Payer/Rate Groups

(Topic Last Updated On: 06/08/2015)

The Payer/Rate Groups menu item on the Accounting menu launches the Payer/Rate Groups screen. This screen is used to create groups to which patients will be assigned for billing, regardless of whether or not a patient is a self-pay patient or insured by a third party. This screen is the starting point for setting up how a facility's patients will be charged for rendered billable services in Methasoft. 'Basic (Self-Pay)' Payer/Rate Groups are intended for patients who do not require the additional data necessary for generating claims for billing third party payers on their behalf. Advanced (Third Party Billing) Payer/Rate Groups are intended for patients with insurance coverage accepted by the facility, in order for Methasoft to require the entry of the additional data required for generating third party billing claims. 'Basic (Self-Pay)' Payer/Rate Groups defined on this screen appear available for selection on the Basic Dosing Charging Information screen, for easy Rate Group assignment of self-pay patients. Advanced (Third Party Billing) Payer/Rate Groups are available for selection on the Billing Episodes screen, which requires the additional data necessary for generating third party claims.

Field Descriptions

Payer Name

This field is used for entering the name of each Payer/Rate Group added on this screen. Refer to the screen shot above to see commonly used examples of how Payer/Rate Groups are named. Often a description of the rates involved is included in the names of Self-Pay Rate Groups for more efficient selection of Payer/Rate Groups throughout the system as well as greater visibility on related reports. This is generally not true for Third Party Payer names, because this data is exported to the NM103 element of the NM1 segment of Loop 2010BB on 837P export files. If the data transmitted in this element is missing or not precise the export file (claim) may be rejected..

Abbreviation

This field is used for entering an abbreviated form of the Payer Name, and will appear on various screens throughout the system and on related reports. This value is not exported to billing export files.

ID Code Type

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for selecting the type of Primary Payer ID Code to be entered in the ID Code field below it. PI - Payer ID is selected by default because to date the National Plan ID has not taken effect, and thus this ID qualifier is the only value being used by any facility. For third party Payers, this field is required because the value selected is exported to the NM108 element of the NM1 segment of Loop 2010BB on 837P export files. If the data transmitted in this element is missing or not precise the export file (claim) may be rejected.

ID Code

Though this field is irrelevant for Self-Pay Payer/Rate Groups, it can potentially be useful as additional descriptive information displayed throughout the system and on related reports. The field is used for entering the Primary Payer ID code of a third party Payer. The ID entered in this field is determined by each third party Payer, and can often be found by visiting the Payer's website or by reviewing a list of Payer IDs prepared by a facility's billing export file Clearinghouse. For third party Payers, this field is required because the value entered is exported to the NM109 element of the NM1 segment of Loop 2010BB on 837P export files. If the data transmitted in this element is missing or not precise the export file (claim) may be rejected.

Address Line 1

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for entering the first line of Payer Address information, the street address, as specified by a third party Payer. For third party Payers, this field is required because the value entered is exported to the N301 element of the N3 segment of Loop 2010BB on 837P export files. If the data transmitted in this element is missing or not precise the export file (claim) may be rejected.

Address Line 2

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for entering the second line of Payer Address information, for example a Suite letter or number, as specified by a third party Payer. For third party Payers, this field may be required because the value entered is exported to the N302 element of the N3 segment of Loop 2010BB on 837P export files. If the data transmitted in this element is missing or not precise the export file (claim) may be rejected.

City

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for entering the city of the Payer's address, as specified by a third party Payer. For third party Payers, this field may be required because the value entered is exported to the N401 element of the N4 segment of Loop 2010BB on 837P export files. If the data transmitted in this element is missing or not precise the export file (claim) may be rejected.

State

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for selecting the state of the Payer's address, as specified by a third party Payer. For third party Payers, this field may be required because the appropriate abbreviation based on the state selected is exported to the N402 element of the N4 segment of Loop 2010BB on 837P export files. If the data transmitted in this element is missing or not precise the export file (claim) may be rejected.

Postal Code

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for entering the postal/zip code of the Payer's address, as specified by a third party Payer. For third party Payers, this field may be required because the value entered is exported to the N403 element of the N4 segment of Loop 2010BB on 837P export files. A Payer may require the entry of the full 9-digit postal/zip code in this field for claim processing. If the data transmitted in this element is missing or not precise the export file (claim) may be rejected.

Phone

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for entering the phone number of the Payer, as specified by a third party Payer. For third party Payers, the value entered in this field is for informational purposes only, and is not exported when electronic export files are generated.

Fax

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for entering the fax (facsimile) number of the Payer, as specified by a third party Payer. For third party Payers, the value entered in this field is for informational purposes only, and is not exported when electronic export files are generated.

Secondary ID Code Type

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for selecting the type of Secondary Payer ID Code to be entered in the Secondary ID Code field below it. For third party Payers, this field is may be required depending on the Payer, which will also specify the type of code to be used. If a Payer requires Secondary ID Code data to be submitted for processing electronic claims, the value selected is exported to the appropriate REF01 element of the Payer Secondary Identification REF segment of Loop 2010BB on 837P export files. When required, the most common value selected in this field is 'EI - Employer Identification Number'. If the data transmitted in this element is missing or not precise the export file (claim) may be rejected.

Secondary ID Code

This field is irrelevant for Self-Pay Payer/Rate Groups. The field is used for entering the Secondary Payer ID code of a third party Payer, if mandated by the Payer. The Secondary ID Code entered in this field is determined by each third party Payer, and can often be found by visiting the Payer's website or by reviewing a list of Secondary Payer ID codes prepared by a facility's billing export file Clearinghouse. If required by a third party Payer, the value entered is exported to the appropriate REF02 element of the Payer Secondary Identification REF segment of Loop 2010BB on 837P export files. If the data transmitted in this element is missing or not precise the export file (claim) may be rejected.

Additional Information

This field is used for entering any useful additional information regarding a Payer/Rate Group. Often it is used to store the name of a Payer's contact person for a facility. This field may be useful for Self-Pay Payer/Rate Groups as well. The value entered in this field is for informational purposes only, and is not exported when electronic export files are generated.

Insurance Type Code

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is set to the blank selection by default, and is used for selecting the Insurance Type Code if required by the Payer. Most Payers do not require this data to be submitted with claims, thus this field is generally left blank. If a value is selected in this field it will be exported to the Loop 2000B SBR05 element. Only the Payer can tell you which value to select in this field if the Payer requires a value to be submitted for this data element.

Claim Filing Indicator Code

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is set to the blank selection by default, but selecting a value in this field is almost always required by every Payer. This field is used to set the appropriate Claim Filing Indicator Code value as mandated by a Payer. The value selected is exported to the Loop 2000B SBR09 element. Only the Payer can tell you which value to select in this field if the Payer requires a value to be submitted for this data element.

Lines Per Claim

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for defining the number of Service Lines per Claim that will be generated when claims are generated on the Claims Generator screen. Claims and service lines are then exported accordingly on 837P export files. Methasoft defaults a value of 50 in this field when a new Payer is added, which is generally acceptable by most Payers, and is the maximum number allowed by the 837P export format. However some Payers have specific requirements, such as 6, or 1, in which case this value should be changed accordingly.

Payer Category

This field is used for categorizing or grouping Payer/Rate Groups, by selecting a Payer Category for each Payer. The screen shot above (see grid) illustrates how Payer Categories are commonly used. Payer Categories are defined by a facility using the Code Tables screen (Code Table Type - 'Payer Category') which is accessed from the Administration menu. Payer Categories are highly useful for both Self-Pay and Third Party Payer/Rate Groups, because it allows a facility to group accounting and claim data at a higher level than a single Payer/Rate Group. This functionality is particularly useful in regards to reporting since many related reports have the option to run a report using a Payer Category filter on the Run Reports screen.

Billing Prov. Secondary ID Type (5010)

This field is irrelevant for Self-Pay Payer/Rate Groups. Though it is not common, some Payers may require a Billing Provider's Secondary Identification code to be exported and placed in Loop 2010BB on the 837P export file, and will specify the type of secondary ID to be used. This field is set to the blank selection by default because this requirement is rare. Only make a selection in this field if required to do so by a Payer. If required, then selecting a value in this field is used not only for indicating to Methasoft that the Loop 2010BB Billing Provider Secondary Identification REF segment is being mandated by a Payer, but also to indicate which type of secondary ID code to use, as entered on the Billing Providers screen in the 'Additional Reference ID Type' and 'Additional Reference ID' fields. If used, and if this Billing Provider data is correct on the Billing Provider's screen, then the appropriate values will be exported to the appropriate REF01 and REF02 elements of this Loop 2010BB REF segment.

Validation Level

This field is required for each Payer added on this screen. 'Basic (Self-Pay)' should be selected for entered Rate Groups to which self-pay patients will be assigned. 'Advanced (Third Party Billing)' should be selected for entered Payer/Rate Groups involving third party payers, generally health insurers. The selection made in this field is important for 2 reasons: 1.) Only Payer/Rate Groups with a Validation Level set to 'Basic (Self-Pay)' will appear available for selection on the Basic Dosing Charge Information screen. 2.) On the Billing Episodes screen, many more fields are required if the Payer selected has an 'Advanced (Third Party Billing)' Validation Level.

***Note: In theory, a facility should always use the Basic Dosing Charge Information screen to set up Self-Pay patients, because it's far more efficient and automatically inserts a Billing Episode for the patient 'behind the scenes'; i.e., for Self-Pay patients there should rarely be a reason to need to use the Billing Episodes screen.

Claim Date Type

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for indicating to Methasoft whether or not a Payer requires data to be submitted in the 'Date - Initial Treatment' or 'Date - Admission' DTP segments of Loop 2300. By default, the selection in this field is blank, which will result in neither of these DTP segments being exported. If a non-blank selection is made in this field, then when exporting claims the system will populate the selected DTP segment appropriately in the 2300 Loop (elements DTP01, DTP02, and DTP03). The only apparent difference on the export file will be the DTP02 element, which is the date type qualifier code - either 435 or 454 as mandated by the Payer. Regardless of which type of date is used, the actual date exported in the DTP03 element will be the patient's 'Intake Date' as entered on the Dosing Information screen, or if no Dosing Information has been saved for the patient, then the date on which the patient's Profile was saved in Methasoft.

Claim Note Reference Code

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for indicating to Methasoft whether or not a Payer requires the Loop 2300 NTE segment, and if so, which Note Reference Code value the Payer is requiring to be exported to the NTE01 element on the export file. This field is set to the blank selection by default because it is an uncommon Payer requirement. If a selection is made in this field, then the appropriate Claim Note Text should be entered in the 'Claim Note Description' field below this field, otherwise the export file will be rejected due to an incomplete NTE segment.

Claim Note Description

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for entering the Claim Note Text as defined by the Payer, if the Payer requires Loop 2300 NTE segment data and a non-blank selection has been made in the Claim Note Reference Code field above this field. Only the Payer can tell you what text must be entered in this field. The text entered in this field will be exported to Loop 2300 NTE02 element on the export file.

Claim Frequency

This field is irrelevant for Self-Pay Payer/Rate Groups. This field is used for overriding the Claim Frequency Type Code value exported to Loop 2300 sub-element CLM05-3, which corresponds to the 'status' of a claim both within and outside of Methasoft. The most common value exported to this sub-element is 1 - Original Claim. If this field is left blank, then when a claim is exported for the first time, the exported value for this sub-element is 1. However if the same claim is then re-exported, a value of 6 will be used. Generally 6 corresponds to 'Corrected' or 'Adjusted' claim, but this can vary by Payer. A value of 7 generally corresponds to 'Replacement' claim, and a value of 8 generally corresponds to 'Voided' or 'Cancelled' claim, but again this can vary by Payer. If this field is left blank, the only possible export values for this sub-element are 1 and 6 - 1 following the first export, and 6 from there going forward unless the claim is deleted and re-generated. Putting a value in this field allows users to override this functionality and force a specific numerical value as required by a Payer. This field is generally left blank. Otherwise the most common value entered in this field is 1, so that every claim exported to the Payer goes out with a Claim Frequency Type Code value of 1, no matter how many times the claim has been re-exported. This field can be highly useful for efficiency depending on your billing practices and Payer requirements for this particular sub-element.

Receiver Format ID

This field is rarely used by facilities that are using the Batch Payments screen to Load 835 EDI ERA files, and require multiple Receiver Format records to associate with multiple Payer/Rate Groups. This association is necessary in such facilities for the appropriate Receiver Format selection to be made on the Batch Payments screen in '835 File' Payment Mode, allowing Methasoft to properly Load a selected Transaction Set from an 835 EDI file.

Grid Columns

Payer Name

This column displays the name of the Payer/Rate Group entered in the 'Payer Name' field.

Abbreviation

This column displays the abbreviation for the Payer/Rate Group entered in the 'Abbreviation' field.

ID Code Description

This column displays the type of Primary ID Code type selected for the Payer/Rate Group in the 'ID Code Type' field.

ID Code

This column displays the Primary ID Code of the Payer/Rate Group entered in the ID Code field.

Payer Category

This column displays the Payer Category associated with the Payer/Rate Group as selected in the 'Payer Category' field.

Validation Level

This column displays the Validation Level associated with the Payer/Rate Group as selected in the 'Validation Level' field.

Procedures

How to Add a 'Basic (Self-Pay)' Rate Group
1.) Press the New button. 2.) Enter a 'Payer Name' that describes the Self-Pay rate group adequately for clarity on related screens and reports on which it will appear. 3.) Enter an abbreviated form or description of the Payer Name in the 'Abbreviation' field that appropriately describes the rate group being added. 4.) (Optional) Enter (or copy) the same text entered in the 'Abbreviation' field in the 'ID Code' field, for increased visibility/clarity on related screens and reports. 5.) Enter at least one character of alphanumeric text in the 'Address Line 1' field, because it is a required field, but irrelevant for Self-Pay Rate Groups. 6.) Enter at least one character of text in the 'City' field, because it is a required field, but irrelevant for Self-Pay Rate Groups. 7.) Select any state in the 'State' field, because it is a required field, but irrelevant to Self-Pay Rate Groups. 8.) Enter at least one number in the 'Postal Code' field, because it is a required field, but irrelevant for Self-Pay Rate Groups. 9.) (Optional) Enter any useful note or information regarding the Rate Group in the 'Additional Information' field. 10.) Select 'Basic (Self-Pay)' in the 'Validation Level' field. 11.) Press the SAVE button. The Rate Group is now saved and appears on the grid.

How to Add an 'Advanced (Third Party)' Payer
1.) Press the New button. 2.) Enter the name of the payer in the 'Payer Name' field - if you are exporting EDI files to submit claims, ensure this name is entered exactly as mandated by the Payer.. 3.) Enter an abbreviated form or description of the Payer in the 'Abbreviation' field however you like, as this data is not exported or submitted to Payers. 4.) Until the National Plan ID becomes effective, make sure the default value of 'PI - Payer ID' is selected in the 'ID Code Type' field. 5.) Enter the Payer's Primary ID Code in the 'ID Code' field exactly as mandated by the Payer. 6.) Fill in all Address fields as mandated by the Payer. At a bare minimum you will be required to enter some data in the 'Address Line 1', 'City', 'State', and 'Postal Code' fields (the Payer may require a 9-digit postal/zip code to be entered). 7.) Enter the Payer's phone and fax (facsimile) numbers in the 'Phone' and 'Fax' fields. Though this data is not required or exported, it will likely be very useful to have on file. 8.) If required to do so by the Payer, enter Secondary ID Code data in the 'Secondary ID Code Type' and 'Secondary ID Code' fields, exactly as mandated by the Payer. 9.) (Optional) Enter any useful note or information regarding the Payer in the 'Additional Information' field. 10.) If required by the Payer, which is unlikely, select the 'Insurance Type Code' value as mandated by the Payer. 11.) If required by the Payer, which is highly likely, select the 'Claim Filing Indicator Code' value as mandated by the Payer. 12.) Unless instructed otherwise by the Payer, leave the default value of 50 in the 'Lines Per Claim' field. 13.) (Optional, but Recommended) Once you have defined Payer Categories in the 'Payer Category' Code Table (accessible from the Administration menu), select the Payer Category that is appropriate for the Payer being added. 14.) Leave the 'Billing Prov. Secondary ID Type' field blank, unless specifically instructed by the Payer that a Billing Provider Secondary ID Code must be present in Loop 2010BB. 15.) Select 'Advanced (Third Party)' in the 'Validation Level' field. 16.) Leave the 'Claim Date Type', 'Claim Note Reference Code', 'Claim Note Description', and 'Claim Frequency' fields blank, unless specifically instructed by the Payer that data is needed in these fields (which is unusual). 17.) Press the SAVE button. The Payer is now saved and appears on the grid.

How to Edit a Payer/Rate Group
1.) Select the Payer/Rate Group to be edited on the grid. 2.) Press the EDIT button. 3.) Make changes as needed to data in the detail fields for the selected Payer/Rate Group. 4.) Press the SAVE button.

How to Delete a Payer/Rate Group
1.) Select the Payer/Rate Group to be deleted on the grid. 2.) Press the DELETE button. A 'Delete this Record?' application message will appear, confirming you wish to delete the selected Payer/Rate Group. 3.) Press the YES button to delete the Payer/Rate Group or No to cancel.

Considerations

For Basic (Self-Pay) Payers - Use the Basic Dosing Charge Information Screen

After setting up 'Basic (Self-Pay)' Rate Groups and associating them with at least one Dosing (or Unmanaged - Dosing Periodic) billable service, these Rate Groups will appear available for selection on the Basic Dosing Charge Information screen. The Basic Dosing Charge Information screen essentially replaces the Payment Information screen available in older versions of Methasoft, and allows users to efficiently set up self-pay patients to be charged for Dosing. The Basic Dosing Charge Information screen also allows users to override the amount(s) a patient will be charged, both to their Patient and/or Third Party Balance(s). It is very important to understand the reason why only 'Basic (Self-Pay)' Rate Groups are available for selection on this screen, while at the same time this screen can be used to view and override Third Party Balance charge data: It's because Methasoft's Accounting functionality is used in many different ways by many different facilities. There are many facilities that manage Third Party Balances for patients but do not ever generate or export claims in Methasoft. If your facility is such a facility, then use the Basic Dosing Charge Information screen as much as possible. Other facilities generate claims, but never export them. Thus they are often in a similar situation where they can solely use the Basic Dosing Charge Information Screen. It's only when a facility wishes to generate then export EDI billing files and submit them to clearinghouses and/or Payers, that 'Advanced (Third Party) Payers must be set up, the Billing Episodes screen must be used, and far more data must be entered on other related screens. So set up your Payer/Rate Groups accordingly, in order to maximize efficiency while allowing Methasoft to meet all of your facility's Accounting and/or Billing needs.

For Basic (Self-Pay) Payers - Setting up Rate Groups in Light of Basic Dosing Charge Information Override Functionality

The Basic Dosing Charge Information screen allows users to override the amount(s) being charged for Dosing or Unmanaged (Dosing Periodic) billable services to both Patient and/or Third Party Balance(s) at the individual patient level. So it's important to keep that in mind when setting up 'Basic (Self Pay)' Rate Groups, because there are multiple ways you can go about it. For example, if your facility has a sliding-scale based fee schedule for Dosing that contains 36 different possible rates, do you set up 36 Rate Groups, or do you simply set up 1 Rate Group and use Overrides on the Basic Dosing Charge Information screen to handle the sliding-scale? In our opinion the route to take depends on how many patients are likely to be charged a specific rate. If in this example, you have 500 active patients, and 440 of them are on one rate, then clearly a Rate Group should be set up for that rate. If of the other 60 patients, 40 of them are on another rate, then set up a second Rate Group for that rate. Overrides could then be used for the remaining 20 patients, for example if those 20 patients are spread out across 10 different rates. If on the other, continuing with this example, all 36 rates are commonly used by more than one patient, then it likely in your best interest to set up a Rate Group for each of the 36 rates, because this will allow your uses to more efficiently set up new patients to be charged properly.

For Advanced (Third Party) Payers - Use the Billing Episodes Screen

If your facility is going to use Methsoft's electronic billing export (EDI) functionality, then it is imperative to set up 'Advanced (Third Party)' Payers and use the Billing Episodes screen instead of the Basic Dosing Charge Information screen. This is due to all of the additional detailed data necessary for exporting acceptable/payable electronic billing claims.

For Advanced (Third Party) Payers - Gathering Payer Requirements

As described above in the Field Descriptions section of this topic, it is imperative that you find out exactly what your Payer wants you to submit in order to successfully submit electronic billing claims and get paid for them. Most electronic file rejections are due to very basic data entry issues - incomplete, inaccurate, or missing data in specific fields required by the Payer. Claim denials are an entirely different matter, and are most commonly due to lack or loss of coverage, lack of prior authorizations, and/or contractual disputes or misconceptions.

Editing Payers for Third Party Billing - Potential Timing/Workflow Issues Related to Claim Generation/Billing Export

When editing a Payer for whom claims are being exported, it is very important to consider the timing of the edit. For example, some data entered on this screen might be stored in Methasoft at the time of Claims generation, and other data might be retrieved only at the time of exporting generated Claims. Thus, if Claims have already been generated but not yet submitted to a Payer, it is generally a good rule of thumb to delete these unsubmitted claims prior to editing the Payer. All staff responsible for billing activities within a facility should make sure they understand the billing workflow within their facility, and communicate changes that are being made in Methasoft accordingly, in order to minimize billing export file rejection. The same principles above apply when deleting a Payer, though the system may prevent you from deleting a Payer in some circumstances.

Dropdown Selection Fields - (4010) and (5010) Value Indicators

In numerous dropdown selection fields used on various Billing-related screens, you will notice '(5010)', '(4010)', or nothing following each value. These indicators are there to allow Methasoft to continue to support customers submitting 4010 EDI files until the transition from 4010 to 5010 is fully complete, at which time deprecation of 4010 functionality is expected. If '(5010)' appears following a value, this means that the value is only valid for 5010 EDI file submissions. If '(4010)' appears following a value, this means that the value is only valid for 4010 EDI file submissions. If nothing appears following a value, this means that the value can be legitimately used for both 4010 or 5010 EDI file submissions (i.e., these values were carried over from 4010 to 5010).

Dynamic Enable / Disable, Cascading (Filtered) Dropdown Selections, and Required Field Functionality

This screen includes functionality that will automatically enable or disable fields, filter subsequent dropdown combo field selection lists, and/or require fields dynamically depending on the selections made in other related fields. For example, if no value is selected in a Secondary ID Code Type field, then the Secondary ID Code field will be disabled. But once a value is selected in the Secondary ID Code Type field, not only does the Secondary ID Code field become enabled, it also becomes required. An example of Cascading (Filtered) Dropdown functionality is when a value selected in one combo dropdown field determines which dropdown values are available for selection in another dropdown field by filtering out invalid selections. This functionality exists to minimize erroneous data entry, and particularly the generation / export of invalid EDI files such as the 837P, which will be rejected by either a clearinghouse and/or payer. This functionality is in addition to, and when applicable will override, initial required field functionality which operates when a New record is being entered, no data is entered in any field, and the Save button is pressed.