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We are having problems sending Amerigroup claims.

Amerigroup seems to want the provider's taxonomy code in the 2000PRV and 2310B segments for group practices. But from what I can tell, if the practice is marked as a group practice in the system, the 2000PRV segment does not create.

Is there a way to get the 2000PRV and the 2310BB segment to both generate for group practices for Amerigroup? Do we need to put a 'C' in the entity type in the EDI Receiver Extra Tab?

Thank you for the help.

Swati

Hi Swati, what direct module are you using and what version of Medisoft do you have?

Hi Gavin,

We are using version 12 with service pack 2. We have 8.1 Advantage. The direct module is AVAP with the latest EDI patch applied. We are in Texas and using Availity as our clearinghouse.

Any help is much appreciated.

Swati

OK, try this.

1. On your provider record, setup a 10-digit taxonomy code. The 10th digit must be an alpha character.
2. Do not setup an EDI Reciever Type. This is typically NOT required for Availity.
3. If this is a group practice, then check the group practice option on your EDI Reciever.
4. If this is NOT a group practice, then enter 2310B in Extra 1 field of your EDI Reciever.
5. Then enter 2310B in Extra 1 field of your Amerigroup insurance carrier.
6. Make sure your Availity module is at least v12.09.

There have been a few cases where we have had to setup two or more receivers for one direct module or another. We have not had to do this yet with Availity.

Hi Gavin,

Unfortunately this did not work. We have installed the latest EDI 12.10 release that is on the Medisoft site.

This version was supposed to address this issue of creating the 2310B PRV loop for a group practice. On the earlier version, we were not able to create the 2310B PRV loop for taxonomy codes when the practice was a group.

From my understanding, Amerigroup is the only one requiring the taxonomy in both the 2000 PRV and 2310PRV. All others require it only in one place - individual - in 2000 PRV and group - 2310PRV.

In this version, if we mark the EDI Receiver as a group practice, then the 2000 PRV segment does not create and the taxonomy is entered in 2310B. If we do not mark the EDI receiver as group practice, then the taxonomy is put in 2000.

Any additional thoughts?

Thank you.
Swati

Try this.

Setup a new reciever for Availity and call it Avality Taxonomy. Setup everything on that receiver just like your standard Availity receiver. Then, uncheck the group practice option for this new reciever. When you generate your Availity billing file, do your Availity Taxonomy first and filter on Amerigroup. Once Amerigroup is processed and uploaded, then go back and bill everything else for Availity. If you end up with multiple insurance companies that require the claim file this way, then setup billing code T for taxonomy and filter these claims by the billing code.

This is what i already tried but this does not result in having the taxonomy code placed in loop 2000A segment PRV and Loop 2310B segment PRV for a group practice.

By not checking the group practice - it creates the loop 2000A segment PRV but it does not create the 2310B segment.

If you mark it as a group it will not create the 2000A segment but will create the 2310 segment. I don't know how to get it to create both.

It seems that this issue was addressed in version 12.05 (see below - from your website). It seems that exceptions were created for certain payer IDs to create the 2000A Segment PRV for group claims. This is what we need done for Amerigroup claims in Texas.

Version 12.05 1/11/08
All Modules

12160 - Modified the application to create Loop 2000A Segment PRV for Payer ID MC048 and Payer ID MC087 when sending as a group. Modified the Crosswalk to document this exception.

AVAP
11861 - The application code for the AVAP module was changed to not send Loop 2000A Segment PRV segment when sending AVAP claims for a group. Crosswalk also updated to reflect this change.

Thanks,
Swati

OK, on the Availity Taxonomy Reciever that I just now had you setup, set the Receiver Type = C. Check the group practice box again. Ignore what I said earlier about the reciever type code. Apparently an exception was coded hinging on this value.

If it is OK to generate all your claims this way, then you can probably consolodate to one Availity reciever record.

Hi Gavin,

Sorry to be such a pest...but i have already tried putting a C in the receiver type. If the group practice is selected it still does not create the 2310B segment.

If i don't set up as a group and put in the C - it only creates the 2000A PRV segment. It does this with or without a C for a non-group practice.

so i can get one but not the other.

Thanks,
Swati

It sounds like we have worked our way into a corner. I'll send this over to Medisoft's programming department to see if there is either an undocumented way to get AVAP to do both or program a solution for this.

OK, I still haven't got any information specific to Amerigroup, but I know for other payers where people have had this issue it was because they did not have both their group NPI and individual NPI registered with that payer.

As a last resort, I am told that if you can downgrade to AVAP v12.07 it will create both segments. The thing is, if it creates both segements for Medicare and Tricare we know they will reject those claims.