Setting up the program

• There are several pieces of information that must be entered into the program in order to submit a claim file.
• The provider data, patient data, payer data and submitter data should all be entered in the Reference File Maintenance folder.
• Proceed to the Reference File Maintenance folder by clicking on the third icon.

Submitter

• Submitter: Reference File Maintenance, Codes/Misc, Submitter, Institutional, Payer ID 09101, Copy
• Required: ID (Sender/Submitter number), Name, Address, City, State, Zip (all 9 digits), Phone, Contact
• Optional: Fax
• Requested: Email [Save with errors if unavailable]
• Leave blank:  EIN, Country

Submitter: ANSI information

• Reference File Maintenance > Codes/Misc > Submitter > Institutional > ANSI Info
• Auto populates: Submitter Intchg Qual. (ZZ) and Receiver Intchg  Qual. (ZZ)
• Leave blank: All other fields unless directed by PC-ACE Support

HCPCS code information 

• HCPCS:  Reference File Maintenance, Codes/Misc, HCPCS
• Updated each quarter as appropriate
• Ability to narrow search using search options
• View effective date range of code
• Ability to add new codes

HCPCS modifier information

• Modifiers:  Reference File Maintenance, Codes/Misc, Modifiers
• Updated each quarter as appropriate
• View effective date range of code
• Option to add new codes

ICD code information

• ICD Codes:  Reference File Maintenance, Codes/Misc, ICD
• Updated each quarter as appropriate
• Ability to narrow search using search options
• Updated to contain ICD-10 codes effective 10/1/2015
• View effective date range of code

Physician information

• Reference File Maintenance, Codes/Misc, Physician
• Required: Physicians Last Name, First Name, NPI
• Optional: Physician ID (if entered, Type is required), Address, City, State, Zip (to include last 4), Phone, Taxonomy
• Leave blank: Federal Tax ID/Type

ANSI code set maintenance

• Setup: Reference File Maintenance, Codes/Misc., Misc. ANSI
• Updated each quarter as appropriate
• Provider Taxonomy Codes
• Claim Adjustment Reason Codes
• Remittance Remark Codes
• Claim Status Response Codes

Institutional TOB, CON/OCC/SPAN/VAL

• Setup: TOB, CON/OCC/SP/VAL and Revenue Codes: Reference File Maintenance > Codes/Misc > TOB, CON/OCC/SP/VAL > Revenue Code
• Updated each quarter as appropriate
• Can be updated manually if revisions (new/revised codes) become available before a release is received
• Select LOB (MCA) for TOB
• Select Type (Condition, Occurrence, Span, Value Codes)

Institutional provider information

General 

• Setup: Provider: Reference File Maintenance > Provider (Inst) > General Info
• Required: Name, Address, City, State, Zip (to include last 4), Phone, Contact, Provider ID/No., LOB – MCA, Payer ID – 09101, NPI, Tax ID/Type
• Optional: Tax Sub ID and Taxonomy/Type, Remarks
• Leave blank: Tag, Country, Site, Provider Associations

Extended

• Setup: Provider: Reference File Maintenance > Provider (Inst) > Extended Info
• Required: Provider Accepts Assign
• Leave blank: All other fields, unless directed by PC-ACE Support.

Payer information

• Setup: Reference File Maintenance, Payer
• Required: Payer ID, LOB – COM, Full Description, Address, City, State, Zip (to include last 4), Source (CI), Media (E)

• Optional: Receiver ID leave blank, Contact Name, Phone, Ext, Fax, Usage 

  (U for Institutional, B for both Professional and Institutional or leave blank or B for both Professional and Institutional)

• Leave blank: ISA08 Override

Patient information: Medicare primary

General

• Setup: Reference File Maintenance, Patient, General Information
• Required: Last Name, First Name, PCN, Address, City, State, Zip, Sex, DOB, Signature on File (first field), Release of Info, ROI Date
• Optional: MI, Gen, Phone, Notes, Marital Status, Employment Status, Student Status, Death Ind., DOD
• Leave blank: Country, Discharge Status, Signature on File second field
• Auto populates: Active Patient - Y

Primary insured

• Setup: Reference File Maintenance, Patient, Primary Insured (Inst)
• Required: Payer ID (right click to select from Payer Database to auto-populate Payer ID, Payer Name and LOB), Rel., Last Name, First Name, Insured ID, Address, City, State, DOB, Assign of Benefits, Release of Info, ROI Date
• Optional: MI, Gen, Phone, Employ Status, Retire Date
• Leave blank: Group Name, Group Number, Claim Office, Country

Patient information: Medicare secondary

General

• Setup: Reference File Maintenance, Patient, General Information
• Required: Last Name, First Name, PCN, Address, City, State, Zip (does not require last 4 but is
  recommended), Sex, DOB, Signature on File (second field), Release of Info, ROI Date
• Optional: MI, Gen, Phone, Notes, Marital Status, Employment Status, Student Status, Death Ind., DOD
• Leave blank: Country, Discharge Status, Signature on File (first field)
• Auto populates: Active patient - Y

Primary insured

• Setup:  Reference File Maintenance > Patient > Primary Insured (Inst)
• Required: Payer ID (right click to select from Payer Database to auto-populate Payer ID, Payer Name and LOB), Group Number, Rel, Last Name, First Name, Insured ID, Address, City, State, DOB, Assign of Benefits, Release of Info, ROI Date
• Optional: Group Name, MI, Gen, Phone, Employ Status, Retire Date
• Leave blank: Claim Office, Country

Secondary insured

• Reference File Maintenance > Patient > Secondary Insured (Inst) > Separate Inst & Prof > Secondary Insured (Inst)
• Required: Payer ID (right click to select from Payer Database to auto-populate Payer ID, Payer Name and LOB), Group Number, Rel, Last Name, First Name, Insured ID, Address, City, State, DOB, Assign of Benefits, Release of Info, ROI Date
• Optional: MI, Gen, Phone Employ Status, Retire Date
• Leave blank: Claim Office, Country, Group Name, Group Number