Provider Enrollment

Provider Enrollment

Claim.MD's Provider Enrollment page simplifies your organization's healthcare billing paperwork and portal completion process, allowing you to efficiently enroll with payers to submit claims, receive electronic remittance advice (ERA), and eligibility services. Prov Enrollment is only done for payers matching how you are currently actively credentialed or registered with specific payers.

Accessing Provider Enrollment

• Click on Provider Enrollment in the left-hand navigation menu.
  

Important Notice

Adding a Provider

Ensure all billing providers, including individual and organizational National Provider Identifiers (NPIs), are added to the provider list. Enrollments should only be finalized when designating the provider as the Billing Provider.

Steps to Add a Provider

1. Click the Add Provider button.
2. A pop-up box will display. Enter the following details:
   • Provider NPI (Atypical providers without an NPI should enter only the Tax ID).
   • Provider Tax ID (Re-enter for confirmation).
3. Click Continue.
4. The provider will be added to the list with their information retrieved from the NPPES database.

Adding Multiple Providers via a Spreadsheet

1. Click Add Provider
2. Skip the Provider NPI and Tax ID fields. Click Import Spreadsheet (XLSX) at the bottom of the pop-up window.
   
3. Click Choose File and select the XLSX file from your drive.
   
4. Click Upload Filesto process the file.

   WARNING

   The NPI and Tax ID columns must be numeric only. Dashes (-) and other characters are not allowed.

Edit Provider

If the NPI record is incomplete, a pop-up will display indicating missing information. Add the required details and click Save Provider.

If a pop-up box window does not display,  it is advised to still review and edit the provider information for accuracy. To do this:

1. Click the Edit button next to the provider.
   
2. Ensure Address, City, State, and Phone Number are correct.

   It is especially important to enter the full 9-digit ZIP code (ZIP+4) correctly. Do not include a dash between the ZIP code and the +4 extension.

3. Click Save Provider to finalize changes.

💡 Optimize Your Reporting with Claim Grouping

Enabling Claim Grouping allows for better organization and filtering of claims and ERA reports, making it easier to track financial and billing data efficiently.

Steps to Enable Claim Grouping:

1. Click the Edit button next to the provider.
2. Check the Show In Claim Group checkbox.
3. Click Save Provider to apply the changes.

Pending Approval

When a provider record requires additional approval, a "Pending Approval" indicator will appear on the provider enrollment screen (see screenshots below). This signifies that a verification request has been initiated, and an automated phone verification message will be sent to the contact information listed in the NPPES database. The designated contact must confirm or decline the request to proceed.

It is essential to ensure that the contact details in the NPPES database are accurate and up-to-date. If approval is granted, the enrollment process will continue, and the required documents will be processed and submitted. Until approval is received, the enrollment will remain in a pending status.

Enrollment

After adding providers, the next step is to complete Electronic Data Interchange (EDI) enrollment for each billing provider with every payer that will:

• Receive the provider’s claims.
• Return Electronic Remittance Advice (ERA) and eligibility information.

How to Enroll a Provider

• From the Provider List, click on a provider record to view the list of common payers for their geographic region.
  
• Select whether to view Professional (1500) claims or Institutional (UB04) claim types. Claim types can be managed within Account Settings.
  
• If a payer is not listed, use the Payer Search field in the top-right corner to search by Payer Name or Payer ID.
  

Payer Enrollment Status

Each payer will display an enrollment status across three columns:

• 1500 Claims
• ERA (Electronic Remittance Advice)
• Eligibility

Each of these transactions requires separate enrollment for each payer.

Enrollment Methods

• No Enrollment Required: Claims can be submitted immediately.
• Auto-Enroll: ERA enrollment is automatic upon claim submission.
• Enrollment Required: Follow additional steps for payer-specific registration.
• Quick Enroll: Available for ERA and Eligibility, enabling one-click enrollment.

No Enrollment Required

If a payer displays No Enrollment Required for Claims, ERA, or Eligibility, then claims can be submitted immediately without further action.

Auto-Enroll

If a payer is designated as "Auto-Enroll" in the ERA column, the provider will automatically receive ERA when claims are submitted through Claim.MD.

Enrollment Required

If the Claims, ERA, or Eligibility column for a payer indicates "Enrollment Required," additional steps are necessary before proceeding with enrollment.

Steps to Complete Enrollment

1. Review and submit any required paperwork.
2. Follow the instructions for payer portal enrollments.

Paperwork Submission

• Electronic forms must be reviewed, completed, and signed before submission.
• For certain payers (e.g., Medicare Part B), only an authorized user can complete and sign the form.
• Additional supporting documents may be required.
• A pop-up box will guide users to enter missing information (highlighted in red) and upload necessary attachments.

Next Steps

Once the form and attachments are submitted, a confirmation window will provide further instructions. Some forms will be automatically faxed, requiring no additional action.

Submitting Enrollment

1. Click on the provider's name in the Provider List.
2. Locate the payer using the Payer ID number (often found on the back of a patient’s insurance card).
3. Under the 1500 Claims column, click the Enrollment Required button.
4. Complete all required fields, attach necessary documents, and click Submit Document.
5. If using Claim.MD for ERA or Eligibility, click the corresponding Enrollment Required button for these transactions.

More Information

The Email Form option allows authorized external users to complete and sign the form.

1. Click the Email Form button.
2. Enter the authorized user’s email, name, phone number, and title in the pop-up window.
3. Click Send Email to send the form.

Instructions on Payer Portal Enrollments

Some enrollments require additional steps, such as entering information into payer portals. Once all details are entered and necessary documents are submitted, click the Mark Complete button.

Steps to Complete Portal Enrollment

1. Click on the provider name in the Provider List.
2. Locate the payer using the Payer ID number (often found on the back of a patient’s insurance card).
3. Under the 1500 Claims column, click the Enrollment Required button.
4. Follow the necessary links and complete all required information on the third-party payer site.
5. If using Claim.MD for ERA or Eligibility, click the respective Enrollment Required button.
6. Once all steps are completed, click the Mark Complete button.

More Information

Use the dropdown menu at the top of the screen to switch between Institutional/UB04 and Professional/1500 claim enrollments. Unused claim types can be disabled in Account Settings.

Quick Enroll (Available for ERA and Eligibility Only)

Quick Enroll allows providers to instantly enroll with payers that have pre-authorized Claim.MD for Electronic Remittance Advice (ERA) and Eligibility transactions. This feature is not available for 1500 Claims.

Steps to Use Quick Enroll

1. Click on the provider name in the Provider List.
2. Find the correct payer using the Payer ID number (often found on the back of a patient’s insurance card).
3. If Quick Enroll is available, a Quick Enroll button will appear under the ERA or Eligibility column. Click it to complete the enrollment.

Not Available

If a payer’s 1500 Claims, ERA, or Eligibility column displays Not Available, it means electronic enrollment is not supported for that payer.

Entering a Legacy or Submitter ID

The Legacy ID is used to generate claims and automatically populate the provider ID for atypical providers who do not have an NPI. Note that each payer has a different Legacy ID format.

For payers requiring a Submitter ID, providers must enter their unique, provider-specific Submitter ID into the designated field.

Steps to Enter a Legacy/Submitter ID

1. Click the arrow to the left of the payer record.
2. On the right side, enter the Legacy Provider ID or Submitter ID.
3. Click the Save button next to the Legacy Provider/Submitter ID field.

Re-enrollment

Re-enrollment may be required if the original enrollment failed, was never processed, or if the payer's routing has changed. Providers may also need to re-enroll if their office updated payer routing settings, or for other reasons that may impact their Claim.MD connection.

Steps to Re-Enroll

1. Select the correct provider from the list.
   
2. Find the "Completed" link for Claims, ERA, or Eligibility next to the correct payer.
   
3. Click the Re-Enroll button at the bottom left.
   
4. Click the Enroll button when prompted. The enrollment process may involve Quick Enroll, paperwork submission, or external payer portal links.
   

Paperwork Submission

• Enrollment often requires completing and signing electronic forms.
• For Medicare Part B and similar payers, the form must be signed by an authorized user.
• Some enrollments require additional paperwork outside the system.
• A pop-up box will guide users through required information and attached documents.

Re-Enrollment

Re-enrollment may be necessary due to processing failures or provider routing changes. Click Re-Enroll and follow the prompted steps.

Entering a Legacy or Submitter ID

Legacy IDs and Submitter IDs may be required for certain payers. These identifiers allow claims to be submitted when an NPI is not applicable.

1. Click the arrow next to the payer record.
2. Enter the Legacy Provider ID or Submitter ID as required.
3. Click Save to finalize.

Final Steps

Once all required enrollments are complete, providers can begin submitting claims and receiving ERA through Claim.MD.