entry for the office. In this manner, each
time you create a claim for this Provider, the Facility field will automatically populate with this location
so that you do not have to enter it each time. This information prints in Box 32 of both the CMS 1500
Claim Form and the HCFA 1500 Claim Form.
1. In the Name field, enter the Billing Providers full name. In small offices, where the Provider does
business as himself or herself, the Billing Provider name will be the same as the Rendering Providers
name. If so, this field should remain blank. In cases where the Billing Provider is the Business itself
(such as the Clinic name or the Business name), enter that name in this field. This information will print
in Box 33 of the HCFA/CMS 1500 Claim Form.
2. In the Entity field, if the Billing Provider is the same as the Rendering Provider, select Person from the
drop-down menu. If the Billing Provider is the Business itself, select Non-Person.
3. In the NPI field, enter the NPI number pertaining to the entity used in the Name field. The choice will be
either the Providers own NPI number (if his or her name was used), or the NPI number of the Business
(if the business entity name was used). This information will print in Box 33A of the HCFA/CMS 1500
Claim Form.
4. Enter the Address, Zip, City, and State, in the fields provided. This information will print in Box 33 of
the HCFA/CMS 1500 Claim Form.
5. Enter the Phone, Fax, and Cell numbers in the fields provided.
1. In the field below the column labeled Type, begin by clicking on the Add button (at the bottom of this
screen), and left-click on the first field to open and select the Insurance Company type (Medicare,
Medicaid, BCBS, etc) which will represent this row.
2. Tab to the column labeled 24J/Electronic field and in the field below, enter the Provider ID number
assigned to the Rendering Provider by the Insurance Company type selected in the Type column. For
example: if the type selected is Blue Shield, enter the Rendering Providers Blue Shield ID number. For
Commercial insurance types, you will enter the Rendering Providers Tax ID.
3. Tab to the column labeled 31 and in the field below enter the Provider ID number assigned to the Billing
Provider by the Insurance Company type selected in the Type column. For example: if the type
selected is Blue Shield, enter the Rendering Providers Blue Shield ID number. For Commercial
insurance types, you will enter the Rendering Providers Tax ID.
4. Tab to the column labeled 33B and in the field below enter the Provider ID number assigned to the
Billing Provider by the Insurance Company type selected in the Type column. For example: if the
type selected is Blue Shield, enter the Rendering Providers Blue Shield ID number. For Commercial
insurance types, you will enter the Rendering Providers Tax ID.
5. Continue the above steps for the 6 basic Insurance Types: Blue Cross-, Blue Shield, Medicare,
Medicaid, Champus, and Commercial.
6. Click the Save button when done.
E. Clearinghouse
When setting up your Clearinghouse, the first field titled Code: is the shortcut section for your
clearinghouses. The line Website: allows for the automatic launching of your clearinghouse's webportal for claim submission once the newly created electronic claim file has been created. Simply copy
and paste the desired URL into the field.
1. The section titled Name of Receiver is where you will put your clearinghouse.
2. The Receiver I.D. is specific for each clearinghouse and it is recommended to obtain that from your
clearinghouse.
3. The Submitter I.D. will be specific to you and your
practice and will be given to you by your
clearinghouse.
4. Lines 6-10 are most commonly not used, however; if
required by your clearinghouse/insurance please refer
to the Pro Health Billing User Manual for more
details.
5. The section labeled Type: is referring to the type of
data you are sending. When you first set, up your
clearinghouse, you will be required to send in some
test claims and when doing so you need to switch this
line to Test Data in the drop down menu. Once all
testing has been completed and you are ready to move
forward with sending real claim, you will need to
change this line back to Production Data.
6. For the section titles, ISA 07 Value please refers to
your clearinghouse ISA Heading guidelines if
applicable.
7. For the last line Show Zero Payments as 0.00 in:
please select Claim Level and/or Service Line Level depending on where you would like 0.00$
payments to be visible.
8. Click Save.
F. Insurance
This section will allow you to configure the information for each Insurance company that your provider
needs to bill to. From the top navigational Menu, select Set Up, then Insurance.
1. Click on the Add button at the bottom of the Insurance Data screen to open a blank Edit New
Insurance Data screen.
2. Informational Fields:
A. Insurance Code: Create a code name or number for this Insurance, which will allow you to
identify this Insurance when this code appears on various screens and reports. For example: Blue
Cross of California would be coded as BCCA.
B. Name: Enter the name of the Insurance Company. This number will appear in box 11C or 9D of
the HCFA/CMS 1500 Claim Form.
3. Type: From the menu provided in this field, select the type of insurance company this is (i.e.: Blue
Cross, Medicare, Medicaid, Commercial, CHAMPUS, etc.).
Note: The selection made in this field will need to match the information you will use in the ID
Type field at the bottom of this screen. Although there are many options, you will only use the
following 5: Blue Cross/Blue Shield, Medicare, Medicaid, Champus, and whatever does not fall
under those first four you then choose Commercial.
4. Enter the Address, Zip, City, State, Phone, Fax and Cell numbers in the fields provided. This number
will appear in the header (top right hand side) of the HCFA/CMS 1500 Claim Form.
5. Type of Billing: From the drop-down menu provided, select the manner in which claims to this Insurance
Company will be sent (for now, select Paper).
6. Accept Assignment: If you accept assignment of benefits from this insurer, select Yes; if not, select
No. This information will appear in box 27 of the HCFA/CMS 1500 Claim Form.
7. ID Type: From the menu provided in
this field, select the type of insurance
company this is (i.e.: Blue Cross,
Medicare, Medicaid, Commercial,
CHAMPUS, etc.). The ID Type selected
here will tell the software to use the
Provider ID number entered in the
Insurance ID fields in the provider setup
(refer to section Software Setup Providers for additional information).
These numbers will then appear in box
24J and box 33B of the HCFA/CMS
1500 Claim Form. Note: Although there
are many options, you will only use the
following 5: Blue Cross/Blue Shield,
Medicare, Medicaid, Champus, and
whatever does not fall under those first
four you then choose Commercial.
7. Field 11 Blank: Check this box if the Insurance Company requires that the Insureds Policy Group or
FECA Number field (Box 11) of the HCFA/CMS 1500 Claim Form NOT be filled in. (Normally, this
option is not checked for almost
all insurances).
8. 11a, 11b, 11c, and 11d blank:
Check this box if the Insurance
Company do not require the
following fields of the
HCFA/CMS 1500 Claim Form be
filled in: Insureds Date of Birth
(11a), Employers Name or
School Name (11b), Insurance
Plan Name or Program Name
(11c), and Is There Another
Health Benefit Plan? (11d).
(Normally, this option is not
checked for almost all
insurances).
9. Print Referring ID in Box 23:
When the Referring Providers ID
Number is required in Box 23
(Prior Authorization Number) on
the HCFA/CMS 1500 Claim Form
instead of Box 17A (Referring
Provider Info).
10. Click the Save button when done.
1. Calculate Actual Anesthesia Minutes: The Pro Health Billing program automatically rounds off
Anesthesia minutes when creating the claim. Check this box if you want the Anesthesia time to show in
actual total minutes (not rounded off) for the procedure
rendered to print in the grayed area above the first
Place of Service Code entered on line 1, Box 24B, of
the HCFA/CMS 1500 Claim Form.
2. Minutes only on 1500 form section 24G: The Pro
Health Billing program will automatically print the
total number of Anesthesia units (the Anesthesia
minutes calculated into units plus the units for the
procedure itself) in Box 24G of the HCFA/CMS 1500
Claim Form. Check this box if you want the software
to print the anesthesia minutes only (and not the
combined units) in Box 24G.
3. Calculate a Unit per 10 Minutes: Anesthesia minutes are automatically calculated as one unit of
Anesthesia time per 15 minutes. Check the box to have software calculate 1 unit of Anesthesia time per
10 minutes instead.
4. Click the OK button when done.
G. Diagnosis
From the Top Navigational Menu, select Set Up, and then Diagnosis.
1. Adding a Diagnosis Code: Click on the Add button at the bottom of the Diagnosis Data screen to open a
blank Edit New Diagnosis Data screen.
2. Code: Enter the Diagnosis Code number. (Will appear in Box 21 #1-4 of the HCFA/CMS 1500 Claim
Form)
3. Shortcut: Enter a Shortcut code (i.e.:
HA for Headache) in this field if you
would prefer to not have to enter the
Diagnosis Code when adding it to a
claim. Entering the Short-Cut code in
the Diagnosis Code field within the
claim itself will bring up the
Diagnosis Code and print it on the
claim or enter it in the appropriate
location when transmitted
electronically.
4. Description: Enter the description of
the Diagnosis Code (up to 35
characters long).
5. Click Save
6. The word Incomplete will appear to
the right of a Diagnosis Code in the Code Status field of the Diagnosis Data table when the code is
considered a Category Code. NOTE: Most Insurance companies will deny any claims submitted for
payment processing that include an incomplete Diagnosis Code.
7. Making a Diagnosis Code Inactive
A. It is the responsibility of the user to make sure all Diagnosis Codes used are current. There are
books available that are published yearly showing what codes are new and which ones are no
longer active. You would need to edit the Diagnosis Code to mark it as Inactive so that you do
not use it by mistake on current claims.
B. From the Top Navigational Menu, select Setup, then Diagnosis.
C. Left click on the Diagnosis Code you want to make Inactive. You can then click on the Edit
button at the bottom of the screen or double-click on the Diagnosis Code to open it.
D. Inactive: Check this box if this Diagnosis Code is no longer active.
E. Click Save when done.
H. Procedure Codes
Procedure Codes print in Box 24D of the HCFA/CMS 1500 Claim Form. From the Top Navigational
Menu, select Set Up, and then Procedure.
1. Click on the Add button at the bottom of the Procedure Codes screen to open a blank Edit New
Procedure Code screen.
2. In the Code field, enter the actual CPT (or HCPCS) code number. Note: Once entered in this setup, the
Procedure Code itself is un-editable, only the description and other related fields are editable. If the
Procedure Code entered is incorrect, or has since changed in the current version of the CPT Code Book,
you need create a new Procedure Code entry.
3. In the Modifiers Defaults fields, select a Modifier Code from the drop-down menu if this Procedure (or
HCPCS) Code must always be billed with that Modifier Code. (Refer to section Modifiers for
information on how to create a
Modifier Code).
4. In the S-Cut field, enter a Shortcut
for this code. A shortcut will prove
especially useful when duplicates of
the same code are created in order to
bill different insurers a different
amount for the same service
rendered. This shortcut does not
appear on the claim form nor on the
Patients statement; only will the
CPT code it represents appear. The
example below shows an original
code along with 2 shortcut versions
of the same code and how they
would be used: Note: You can add
up to 3 characters (alpha or
numeric) in front of the Procedure
Code to create a shortcut. Then,
when you go about entering the
charges on a claim, you type the entire shortcut in the Procedure Code field to make it appear. For
example: 99212 with S-Cut M for Medicare would be entered as M99212.
5. In the Description field, enter the Procedure Codes description up to 500 characters long.
6. Check the box labeled Print Description on 1500-Form if the Insurance Company wants the Procedure
Code description printed on the HCFA/CMS 1500 Claim Form (only 59 characters will print).
7. In the Type field, enter the type of Procedure Code this is (i.e.: Office Visit, Lab, X-Ray, etc.)
8. In the Unit(s) field, enter 1 as the minimum number of units to appear on the claim when this Procedure
Code is selected when a claim is created.
9. Check the box labeled $ Per Unit and enter the amount to be charged per unit when this Procedure Code
is selected when a claim is created.
Note: If the Procedure Code is for Anesthesia Services, leave this field blank.
10. Check the box labeled Do Not Bill Insurance (Patient Only) if you want the bill to go to the Patient only
and not the Insurance Company. Situations where you would use this feature are when billing services
that are not covered by traditional medical insurance (i.e.: Vitamins, Convenience Items, Massages,
Optional Tests, Report Copies, Late Fees, etc.)
11. Check the box labeled Add Sales Tax % and enters the percentage amount to be added as Sales Tax
when billing this Procedure Code. (This may not apply to your type of billing and may be left blank.)
12. Check the box labeled Canceled Visit if you want to track how many Canceled Visits are billed to a
Patient. The number of Canceled Visits a Patient has been billed for is tracked under the Summary tab
of the Edit Patient Data Screen. (Please refer to the section titled PATIENTS for more information).
Some practices may charge a Patient for not canceling a visit in advance or for failure to show up to a
scheduled visit. You can create a NO SHOW Procedure Code such as 99999 (or using the word
NOSHOW) to use to bill your Patient.
13. Click the Save button when done.
J. Modifiers Codes
From the Top Navigational Menu, select Set Up, and then Modifier.
1. Click on the Add button at the bottom of the Modifier Data screen to open a blank Edit New Modifier
Data screen.
2. In the Code field, enter the actual Modifier Code numbers or letters (letters must be in UPPERCASE
text). Do not include a dash in front of the entry made (For example: Modifier Code -59 should be
entered as 59 only).
3. In the Description field, enter the description of the
Modifier Code (up to 55 characters in length).
4. In the +/- Units field, enter the number of units the
Modifier Code adds to or takes away from the
Procedure Code it is modifying. If it takes away
from, then enter a negative in front of the unit (i.e.: -
5 would be entered if it takes away 5 units). (This may not apply to your type of medical practice and
may be left blank.)
5. In the Adjust Units by % field, enter the percentage to be adjusted by the modifier code for the number
of Procedure Code units being used. (This may not apply to your type of medical practice and may be
left blank.)
6. Click the OK button when done.
K. Patient Demographics
To access the Patient's Data screen, click on the Patient's Icon on the Left Navigational Menu, or,
from the Top Navigational Menu, select Patients Data. From the Left Navigational Menu, click on the
PATIENT'S icon to open the Edit New Patient Data screen as displayed below. All green colored fields
are mandatory and must be completed before being able to save the created record.
1. Patient Account # (PAN): In this field an account number is automatically populated (assigned by the
software) based on your selections under the System/ Options/ Data section of the Pro Health Billing
program. You can edit the assigned number by double-clicking in this field and selecting Yes when
asked if you are sure, you want to edit this field. The Patient Account Number will appear in Box 26 of
the HCFA/CMS 1500 Claim Form.
2. Last Name: In this field, enter the Patients Last Name (up to 18 characters in length). This will appear
in Box 2 of the HCFA/CMS 1500 Claim Form.
3. First Name: In this field, enter the Patients First Name (up to 15 characters in length). This will appear
in Box 2 of the HCFA/CMS 1500 Claim Form. Note: If you have patients with titles after their names,
such as Jr., Sr., III, etc., the title is entered in the First Name field to the right of the name. For example,
John Michael II is entered as: Last Name: Michael, First Name: John II.
4. MI: In this field, enter the Patients Middle Initial. This will appear in Box 2 of the HCFA/CMS 1500
Claim Form.
5. Home Phone: In this field, enter the Patients home phone number including their Area Code. This will
appear in Box 5 of the HCFA/CMS 1500 Claim Form.
6. Work Phone: In this field, enter the Patients work phone number including their Area Code, and their
phone extension (ext) if applicable.
1. Enter the Patients Address, Zip, City, & State in each of the corresponding fields. As with all other
address fields in the Pro Health Billing software program, when you enter the Zip Code in the Zip field,
the City and State fields will automatically populate. This information will appear in Box 5 of the
HCFA/CMS 1500 Claim Form.
2. Cell Phone: In this field, enter the Patients cell phone number.
3. Lawyer: In this field, if the Patient is represented by Attorney, enter the Lawyers full name here.
4. Email: In this field, enter the Patients email address. If you use an email client such as Microsoft
Outlook (or similar), you can click on the button to the right of the field to launch it and create an email
to send to your client.
5. SSN: In this field, enter the Patients Social Security Number with no dashes in between (the software
will enter those for you).
6. Sex: Select either (F) for Female, or (M) for Male from the drop-down menu provided in this field to
specify the Patients gender. This will appear in Box 3 of the HCFA/ CMS 1500 Claim Form.
7. D.O.B.: In this field, enter the Patients Date of Birth as a two-digit month, two-digit day, and four-digit
year. This will appear in Box 3 of the HCFA/CMS 1500 Claim Form.
8. Employment Status: From the menu provided in this field, select the Patients Employment Status as
either: Employed, Full Time (FT) Student, Part
Time (PT) Student, Retired, or Unemployed. This
will appear in Box 8 of the HCFA/CMS 1500
Claim Form.
9. Marital Status: From the menu provided in this
field, select the Patients Marital Status as either:
Divorced, Legally Separated, Married, Partner,
Registered Domestic, Single, Unknown, or
Widowed. This will appear in Box 8 of the
HCFA/CMS 1500 Claim Form.
10. Signature on file: A check mark will default in this
box. Uncheck this box if you do not have the
Patients signature on file. This will appear in Box
12 of the HCFA/CMS 1500 Claim Form.
11. Provider: This field will automatically populate
with Primary Provider name. If you have more than
one Provider in the system, use the drop-down
menu to select a Primary Provider for this Patient,
or add a new one. The Primary Provider selected
here can be different from the actual Provider that
renders the service when you create the Patients
claim. This will appear in Box 31 of the HCFA/CMS 1500 Claim Form.
12. Referring: In this field, select the name of the Provider who referred the Patient to you from the list
provided, or add a new one. This will appear in Box 17 of the HCFA/CMS 1500 Claim Form.
1. If the Patient has insurance, click in the circle fronting the word Insurance and continue with the steps
below. (If the Patient does have insurance, click in the circle fronting the word Patient Pay). Click on
the Add button to open the Add New Patient Insurance screen.
2. In the Type field, select the type of insurance this is (Primary, Secondary, Tertiary, or Independent).
However, you can only enter a Secondary or Tertiary insurance if a Primary insurance already exists.
3. Active?: In this area, select Yes if this is an Active insurance, or No if this insurance has become
Inactive. (If you make an insurance Inactive, you must put an Expiration Date in the Expiration field).
The selection will automatically populate as Yes the first time you enter a Primary Insurance.
4. In the Insurance field, select Insurance Company name from the drop-down menu. If the Insurance
Company does not exist on the list, click on the word Add from within that menu to add a new one. This
will appear in Box 11c of the HCFA/CMS 1500 Claim Form.
5. In the ID# field, enter the ID number that appears on the Patients insurance card. This will appear in
Box 1a of the HCFA/CMS 1500 Claim Form.
6. In the Group# field, enter the Group number that appears on the Patients insurance card. This will
appear in Box 11 of the HCFA/CMS 1500 Claim Form.
7. In the Employer field, enter the name of the Employer for whom the insurance policy is offered through.
This may or may not be the same as the Patients employer. This will appear in Box 11b of the
HCFA/CMS 1500 Claim Form.
8. In the Start date field, enter the start date of the insurance coverage as a two-digit month, two-digit day,
and four-digit year. This information can be obtained when verifying Patient coverage with their
insurance company.
9. In the Expiration date field, enter the start date of the insurance coverage as a two-digit month, two-digit
day, and four-digit year. ONLY enter a plan expiration date when the insurance has ALREADY expired.
(This field is required if making an insurance Inactive).
10. In the Co-Pay field, enter the amount of the co-payment to be collected per visit (no $ sign), or the
percentage of the visit to be charged as a co-payment each time the Patient sees you. This information
can be obtained when verifying Patient coverage with their insurance company.
11. Is the Patient the Subscriber? If the Patient is the subscriber of his or her insurance (the insurance is
under their name), click the OK button
and follow the same steps above to enter
their Secondary and/or Tertiary
insurances. If the Patient is NOT the
subscriber (meaning they are covered by
someone else such as their parent or
spouse), select No in the Insured Same
as Patient option, and then continue
with the steps below:
12. The Address, City, State and Zip fields
will fill in based on the information
provided under the Demographics Tab.
If this information is incorrect, make the
changes as necessary in these fields.
This will appear in Box 7 of the HCFA/
CMS 1500 Claim Form.
13. In the Last Name and First Name field, enter the name of the subscriber of the insurance. This
information can be obtained when verifying Patient coverage with their insurance company. This will
appear in Box 4 of the HCFA/ CMS 1500 Claim Form.
14. Sex: Select either (F) for Female, or (M) for Male from the drop-down menu provided in this field to
specify the Patients gender. This will appear in Box 11a of the HCFA/ CMS 1500 Claim Form.
15. D.O.B.: In this field, enter the Subscribers Date of Birth as a two-digit month, two-digit day, and fourdigit year. This will appear in Box 11a of the HCFA/ CMS 1500 Claim Form.
16. From the drop-down menu in the Patient Relationship to the Insured field, select either Child, Other, or
Spouse. This will appear in Box 6 of the HCFA/ CMS 1500 Claim Form.
17. Signature on file: A check mark will default in this box. Uncheck this box if you do not have the
Subscribers signature on file. This will appear in Box 13 of the HCFA/CMS 1500 Claim Form.
18. Does the Patient have another Insurance policy? If the Patient has other insurance, click the OK button
and follow the same steps above to add their Secondary and/or Tertiary insurances.
L. Claims
Click on the Patient's icon on the Left Navigational Menu, or, from the Top Navigational Menu, select
Patients Data.
1. Click on the Patient's icon on the Left Navigational Menu, or, from the Top Navigational Menu, select
Patients Data.
2. Find Patients Record and double click on their name to open the Edit Patient Data screen.
3. Click on the Add Claim button at the top of the opened record to open the Edit New Claims Data screen
The General Claim Information section is separated into three sections: the Left Side, Middle Section,
and the Right Side.
The Left Side:
1. Name & Patient Account Number: The first field is for the Patient Account Number while the field next
to it to the right is where the Patients Name (Last Name, First Name MI) will be entered. This
information is entered automatically when creating a claim from within the Patient Record.
2. File Date: This field is automatically populated with the date the claim is being created. You can change
this date by highlighting over the date in this field and typing the date, you want to use.
3. Rendering Physician: This information is entered automatically based on the Provider selected in the
Patient Record under the Demographic Tab. You can change the Rendering Physician by clicking on the
drop down menu and selecting one from the available list. This information prints in Box 31 of the
HCFA/CMS 1500 Claim Form.
4. Insurance: This information is entered automatically based on the Primary Insurance entered in the
Patient Record under the Insurance Tab. If the Patient has both a Primary and an Independent Insurance,
and you need to change it from Primary to Independent, click on the drop down menu and select it from
the list. This information prints in Boxes 1, 1a, 4, 7, 11 (A-D) of the HCFA/CMS 1500 Claim Form.
5. Facility: This information is entered automatically if the Rendering Provider record includes a default
facility. If not, click on the drop down menu and select it from the list. This information prints in Boxes
32, 32A, and 32B of the HCFA/CMS 1500 Claim Form.
6. Referring Physician: This information is entered automatically based on the Referring Physician
selected in the Patient Record under the Demographic Tab. You can change the Referring Physician by
clicking on the drop down menu and selecting one from the available list. This information prints in
Boxes 17, 17A, and 17B of the HCFA/CMS 1500 Claim Form.
7. Supervising Physician: You can select a Supervising Physician by clicking on the drop down menu and
selecting one from the available list. The Supervising Physician list uses the same providers as the
Referring Physician list.
8. Ordering Physician: You can select an Ordering Physician by clicking on the drop down menu and
selecting one from the available list. The Supervising Physician list uses the same providers as the
Referring Physician list.
The Middle Section:
9. Current Illness Date Field: This information is entered automatically based on the Current Illness Date
entered in the Patient Record under the Default Tab. If not, you can enter it yourself. This information
prints in Box 14 of the HCFA/CMS 1500 Claim Form.
10. Same or Similar Date Field: Enter the date the Patient has experienced this same illness or issue before.
This information prints in Box 15 of the HCFA/CMS 1500 Claim Form.
11. Date Last Seen Field: Enter the
date the Patient was last seen by
the Referring Provider. This
information prints at the top of
the date fields of the 1st line
item in Box 24A of the
HCFA/CMS 1500 Claim Form
with the date followed by the
words Last Seen by Referring
MD.
12. Medicaid/Lab Options Button:
If you bill Medicaid Claims, or
if you bill claims with Lab
services, this section applies to
you. If not, move on to the next
section. When you click on the
Medicaid/Lab button it will
open the Medicaid/Lab Set Up
screen with the top portion for
Medicaid Claim filing, and the
bottom portion having to do with
Lab services billed on your claim. For Medicaid related services: the fields provided are used when you
resubmit a claim to Medicaid. Fill in the appropriate fields with the Resubmission Code Number and/or
Original Reference Number as given you by Medicaid, and click the SAVE button when done. This
information prints in Box 22 of the HCFA/CMS 1500 Claim Form. For Lab related services: If you are
billing for lab services that you sent to an outside laboratory to process (whereby they bill you and you
bill the Patient or their Insurance), select YES. If not, select NO. If YES, enter the charges in the fields
provided. This information prints in Box 20 of the HCFA/CMS 1500 Claim Form.
13. Acute Manifestation Date, Condition, and X-Rays: These three items are for Chiropractic services. If
they do not apply to you, move on to the next section. When billing for Chiropractic services, enter the
Acute Manifestation Date in the ACUTE MAN field and select the CONDITION from the drop down
menu. If X RAYS were taken, place a click in the box to the right of the label XRAYS? and in the
Box 19 field, enter the X RAY date (i.e.: X RAY 010197).
The Right Side:
14. Hospitalized From/To Date Fields: Enter the date the Patient was hospitalized when a medical service is
furnished because of, or subsequent to, a related hospitalization. This information prints in Box 18 of
the HCFA/CMS 1500 Claim Form.
15. Unable to Work From/To Date Field: If the Patient is employed and is unable to work in his/her current
occupation, enter the date when the Patient is unable to work. An entry in this field may indicate
employment related insurance coverage. This information prints in Box 16 of the HCFA/CMS 1500
Claim Form.
16. Condition/State/Date (Accident Related: The following three items are to be completed if the services
being billed are as a result of the Patient being involved in an Accident (all three must be completed):
17. Condition: Select what type of accident the Patient was involved in from the drop down menu provided
in this field. This information prints in Box 10 (A, B, or C) of the HCFA/CMS 1500 Claim Form. State:
Select the State where the Patients accident occurred in. This information prints in Box 10B Place of
the HCFA/CMS 1500 Claim Form. Date: Enter the date when the Patients accident occurred. This
information prints in Box 14 of the HCFA/CMS 1500 Claim Form.
18. 10d Local Use Field: This field is normally left blank; however, according to Medicares instructions,
when billing a claim to Medicare when a Patient also has Medicaid, you must enter the Patients
Medicaid number preceded by the letters MCD in this field. This information prints in Box 10D of the
HCFA/CMS 1500 Claim Form.
19. Box 19 Field: Use the Box 19 field to place information that a specific insurance carrier may need when
billing your claim. For example, Medicare has a long list of items that could go in this field when billing
Medicare for services. Other insurance carriers may have specific instructions as well. This information
prints in Box 19 of the HCFA/CMS 1500 Claim Form.
20. ANESTHESIA INFORMATION (MIDDLE SECTION): This section pertains to Anesthesiology related
claims. If this does not apply to you, move on to the next section.
21. Start/End Time Fields: There are two boxes immediately the word Anesthesia. These boxes represent
the Start and End Time of the anesthesia service. In the left box enter the Start Time of the Anesthesia
Service. In the box on the right of the word TO, enter the End Time of the Anesthesia Service. The
time is entered in Military Time. For example: 11:00am would be entered as 1100, 1:30pm would be
entered as 1330. This information prints at the top of the date fields of the 1st line item in Box 24 of the
HCFA/CMS 1500 Claim Form with the words Begin ____ End ___ Time.
22. Total Minutes Field: The total number of minutes of anesthesia time is automatically filled in for you
based on the start and end time entered in the previous fields. It is calculated at 60 minutes per hour.
23. This information prints at the top of the date fields of the 1st line item in Box 24 of the HCFA/CMS 1500
Claim Form with the words ____ Minutes.
24. Minutes into Units Field: The number of units shown in this field is automatically filled in for you. It is
calculated at 1 unit for every 15 minutes of time from the Start Time to the End Time, and is used to
calculate the number of units in Box 24G of the HCFA/CMS 1500 Claim Form for the Anesthesia
procedure code billed.
25. Minutes $ Field: The amount calculated in this field is based on the Fee Schedule initially set up for the
Rendering Physician.
PROCEDURES (BOTTOM SECTION):
26. Click on the ADD button to open the Edit New Transaction Data screen.
27. To move from field to field when entering claim information, click the Tab button on your keyboard.
To move from line to line, click the Enter button on your keyboard.
28. The screen displays 6 line items matching the 6 line items that can be printed on in Box 24 of the
HCFA/CMS 1500 Claim Form. If your claim has more than 6 line items, you will be given the
opportunity at the end to SAVE & ADD.
29. Diagnosis Fields: These are the 6 fields for adding of the Diagnosis Codes (corresponds with the 6
fields in Box 21 of the HCFA/CMS 1500 Claim Form). Enter (or select from the drop down menu that
appears in this field) the Diagnosis Code(s) to be billed on the claim.
30. Dates of Service Fields: Enter the date (or date range) that the services were rendered. If the (to/from)
date is the same, use the Tab button on your keyboard to automatically use & insert the same (to/from)
date. This information will print in Box 24A under the Date(s) of Service column on the HCFA/CMS
1500 Claim Form.
31. Procedure Code Fields: Enter (or select from the drop down menu that appears in this field) the
Procedure Code(s) to be billed on the claim. You can search for a Procedure Code either by code or by
description. Click on the drop down arrow in the Procedures field to open a list of Procedure Codes and
their matching Descriptions. From here, select the code you want to use by double-clicking on it from
the list that appeared. Procedure Codes print in Box 24D of the HCFA/CMS 1500 Claim Form under
the heading CPT/HCPCS.
32. Pointers: The six Pointers option boxes correspond with the 6 Diagnosis Code fields. When more than
one Diagnosis Code is entered, each Pointer box, per line item, will automatically fill in based on the
number of Diagnosis Codes entered. You can manually uncheck the box that does not apply. For
example, if you have three Diagnosis Codes entered and only the 1st code applies to the line item, you
would uncheck the other two. Procedure Codes print in Box 24E of the HCFA/CMS 1500 Claim Form
under the heading Diagnosis Pointer.
33. Modifier Code Fields: Enter (or select from the drop down menu that appears in this field) the Modifier
34. Code(s) to be billed on the claim. Click on the drop down arrow in the Modifiers field to open a list of
Modifier Codes and their matching Descriptions. From here, select the code you want to use by doubleclicking on it from the list that appeared. Modifier Codes print in Box 21 of the HCFA/CMS 1500 Claim
Form under the heading Modifier.
35. Units Field: The Units field will automatically populate with the number of units entered in the
Procedure Code setup for the Procedure Code being used. If not, enter the number of units you are
billing for the chosen Procedure Code. You can also edit the number of units appearing in this field by
highlighting the current number of units and entering the correct one. Units print in Box 24G of the
HCFA/CMS 1500 Claim Form under the heading Days or Units.
36. Dollars Field: The Dollar's field will automatically populate with the amount in the $ Per Unit field in
the Procedure Code setup for the Procedure Code being used. If not, enter the amount of your charge for
the chosen Procedure Code. You can also edit the amount appearing in this field by highlighting the
current number and entering the correct one. This will print in Box 24F of the HCFA/CMS 1500 Claim
Form under the heading $ Charges.
37. Place of Service Field: The Place of Service field will automatically populate with the number
representing the Place of Service selected in the Facility Set Up for the Facility selected when first
creating this claim. If not, from the menu provided in this field click on the number that represents the
Place of Service where the services were rendered (i.e.: 11 Office, 21 Inpatient Hospital, 22 Outpatient
Hospital, etc.). This information will print under the Place of Service column in Box 24B of the
HCFA/CMS 1500 Claim Form.
38. Type of Service Field: Type of Service was an option that used to be needed on the old HCFA 1500
Claim Form. It used to print in Box 24C. This information is no longer necessary on the new CMS 1500
Claim Form. However, if you want to use it, select the type of business entity that best describes your
provider (Is he a Solo Practice, Partnership, Professional Org., etc.?), from the drop down menu
provided in this field.
39. Prior Authorization # Field: If you need to add a Prior Authorization, enter it by selecting Edit from
the drop down menu provided in this field, and then selecting Add in the Prior Authorization For
box that appears in the Edit New Prior Authorization Code window. In the fields provided, enter the
Prior Authorization Number, a short Description as to what this Prior Auth is for, select the Number of
Visits from the drop down menu provided, and enter the date the authorization Expires. Click the Save
button when done and then the Close button to return to the Edit New Transaction Data screen.
Reviewing the Entered Charges and Saving your Work:
40. In the opened Edit New Transaction Data screen, make sure that all of the fields have been entered
correctly. This gives you an opportunity to check your claim before submitting it.
41. If you do not want the Patient to be billed for any remaining balances for this claim, click in the box to
the left of the label DO NOT BILL PATIENT.
42. When done, click the Save button to exit out of this screen and return to the Edit Patient Data
screen.
1. From the Left Navigational Menu select the Paper icon. All claims that have not been billed will be
found in the opened 1500 form: Claims Data screen.
2. Before printing, make sure claim forms are correctly placed in the selected printer.
3. Printing Individual Claims: Select the claim(s) by clicking the box to the left of the Patient Account
Number (PAN) field.
4. Printing All Claims: Select the claims by clicking the Check All button located on the bottom the
screen.
M.
To access this section, it is best to do so through the Patient Record. Click on the Patients Icon on the
Left Navigational Menu, or, from the Top Navigational Menu, select Patients Data. Double-click on
the desired Patient Record, once opened, click on the Pay and adjust button at the top right hand side
of the opened record to reveal a two sided Payments and Adjustments window. You will note the left
side of this two-sided window has two sections: Upper Charges section, which displays the service dates
billed for this Patient, and the lower Transactions section, which displays all transactions to date for
the service date selected. The right side of this two-sided window, named Details, is where the
transaction is broken into its individual fields to allow for entering of the payment and/or adjustment
transaction.
1. Under the section named Charges, find and left click on the service date you will be working on.
2. Preview what transactions have already been posted for this service under the section named
Transactions (appearing immediately below the section named Charges) so that you do not
duplicate an entry.
3. Click the Add button (bottom left side of the screen) to open the fields in the Details window on the
right side of the screen, and complete the following fields:
4. Date: Todays date will automatically be entered in this field. If necessary, enter the date (if different), r
hit the TAB key on your keyboard to move to the next field.
5. Payer: Select the specific payer for which this transaction is being posted. For example, if the Primary
Insurance made a payment or denied a claim, select Primary. In the same manner, select Secondary,
Patient, or Lawyer (as appropriate)
from the menu appearing in this field.
6. Transaction: Select the Transaction
called Payment.
7. In the Pay Type field, select the
method of payment used (Cash,
Check, or Credit Card) from the menu
provided.
8. In the Check # field, enter the check
number.
9. Find and click in the box on the right
of the words Edit Detail at the
bottom of this screen towards the left
side of the Amount field. This will open the fields below the Details column to the right of each
service line for you to enter your payment.
10. For each service line, enter the payment received.
11. If adjustments are needed, click the Save & Adjust button located at the bottom of the screen and
follow the steps in next section. Else, click Save to save the entry made and return to the previous
screen.
1. If you have clicked the Save & Adjust button after entering a Payment (as per the section above) skip
to item # 7. If not, under the section named Charges, find and left click on the service date you will be
working on.
2. Preview what transactions have already been posted for this service under the section named
Transactions (appearing immediately below the section named Charges) so that you do not duplicate
an entry.
3. Click the Add button (bottom left side of the screen) to open the fields in the Details window on the
right side of the screen, and complete the following fields:
4. Date: Todays date will automatically be entered in this field. If necessary, enter the date (if different),
or hit the TAB key on your keyboard to move to the next field.
5. Payer: Select the specific payer for which this transaction is being posted. For example, if the Primary
Insurance made a payment or denied a claim, select Primary. In the same manner, select Secondary,
Patient, or Lawyer (as appropriate) from the menu appearing in this field.
6. Transaction: Select the Transaction called Adjustment.
7. In the Type field, click on the word ADD that appears in the drop down menu, and enter a name for
this adjustment. For example, if this is a Medicare Adjustment, create an entry called Medicare
Adjustment, etc.
8. If you selected the Save and adjust button after saving a Payment entry, the fields under the Details
column will already be opened for you to enter the adjustments per line item. If not, find and click in the
box on the right of the words Edit Detail at the bottom of this screen towards the left side of the
Amount field. This will open the fields below the Details column to the right of each service line for
you to enter your adjustment.
9. For each service line, enter the adjustment amount as stated on the insurance Explanation of Benefits
(EOB). Once entered, use the Tab key to move to the next line.
10. Click Save to save the entry made and return to the previous screen.
N. Patient Statements
Statement Notes:
1. In the opened Statements screen, left click on the Setup button located at the bottom middle of the
screen.
2. Default Footnote: Enter a message that you want printed
on all statements that are current (1 to 29 days). The day
count starts on the first day the Patient is billed.
3. Prompt for 30-day notice: Click this box if you want a
message to print on all statements that are 30 to 59 days
past due. Enter this message in the field provided.
4. Prompt for 60-day notice: Click this box if you want a
message to print on all statements that are 60 to 89 days
past due. Enter this message in the field provided.
5. Prompt for 90-day notice: Click this box if you want a
message to print on all statements that are 90 days or more
past due. Enter this message in the field provided.
Statement Settings:
6. From the Print column, select the desired items to print on the statement (you can select more than
one). The options here are self-explanatory.
7. From the Heading column, select either your Providers information, your Companys information, or
your Facilitys information to be printed at the top of your statement. The information selected will print
in the top center of the statement page. If you would like it to print on the left side of the page to fit into
a Number 9 Invoice Envelope, please select the option
Left Align the From Address.
8. From the Procedure column, select how you want the
services to print onto the statement.
9. Select Detail if you want to print the description along
with the Procedure Code. (Do not select this option if you
want only the Procedure Code to print on the statement).
10. Select Summary if you want to print both the
description of the Procedure Code and the date of service.
11. Select D.O.S only if you want to print only the date of
service (with no Procedure Code).
12. Select Blank if you want to print only the total dollar
amount due (no service date and no description or
Procedure Code).
13. Return to the Statements screen by clicking Ok.
1. If the Patient or Patients that you would like to send a statement to appear on the list provided, select the
box to the left of Patient Account Number (PAN) for that Patient (or Patients), or left click on the
Check All button on the bottom left of this screen to select all of them.
2. To Preview the statement, left click on the Print button located at the bottom left of this screen, then
left click on the Preview button in the newly opened Report Statements screen. Below is a sample of
a printed Statement:
3. To Print the Statement(s), left click on the Print button located at the bottom left of this screen, then
click on the Print button in the Report Statements screen that opens immediately thereafter.
O. Report Setup
From the top navigation menu, select the System tab. Then, select the Reports Setup Option.
1. Under the Printer section, select the Default
Printer drop down menu. Make sure your main
office printer is selected as the default.
2. Confirm that the box next to Default Printer is
checked.
3. Under the Printer section select the Default
Paper drop down menu and select Letter.
(8.5x11)
4. Under the Reports section in the Report drop
down menu select the type of billing you will be
doing. (Paper Billing, Statements, or UB-04.)
5. The Saved Settings drop down menu is where
you will find all of your saved calibration
settings.
P. Printer Calibration
1. Under the System tab, select Report Setup.
2. Under the Reports section in the Report drop down menu, please select the type of billing you
would like to calibrate. (Paper Billing or UB-04.)
3. Place a blank UB-04 or 1500 form in your printer.
4. Click Print Calibrating Page.
5. After you print this page, locate on the calibration page
you printed which vertical and horizontal displacement
numbers line up best with your form.
6. Go back to the Reports Setup page and click the Add
button.
7. Here you will create a pre-saved setting for paper billing.
(1500/UB-04)
8. Enter a desired name for the settings. (I.E. 1500 Form)
9. Now, enter the vertical and horizontal displacement numbers you located earlier on your calibration
page in the left columns labeled Vertical Displacement and Horizontal Displacement.
10. Click Save.
Q. Backing Up
From the Top Navigational Menu, select System Backup Data, and in the opened Backup Data
screen, do the following for each field:
1. If set up properly, the Archives Folder field will contain the following: C:\ProHealth\Backup
(assuming this is a non-networked system). If it is not pointing to this path, left click on the Change
Path button to find the Backup folder within the Pro Health folder on your computer.
2. Click the image located under Backup Data in the
middle left section this screen to perform the backup.
3. Finally, a confirmation message will appear stating that
the backup was successfully saved in the chosen folder.