Technical Support

Setting up a Group Practice

I. Changes in Claim Filling Requirements

When converting from a single doctor practice to a medical group practice, insurance plans frequently require the following changes on their claim forms:

1) The practice name in Block 33.

1) The provider's name in Block 31.

1) The provider's number above PIN# in Block 33.

1) The medical group's number above GRP# in Block 33.

MD VersaForm can be setup to satisfy these requirements with changes in the Practice Provider file, the Patient Ledger, and the Claim print format.

Practice Provider File

The practice ID "0" is used to store the medical group's data. Individual practitioners generally use a two letter code (their initials) in the ID field. The provider code is used in the fields MD_ID and MD on the patient ledger. For insurance claims, the fields Default_ID_Number, Ins_Type, and ID_Number are most important.

Default_ID_Number is used as the group/provider ID number if the group/provider number for an insurance plan is not listed under Ins_Type.

Ins_Type is the name of the insurance plan. It corresponds to Ins1 on the patient's ledger and the field Ins in the insurance plan file. A pick list is available.

ID_Number is the group/provider identifying number the insurance plan requires.

Patient Ledger File

If you want a provider's name in Block 31 and their provider number in Block 33, then the field MD_ID must contain the provider's code prior to creating a claim.

Claim Print Format

Claim print formats control the logic and location about where and which data elements print on a claim. For general directions on how to modify print formats, consult the VersaForm Business From Database manual. With rare exception, most commercial insurance plans use the HCFA-1500 (U2)(12-90) print format. Medicare, however, has its own set of changing rules. Before modifying your Medicare claim print format, find Medicare in your insurance plan file and confirm what is in the field Print_Format. The print format should contain the word "Medicare". Irrespective of the print format, the same modifications should work on all formats.

Provider Name in Block 31

Use the Line column within the print format definition to find lines 60 and below. Inspect the Print-Items column for Doc_Name. It might be located on line 63, col. 3 and might have an "N" in the Pg field. If you find Doc_Name and there is an "N" in the Pg field, then change the "N" to an "A". If you can't find Doc_Name, then enter add it to your format. It could be placed on lines 60, 61 or 63, in column 3 with a size of 20.

Provider Number in Block 33

To place the providers number in PIN# area of the claim, find line 63, column 51. There may be several print items for this location. If you find the Print-ItemDoc_Pin, then activate it by replacing the "N" in Pg with an "A". If you can't find Doc_Pin, then enter it.

Practice Number in Block 33

In a properly configured group practice, the field Provider# will contain the group number and not the practitioner's number.

Sample Setup for Group Practice

Below is a group practice. Note that the practice name is in the Name field and that the group's unique insurance plan identifying numbers are found in the Default_ID_Number and the ID_Number fields.

Sample Setup for Doctor under A Group Practice

Below is the practice file of Doctor Frank Jones, MD. Note the field Submitter_ID contains a "0". That tells the system that this doctor is submitting claims under the group. The field Name will be used to fill in block 31 of the claim. If the doctor's credentials are required, then simply add them after the doctor's name. All of the doctor's insurance plan identification numbers are found on either the ID_Number list or will default to the Default_ID_Number. The Medicare number will also appear in Block 24K.

After a claim has been created, page 3 of the claim will reflect it is a group medical claim. P_MD_ID combines the doctor's code with the group's.

Sample Setup for Independent Doctor within A Group Practice

In the example below, the doctor's claim information will not reflect the medical group's data.

On page 3 of the claim, the doctor's name and numbers are found. The field P_MD_ID contains only the doctor's code.

II. Statement Printing

The preceding changes to the practice/provider file and the patient ledger also impacts statement printing. Unless changed, all statement print formats use the practice/provider file to print who is sending the bill. The practice information that prints at the top of the statement uses the same logic that fills Block 33 on claims.

In our example, patients that have "FJ" in the field MD_ID will receive a bill from the "The Practice" at the clinic address "Frank Jones MD. Patients with "JL" in MD_ID, will get statements that are from "James Larson, MD" at the address on his record.

III. Reports

Except for ledger Report 8, "Charges, Payments And Adjustments by MD", other reports might need to be modified to reflect a multiple doctor environment. For instructions on modifying reports, read Chapter 7 "Reports" in the VersaForm Business Form Database manual.

You may want to add an "MD" column to the report and sort on this field or you may want to add a selection condition to limit the report to one specific "MD".

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