Payer Management is used to configure payers and assign service pricing, DRG, APC, and APC-DRG pricing by payer and facility. It also supports insurance company pricing, guarantor or patient self-pay settings, and contract fee assignment for payers.
Add and Edit Payers
Adding a new payer is performed by clicking the New Payer link and filling in each field. To edit a payer, click the Pen Icon to the right of the payer. Fill in any of the following fields that apply:
Payer Details
Name: This is the name of the payer that will appear on the HCFA Form or is sent to the insurer via a clearing house.
Short Name: This is the shortened name for the payer.
Address 1: This is the first line of a payer’s address. This line is not required.
Address 2: This is the second line of a payer’s address. This line is not required.
Country: Must select the country first.
State: Select the state for the payer.
Zip: Enter the zip code for the payer if it has not been automatically entered after filling in all other address information. A zip code can also be used to fill in the State and City boxes. To do this, enter the zip code in the search box after filling in the Address 1 and/or Address 2. As you enter your zip code the city and state is displayed, choose it from the menu.
Phone: Enter a phone number for the payer.
Fax: Enter a fax number for the payer.
Email: Enter an email address for the payer.
Parent Payer: If this payer is the same as a parent company, select the parent company from the list.
Claim Indicator: This field is used to set the insurance plan type at the top of the HCFA 1500 form. The options are Medicare Part B, Medicaid, Blue Cross Blue Shield, Commercial Insurance and many others.
Payer ID: This is the Id used by the clearinghouse to route the insurance claim. This must be entered for electronic claims processing.
Institutional Payer Id: This is the payer ID used for institutional claim submissions.
ICD9 / ICD10: Select the diagnosis coding format used for claims submitted to this payer.
Default Payer: Checking this box marks the payer as the default payer within the system.
Out of Network: Checking this box identifies the payer as an out-of-network insurance payer.
33b: Checking this box enables Box 33b information for claim submission.
Bill By Provider: Checking this box bills claims under the rendering or billing provider.
Send Facility Taxonomy (33b): Checking this box sends the facility taxonomy code in Box 33b on claims.
Send Referring Taxonomy: Checking this box sends the referring provider taxonomy code with claims.
Send 837I Episode Number: Checking this box includes the episode number when sending 837I institutional claims.
Active / Inactive: Sets whether the payer is active or inactive within the system.
Pay Days: Enter the expected number of days for payment processing from this payer.
Payer Class: Select the payer classification from the available list.
Price List: Select the pricing list associated with this payer.
Coinsurance%: Enter the coinsurance percentage associated with this payer.
Update Patient Coinsurance: Clicking this link updates the patient coinsurance settings for this payer.
Primary / Secondary / Tertiary: Select the delivery method or claim routing settings for primary, secondary, and tertiary claims.
Clearing House: Select the clearinghouse used for electronic claim submission.
Contact Person Name: Enter the name of the payer contact person.
Designation: Enter the designation or role of the contact person.
Mobile#: Enter the mobile number of the contact person.
URL: Enter the payer website URL.
User: Enter the username used for payer portal or website access.
Password: Enter the password used for payer portal or website access.
Bio-Reference Code: Enter or search the bio-reference code associated with the payer.
Instruction: Enter any payer-specific instructions or notes.
RPS Code: Select or enter the RPS code associated with the payer.
Form24J: Enter the Form 24J value if required for claims processing.
Form24JType: Enter the Form 24J type associated with the payer.