Billing Providers (Integrated Billing)

The Billing Provider is the provider and related NPI that will appear on the patient’s claims. How the Billing Provider is selected depends on the billing integration and whether the service is per-diem or ancillary. For ancillary services, you can configure the EMR to use different billing providers as needed. 

There are two types of billing providers within the EMR:

• Billing Provider which will appear in Box 24j.
• Clinical Provider which appears in Box 19. Today, only Arizona (AHCCCS) requires clinical billing providers to appear on claim forms. 

Per-diem Billing Provider

The default Billing Provider for per-diem/Level of Care services has different capabilities depending on your integrated billing solution.

1. CMD/SFTP customers can use the Autopopulate LOC Billing Provider setting to choose the best method for their facility:
   • Authorization
   • Care Team
   • Konnector Billing Provider
   • Same Signer
2. Avea customers will see the billing provider on the patient's UR plan for the related per diem billable items. It is best practice to set levels of care to authorization which will show the selected billing provider in the EMR without clicking on Manage Service and navigating to Avea.

Enable Billing Providers

To use alternative billing providers, you must add the Rendering Provider feature to each user profile in the EMR who should be available to be selected as the billing provider on ancillary services. Super Admins and users with the Manage Users features can make the following updates. 

1. Click on your initials and select Manage Users from the drop-down.
2. From the Active Users tab, click Edit on the profile you want to update.
3. Ensure the provider has an NPI Number added to their profile. This NPI will appear on the claim.
4. From the Features section, select Rendering Provider.
   
5. Click Update to save.
6. You’ll see the feature displayed in the Active Users list.
7. Repeat this step for all billing providers in the organization.

Important: Billing providers must be configured in your integrated billing system and the NPIs must match, or there will be a batch error when submitting a claim from the billing report.

Billing Provider: System Rules

The Kipu EMR follows a specific hierarchy when determining which Billing Provider to use on the claim. 

• Rule #1: Use the billing provider manually selected on the billable evaluation/group session.
• Rule #2: Use the provider that auto-populated on the billable evaluation/group session based on the rule selected in the Billing/Clinical Rendering Provider drop-down on the Evaluation or Group Session template. 
• Rule #3: Use the billing provider on the Konnector.

Note: The billing provider can be manually updated on the billing report before transmission to your integrated billing software, as needed. The Clinical Provider is not visible on the billing report and cannot be updated manually. 

Rule #1

The system reviews the Evaluation or Group Session form. If the form is marked Billable/Ancillary and the Display Billing Rendering Provider drop-down is set to Edit Mode or Edit and View Mode, then the provider manually selected in the Billing Rendering Provider drop-down will be the billing provider.

Only users with the Rendering Provider feature will be available for selection in the Billing Rendering Provider drop-down on the group session/evaluation.

Rule #2

The system reviews the evaluation or group session template. When the form is marked billable and ancillary, the system will automatically populate a provider based on the rule selected in the Autopopulate Billing Provider drop-down. 

The available rules are: 

• Instance Setting [value]: By default, new templates will inherit the instance setting configuration for this drop-down. The value chosen in the instance setting will appear in brackets.
• Konnector Billing Provider: The user who is designated as the konnector billing provider under Settings > Integrations > Konnectors. If you don't pick a billing provider on the service, and select this option, the Konnector Billing Provider will appear on the billing report.
• Form Creator: The user who adds the evaluation or opens the group session will be the billing provider.
• Initial Signer: The first user who signs the evaluation or group session will be the billing provider. 
• Last Signer: The final user who signs the evaluation or group session will be the billing provider. 
• Care Team: If a care team is assigned to the patient, the system will perform the following logic check to determine the billing provider.
  1. If the primary physician has the Rendering Provider feature enabled, the system will use this individual as the billing provider. 
  2. If the primary physician does not have the feature enabled, the system will look at the primary therapist. If the primary therapist has the Rendering Provider feature enabled, the system will use this individual as the billing provider. 
  3. If neither user is a billing provider, no value will be auto-populated in the field. 

Rule #3

If none of the rules above produce a billing provider for the claim, the system pulls in the billing provider from the Konnector. The Billing Provider column on the Billing report is typically blank when the billing provider from the default Konnector is used. 

You can verify this individual under Settings > Integrations > Konnectors.

Level of Care Billing

For billing inpatient and attendance-based levels of care (e.g., any group session or evaluation only marked as Billable), the billing provider is always the provider indicated in the Konnector.

Clinical Billing Provider (Box 19)

Arizona clients can configure two clinical billing providers to appear in Box 19 for ancillary services. This fulfills AHCCS requirement to report the individual practitioner who rendered services on professional claims starting January 1, 2023. 

The Clinical Billing Provider(s) can be configured on Evaluation and Group Session templates marked as billable and ancillary using the Autopopulate Clinical Provider and Autopopulate Secondary Clinical Provider drop-downs. 

The available rules for selecting the clinical billing provider(s) are:

• Instance Setting [value]: By default, new templates will inherit the instance setting configuration for this drop-down. The value chosen in the instance setting will appear in brackets. This value will be one of the options described below.
• Do Not Autopopulate: No provider will be automatically configured as the billing provider. Users can still choose a provider from the drop-down (if configured to be visible). 
• Billing Provider: This will automatically choose the user set as the billing provider as the clinical provider. 
• Form Creator: The user who adds the evaluation or opens the group session will be the clinical provider.
• Initial Signer: The first user who signs the evaluation or group session will be the clinical billing provider. 
• Last Signer: The final user who signs the evaluation or group session will be the clinical provider. 
• Care Team: If a care team is assigned to the patient, the system will perform the following logic check to determine the clinical provider.
  1. If the primary physician has the billing provider feature enabled, the system will use this individual as the clinical billing provider. 
  2. If the primary physician does not have the feature enabled, the system will look at the primary therapist. If the primary therapist has the Rendering Provider feature enabled, the system will use this individual as the clinical billing provider. 
  3. If neither user is a billing provider, no value will be auto-populated in the field. 

If the clinical billing provider is not auto-populated using one of the above rules or is set to Do Not Autopopulate then no clinical billing provider will appear in Box 19. 

Note: The clinical billing provider is not visible on the billing report in the EMR and cannot be updated manually. Viewing the clinical provider(s) added to the claim and making updates to the clinical billing provider must be done in the integrated billing system. Click here to learn how to manage the clinical billing provider in Avea.

Billing Provider Instance Settings (Hidden)

The EMR has four instance settings that set the default billing provider auto-population behavior for ancillary services. These settings can only be configured by a Kipu Staff Member, so please reach out to Support if you'd like the make updates. 

• Display Ancillary Billing Provider: This setting determines how the Billing Provider drop-down appears on Group Sessions and Evaluations marked as billable and ancillary.  
  • Hide: The Rendering Provider drop-down is not displayed.  
  • Edit Mode: The Rendering Provider drop-down will appear when editing the group session and evaluation.  
  • Edit and View Modes: The Rendering Provider drop-down will appear when editing and viewing the group session and evaluation.  
• Autopopulate Ancillary Billing Provider: This setting determines which user is chosen as the billing provider for group sessions and evaluations marked as billable and ancillary.  
  • Do Not Autopopulate: No provider will be automatically configured as the billing provider. Users can still choose a provider from the drop-down (if configured to be visible).  
  • Form Creator: The user who adds the Evaluation or opens the group session will be the billing provider. 
  • Initial Signer: The first user who signs the evaluation or group session will be the billing provider.  
  • Last Signer: The final user who signs the evaluation or group session will be the billing provider. 
  • Care Team: If a care team is assigned to the patient, the system will perform the following logic check to determine the billing provider. 
    1. If the primary physician has the Rendering Provider feature enabled, the system will use this individual as the billing provider.  
    2. If the primary physician does not have the feature enabled, the system will look at the primary therapist. If the primary therapist has the Rendering Provider feature enabled, the system will use this individual as the billing provider.  
    3. If neither user is a billing provider, no value will be auto-populated in the field.  
• Autopopulate Clinical Provider and Autopopulate Secondary Clinical Provider: These settings determine which user is chosen as the clinical billing provider(s) for group sessions and evaluations marked as billable and ancillary. 
• Arizona Clients Only: This setting allows you to control which billing provider appears on Box 19 and should only be configured for clinics with state requirements to send this information on the claim. Today, this is limited to Arizona.
• Do Not Autopopulate: No provider will be automatically configured as the billing provider. Users can still choose a provider from the drop-down (if configured to be visible).  
• Billing Provider: This will automatically choose the user set as the billing provider as the clinical billing provider.  
• Form Creator: The user who adds the evaluation or opens the group session will be the clinical billing provider. 
• Initial Signer: The first user who signs the evaluation or group session will be the clinical billing provider.  
• Last Signer: The final user who signs the evaluation or group session will be the clinical billing provider.  
• Care Team: If a care team is assigned to the patient, the system will perform the following logic check to determine the clinical billing provider. 
  1. If the primary physician has the Rendering Provider feature enabled, the system will use this individual as the clinical billing provider.  
  2. If the primary physician does not have the feature enabled, the system will look at the primary therapist. If the primary therapist has the Rendering Provider feature enabled, the system will use this individual as the clinical billing provider.  
  3. If neither user is a billing provider, no value will be auto-populated in the field.  

Provider Settings (CollaborateMD Only)

Designed for outpatient services, the Provider Settings functionality allows you to specify who is assigned the Rendering Provider credentials for each location under Settings > Billing > Provider Settings. Click here for more information.