Payer Rules Setup

Payer Rules are a set of instructions for WebPT Billing to follow when Electronic Remittance Advices (ERAs) are released and claims are posted. They include the payment code, adjustment code, and transfer rules. 

Establishing Payer Rules and Their Payer IDs

Payer rules must be established for WebPT Billing, as outlined in this article, for each payer prior to 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 Payer ID Not Found and the release checkbox will not be available to select (shown below) until the payer rules have been set up 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 New. Note: Click Search to view/edit the Payer Rules that have already been created.
   
3. Select the correct Payer from the drop-down menu, then make your selections for the payer rules using the following drop-down menus.
   

   Payer: You must make a selection from the Payer drop-down list. You will not be able to establish payer rules for a payer until you receive your first ERA from that payer, allowing RevFlow to assign them a payer number. Each payer that sends you an ERA will appear on this list.

   1. Description: This field is optional. Type a description for the payer payment rules.
   2. Insurance Class: Select the appropriate insurance class for the payer.
   3. 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.
   4. 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.
   5. Transfer Back to Payer, Transfer to Next Payer, Do Not Transfer to Patient: Select one of these radio buttons. These determine what should be done with the remaining balances for claims processed by this payer. For most payers, select Transfer to Next Payer.
4. Click Save.