Payer setup

the payer setup section lets you configure insurance payers for a billing profile, manage their transaction capabilities, and define payer specific contracts and fee schedules each billing profile can have multiple payers, and each payer can support different transaction types such as eligibility checks, claim submission, claim status, and era payments access payer setup go to settings → billing → payer setup the selected billing profile determines which payers, enrollments, and contracts apply during billing decisions billing profile selection at the top of the page, select a billing profile this billing profile owns the list of configured payers is used when submitting claims, checking eligibility, and receiving payments is referenced by billing rules during encounter processing changing the billing profile updates the payer list shown on the page payers list the payers panel shows all payers configured for the selected billing profile for each payer, you may see the payer name enrollment or readiness status badges contract indicators, if contracts exist to add a new payer, click add payer add a payer when adding a payer 1 click add payer 2 search for a payer by name 3 select a payer from the directory once added, the payer appears in the list and can be configured further select a payer click a payer from the list to open the payer details panel on the right this panel shows transaction capabilities enrollment requirements existing contracts linked to the payer if no payer is selected, the panel prompts you to choose one transaction capabilities each payer supports one or more transaction types these are shown under transaction capabilities possible capabilities include eligibility (270/271) – verify patient insurance coverage claims submission (837p) – submit professional medical claims claim status (276/277) – check claim processing status era / payment (835) – receive electronic remittance advice statuses may appear as ready to use – no action required enrollment required – setup is needed before use not available – payer data may need to be re imported enroll for era / payment (835) if era is not enabled, you’ll see an enroll option to enroll 1 click enroll next to era / payment (835) 2 review the enrollment details 3 confirm the billing profile used for enrollment 4 optionally enable sync billing profile with clearinghouse 5 click create enrollment enrollment allows eggmed to receive electronic remittance advice from the payer contracts contracts control fee schedule selection for a specific payer if a payer has contracts, they appear under the contracts section each contract includes effective start date optional end date assigned fee schedule optional default copay amount if no contracts exist, the section will be empty create a contract to add a contract 1 select a payer 2 click add under the contracts section 3 set the effective start date 4 optionally set an effective end date 5 select a fee schedule 6 optionally enter a default copay amount 7 click save the default copay is used to prefill expected copay amounts during insurance check in important notes contracts drive fee schedule selection during billing decisions if multiple contracts exist, date ranges determine which one applies if no contract matches, billing rules or default configuration will be used some payers may show limited capabilities if directory data is incomplete how payer setup is used payer setup is referenced when running eligibility checks submitting insurance claims receiving era payments evaluating billing rules and decision previews accurate payer configuration ensures claims route correctly and payments are processed without delays