Payer Overrides - Provider Overrides

Insurance requirements can be complicated especially when different payers require claims to be populated with different data. For example, one payor may require an SSN in CMS-1500 Box 25, while another requires an EIN or Tax ID for the same field.

With ChiroSpring’s Payer & Provider Overrides feature, you can control exactly how your claims populate, ensuring each submission meets the specific requirements of the insurance company and provider combination.

To get started go to Billing/Settings/Payer & Provider.

Provider IDs & Claim Qualifiers (Important First Step)

Before creating overrides, make sure your Provider IDs and Claim Qualifiers are set up correctly.

These are managed at the User & Room level:

• Users & Rooms - Provider Profile - Provider IDs & Claim Qualifiers

Here is where you enter all provider-specific identifiers, such as:

• NPI
• Taxonomy Code
• State License Number
• SSN
• Medicare / Medicaid Provider Numbers
• Blue Shield Provider Number
• Any additional payer-required IDs

Viewing & Managing Overrides

Here you can see any existing overrides you’ve created, as well as create new ones.

Overrides can be created for:

• Payer & Provider - Trumps any payer or provider only overrides
• Payer - Trumps provider overrides
• Provider - When there are no payer or provider overrides the provider override will be used

Overrides are applied to claims based on the hierarchy below.  Namely, if a payer (e.g. Medicare has an override), but, a provider in the practice wants their Medicare claims to be different, then a "Payer & Provider" override should be created.  This is because the Payer & Provider override would trump the regular override created for Medicare (in this example).  

See the graphic below to help explain hierarchy.  

Click the action button, then "Create new Override".  

Then on"Create Override" tab fill out the appropriate data (see below).

Provide an Override Name and the date range you would like it to apply to.  The override only apply to claims that fall within the start and end date range.  You may leave end date blank.  

Override Type can be Payer or Provider.

When Payer is selected select one or multiple payers from the drop down menu.  

When Provider is selected, choose one or multiple providers in the dropdown menu.  Then, optionally select a Payer if this should be a Payer & Provider override.  

In the right pane, use the "Override Fields" for any of the provided CMS-1500 boxes you would like overridden.  

As an example, if you would like to use SSN in Box 25, toggle this option on and enter that value below.  This might make sense for a Provider Override.  

Perhaps a Payer requires Box 29/2300 loop to contain the amount paid.  Toggle this option on and your claims will contain this information.

All of the Override Fields should be self explanatory.

When a claim has an override, it's data will be greyed out.  See below.  

You may change the payer or provider on a claim as needed.  Keep in mind, if there are overrides associated with either, those fields will be greyed out on the claim.