Top Management Story

Writen by Michael Russell

In this installment of medical billing of claims, we're going to continue with our review of electronically billing claims and the DA0 record, which identifies the payer who is responsible for paying the claim to the provider or patient.

DA0 field 8, positions 32 - 35, is the National Payer Claim Office Number. Every payer is assigned a claim office number. This number is usually stored in a lookup table in the software and retrieved prior to transmission. This number must be sent or the claim will be denied.

DA0 field 9, positions 36 - 68, is the payer name. This cannot be abbreviated. If you're billing New Jersey Medicare then the name must be complete. You can't just put Medicare or the claim will be denied.

DA0 field 10, positions 69 - 88, is the policy group number. Every insurance card has, in addition to the patient ID, a group number that is the same for every patient who uses that carrier. This number must be transmitted accurately or the claim will be denied. The patient ID number is not enough. Red tape - you've got to love it.

DA0 field 11, positions 89 - 121, is the group name. This is the generic group name that is given to the insurance carrier and also must be transmitted unless one does not exist, which may be the case with private insurance.

DA0 field 12, position 122, is the PPO/HMO Partnership Indicator. This is an indicator that tells if the insurance carrier is linked with a PPO or HMO provider.

DA0 field 13, positions 123 - 137, is the PPO/HMO ID Number. If the insurance carrier is affiliated with a PPO or HMO, then they are given an ID number and that number must be included here and transmitted with the claim or the claim will be denied.

DA0 field 14, positions 138 - 152, is the prior authorization number. This is where we get into legalities again. In order for services to be rendered, in some cases, not all, a prior authorization is required. This is to protect against lawsuits and things of that nature. That number must be transmitted here if it exists. This is a conditional field.

DA0 field 15, position 153, is the patient signature indicator. This is simply an electronic signature designating that the patient has signed a release, which the patient had actually to do prior to the procedure. If they were unable to then a guardian needed to sign. This is where we get into the legal representative that was discussed in an earlier article. Bet you didn't know you needed to be a lawyer to understand medical billing.

DA0 field 16, position 154, is the patient signature source. This is a code that designates how the patient signed, if they even signed at all or if a legal guardian signed. These codes are usually pulled from a lookup table.

In our next medical billing installment on the DA0 record, we'll continue with DA0 record field number 17.