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Commercial Payers Setup

Commercial Payers Setup lists insurance companies that can be billed, whether on paper or electronically.

A Commercial Payer can be an organization, facility, contract, school, nursing home, or local government. Payers can be used to record cancelled calls, patient refusals, and other situations that may or may not be billed.

Export:  Will create a CSV file to provide a list of all payers currently entered in setup.

Import: This feature will allow the import of payers from a CSV file for faster data entry.

The imported CSV file must be in a specific format to import correctly.

  • The header (column titles) and fields must be separated by a comma and be enclosed in double quotation marks, even when blank.
  • The required headers (column titles) must all be included and be in the following order: "Name", "Provider Number", "Payer ID", "Commercial Electronic ID", "Address", "Apt/Other", "City", "State", "Zip", "Phone", "Fax", "Contact", "Title", "Last W9 Sent On", "Website", "Notes", "PCS Required for Non Emergency"
  • Name is the only required field.
    • Any empty fields must be enclosed in double quotation marks.
    • States must be abbreviated (Example: PA, OK, FL, etc.)

Example CSV Format

Add: A new value can be added to the list using the plus button on the top right.

When Add is selected, it opens the data entry for adding a new Commercial Payer. Once the new Commercial Payer information is entered, select Save to add the Payer to the list of available Commercial Payers or Save & Add to add the payer to the list and create more. Selecting Cancel will take the user back to the Quick Pick Setup without adding a new Payer.

Helpful tips when completing Commercial Payer Setup:

  • Provider Number typically is a primary identifier for the commercial payer. It appears on the HCFA 1500 and is transmitted on clearinghouse EDI Claims Files if entered. Depending on the Payer, they may request the NPI (National Provider Number) or a Company ID be entered as the Provider Number.
    • For Gateway EDI Commercial Payers, enter the Payer ID provided by the clearinghouse to identify this payer on claims. Enter the Payer ID in both the Payer ID and Commercial Electronic ID fields.
  • Enter the full mailing address (Name, Address, Apt/Other, City, State and Zip) of the payer. When entered, the full mailing address can appear on HCFA 1500 and electronic claims.

When saving a commercial payer, the system validates the city and ZIP code against a geographic database. If the combination is invalid, you'll be prompted with a suggested correction that you can accept or override.

Hint: When insurance companies have multiple claims mailing addresses, create a separate payer for each address.

  • The fields at the bottom of each entry (from the Phone/Fax fields down) are reference only, this data is not sent on claims. Use these fields to store contact information, maintain website usernames/passwords, and identify the last time a W9 Form was provided to this payer. Additional details about the payer can be entered in the Notes field for reference.

  • The PCS Required for Non-Emergency indicates if a Payer requires a PCS for non-emergent transports or not.
  • The Enforce Last Verified At Date if enabled, eligibility check will be enforced for the payer, when “Mandatory” is enabled for Commercial Payers in Billing, Field Configuration and will be required based off the set amount of days in Billing, Configuration Settings. This can be used when a patient's eligibility for a specific payer typically does not last for an extended time frame.
  • The Matching Patient Invoice Comments allow for custom comments to display at the bottom of any Matching Patient Invoices printed for that commercial payer. 
  • The Payer Specific Configurations Section provides options that apply only when this specific commercial payer is used.
    • Auto-Round Mileage automatically rounds fractional mileage to whole numbers using standard rounding rules, with a user prompt for confirmation when fractional values are detected.
    • Payer Category is used for reporting specific sub-categories of Commercial Payers (auto insurance, workman's comp, etc). Reports/Queues using the Payer Category filter or column will see all commercial payers reported as "Commercial" unless a specific payer category is entered in this field for that specific payer. Users can add Payer Categories in the Quick Picks Setup Payer Category section.
  • The Attachments section is used for attaching files associated with this insurance for future reference. Files attached here can be reviewed at any time by visiting the Commercial Payers Setup record.
  • The information entered for a Commercial Payer can be viewed in the Billing Module on the Payers Tab by clicking the More Payer Info Button.

Filter: To narrow the results of a list, begin typing the name you are searching for.

Actions:

Edit: If changes need to be made to an entry, use the edit button.
Delete: Remove an existing entry.