Enhanced Payer Rules Setup

This functionality is currently in Limited Release to a select group of Members. We'll continue gradually rolling out this release over the coming weeks. To access the previous version workflow, please see the Payer Rules Setup article.

Payer Rules are a set of instructions for WebPT Billing to follow when Electronic Remittance Advices (ERAs) are released and claims are posted. Payer Rules can be set up for each inbound ID/Payer Code combination and Pay Level (Primary, Secondary, Tertiary). This provides higher customization for more accurate auto-posting and prevents downstream corrections.

Establishing Payer Rules and Their Payer IDs

As this article outlines, payer rules must be established to post 835s for each payer before releasing the first ERA.

You may also need to add additional Payer IDs to already-established payers, who submit payments under multiple Payer IDs. The Release 835 page will show a status of No Payer Rule Established and the release checkbox will not be available to select until the payer rules have been established and any of its associated Payer IDs added. To add Payer IDs, follow the steps in the Payers article.

Establish Payer Rules

1. Open the Payments menu and select Add/Edit Payer Rules.
   
   
2. To add a new payer rule, click Add Payer Rule. 
   Note: Click  Search to view/edit the Payer Rules that are currently in the system.

3. From the Add Payer Rule drawer, select the Inbound ID and Payer Code you’d want to set up, then make your selections for each payer rule. All required fields are indicated by a red asterisk (*).

   
   

   1. Inbound ID*: The payer routing ID that the 835s are received from. Any Inbound IDs currently on the Release 835s page will be displayed at the top of the list, followed by all other known Inbound IDs that are connected to Payers.
   2. Payer Code*:Indicate the Payer Code that the 835's Inbound ID should be associated with. These should correspond with the payer attached to the patient's insurances on the 835.
   3. Description: Add an optional description of the payer rule
   4. Payer Level*: Select which Payer Level the below options will be applied to. All levels are required to be filled out.
   5. Payment Code: Select the payment code that will be used for payments posted from the Release 835 page. This will also be the default Payment Code selected on the Batch Payments page.
   1. For most payers, select PCON
   1. For Medicare, select PMCR
   2. For Medicaid, select PMCD
   3. For Worker's Compensation, select PWCI
   6. Adjustment Code: Select an adjustment code that will be used for adjustments posted from the Release 835 page. This will also be the default Adjustment Code on the Batch Payments page.
      1. For most payers, select AIWO
      1. For Medicare, select AMCR
      2. For Medicaid, select AMCD
      3. For Worker's Compensation, select AWCA
   7. Insurance Adjustments: Choose to post or skip the insurance adjustments; skipping is more common for Out of Network payers.
      Important: The current logic set up on the Claim Adjustment Reason Code - Company Payer Override page will override selected settings. For example, if you select Post, the system may still skip it because the Adjustment Reason and Payer are set up to be excluded from posting. 
   8. Insurance Balances: Choose to keep the balance with the current payer or transfer it to the next, which includes the patient. For most payers, select Transfer to Next.
   9. Patient Balances: If the remaining balance is transferred from the selected Payer Level to the patient, choose if you want to Keep the balance or fully Adjust the balance to zero. If Adjust is selected, an Adjustment Code must be selected.
   10. Apply to Secondary/Apply to Tertiary: Quickly select Apply to Secondary/Tertiary to copy each payer rule setting selected to the next payer level.
4. Click Save.