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Insurance Companies, Payers, Charge Types (article)

Summary:

All possible payer sources and charge types to the client are managed in this area.

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The left side of the screen shows the list of payers that have already been entered. Select a payer on the left in order to view and edit the applicable information. Enter as much information as possible.

Field Descriptions:

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Exclude from EDE (Electronic Billing) – check this if you do NOT want this payer to be billed in your EDE files

Include on Statements – includes this payer or charge type on all statements for the client

Exclude from Billing Service Calc. – not applicable unless you use a PIMSY billing service

Prohibit Automatic Secondaries – prevents any client with that insurance from having a Secondary claim automatically created. Example: if a client has ABC insurance as their Secondary, when the Primary insurance pays, it will not automatically create the claim for ABC.  This could be because some Payers’ clients do not receive electronic claims or it is crossed over from the Primary. This checkbox prevents double billing to the Secondary.

In Network Group –user group that contains all the providers that are considered In Network

Type Indicator – determine how PIMSY should handle claims made with the payer attached.  For example, if it is a Medicare payer, select the Medicare option.  Same with BCBS and Medicaid.  For any other Insurance company (Cigna, United Health, Aetna, etc.) use the All Others (Other Payers and Ins. Cos.) type.  If it is a Self-Pay or Co-Pay, select the Self Pay/Copay option.  If you have types set for charges like bounced check fees or materials, use the Additional Charges type.  

Billing Code Group – select a billing code group if applicable.   This should contain a list of billing codes that this Payer recognizes and will pay.

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Assign to All Active Clients (Primary) (Secondary) – This button will assign all the active billing codes or all the billing codes in a Billing Code Group to all the Active clients that have this insurance as the Primary Insurance or Secondary Insurance depending on which button you click.  

Make sure you read the pop-up messages that appear when you click these buttons.  

Coding Requirements – This section allows you to control the different diagnosis coding requirements for each payer. PIMSY will only send the preferred diagnosis codes to the payer in electronic billing.

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Bottom Window

Allowed Amounts By Modifiers – set up modifiers for billing codes that apply to the payer selected.

Allowed Amounts by User Title – set up User amounts for this payer if needed.

Default Amounts – enter default amounts for this payer if they are different for this billing code.

Instructions:

Go to the Administration tab and select Insurance Companies, Payers, and Charge Types

On the Default Amounts tab, enter the Billing Code and the Allowed Billing Rate/Unit, the Expected Amount/Unit with a Start Date and End Date. (PIMSY will automatically enter the last two columns - last edited date/by). These are the Default settings for these codes without the specific Title and Modifier requirements.  The system will look here after it has already checked the first two tabs to get specific values for this payer or charge type.

Related Articles/Videos:

If you cannot find what you need in this article, please contact Support (email) or call 877.334.8512 ext. 3.

 

 

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