Credentials: The provider’s medical credentials. (MD, OD, RN etc.)
NPI: The provider’s National Provider Identification number.
Taxonomy Specialty: The provider’s Taxonomy code that identifies the provider type and area of specialization.
Sequence#: This number is auto-populated by CollaborateMD. This is an internal number and not appear on the claim.
Reference#: In the event, you have to enter a provider into the system twice, use this field to help distinguish between the two providers. (e.g., Tax ID, EIN, Provider A, Provider B). This field is informational and does not appear on the claim.
Code: You can use this field to enter a code of up to 3 letters or numbers. This code will then be displayed on certain reports within the Report screen of the application to identify which provider performed the service. This code will not appear on any claim.
Practice for this provider: Click on the magnifying glass to search for the practice you want to associate the provider too. This will be the provider's default practice. Important Note: Once the provider has been saved, the practice listed in this field cannot be changed.
Bill claims under: This field defaults to Self. Click on the magnifying glass to choose the provider that should populate in the billing provider field for all future claims.
Check eligibility under: This field defaults to Self. Click on the magnifying glass to choose the provider all eligibility checks will be submitted under. We recommend configuring one provider for all eligibility checks to be completed under to prevent having to configure multiple providers.
Bill as: Select whether this provider will bill under their individual provider (Provider screen) information or group (Practice screen) information.
Use which ID number: Select whether to bill using the provider’s SSN or EIN number.
Submitter Number: Change Healthcare assigns each new Tax ID number a Submitter Number. This Submitter Number tells Change Healthcare which customer is sending them electronic products such as claims, statements, ERA's, etc. It also allows Change Healthcare to send Clearinghouse reports back into your account. A Submitter Number will automatically be generated under the Internal Use field.
Blue Cross #: Blue Cross assigned number to identify providers.
Tricare/Champus #: Tricare assigned number to identify providers.
Specialty License #: The Referring provider’s Specialty License number.
State License #: The Referring provider’s State License number.
Anesthesia License #: The Referring provider’s Anesthesia License number.
UPIN #: Medicare assigned number to identify providers. This number populates on Box 17a (of the CMS 1500 form)
Default Revenue Code: For UB-04 claims only. Revenue codes are descriptions and dollar amounts charged for hospital services provided to a patient.. Select a default revenue code. The revenue code may change depending on the service provided.