ORGANIZATION PAYERS RULES TAB

Agency rules impact how your agency uses certain features and options available in payroll, scheduling, billing, signatures required on specific forms, etc.

To view a detailed explanation of the rule, access either menu option based on the paths listed above.

ADD PAYER RULE (Top)

To add a payer rule go to the Rules Tab and click on the Green Plus Sign to add a Payer Rule. See Specific Payer Setup for more information.

NOTE: For Careficient Agency Administrators, click on the following to learn more about the privileges for Add Payer Rule.

Enter a "Start Date" prior to starting Careficient and click "Save".

To get the definition of the specific rule, click on the "Magnifying Glass".

NOTE: Not all rules currently have a definition as we are in the process of updating them.

EDIT PAYER RULE (Top)

Click on the "Edit Pencil" to edit the Rule.

NOTE: For Careficient Agency Administrators, click on the following to learn more about the privileges for Edit Payer and Edit Payer Rule.

Make the necessary changes and click "Save" when you are finished.

To get the modification information for the rule, click on the "Get Modification Information" icon.

Click closed when you have finished reviewing the information.

SPECIFIC RULES (Top)

You have the option to add the following Rules

Editing

Admission Type Needed - Admission Type Needed
All Orders must be received - All Orders must be received
Apply and Edit Level of Care coding - Apply and Edit Level of Care service codes
Apply and Edit Level of Care coding - unbundled - Apply and Edit Level of Care service codes - unbundled (non-Medicare only)
Apply M2 Occ. Span and Edit Respite Care>5 days - Apply M2 Occurrence Span and Edit Respite care>5 days
Apply/Edit NOE processing and Occ code 77 - Apply/Edit NOE processing and Occ code 77
Apply/Edit PDGM Data Elements On Non-PPS Invoices
Apply/Edit PPS Data elements on Non-PPS invoices - Apply and Edit PPS Data elements on Non-PPS invoices -
Bypass Services Not Verified Edit - Allow invoicing where unverified records exist
Certification must be received - Certification must be received
Check Physician NPI - Check Physician NPI against CMS Ordering and Referring File
Condition 20 and remarks are required - UB04 - Condition code 20 and remarks are needed
Diagnosis Code Required - Diagnosis Code Required
Do Not Use I9 to I10 mapping - Do Not Use I9 to I10 mapping during cut over
EDI ? DCN not required - EDI - DCN not required
HCPC required for all services - HCPC required for all services
HCPC required for routine services - HCPC required for routine services
Insured Group # Needed - Insured Group # Needed
Insured Group Name Needed - Insured Group Name Needed
Oasis discharge must be locked on a discharge bill - Oasis discharge must be locked on a discharge bill
Payer PI required - Payer Identifier# required
Payer Provider# not required - Payer Provider# not required
Payer Tax ID required - Payer Tax ID required
Physician License Required - Physician License Required
PPS Therapy check - PPS Therapy check
Previous Invoice must be Billed - Previous Invoice must be Billed
Service Facility NPI reporting required - Service Facility NPI reporting required
Skip Rap Payment Edit
Use Primary diagnosis only - Use Primary diagnosis only
Print Time In/Out - Print Time in/out

Generic

Reflect Contractual Adjustment on Invoice - Reflect Contractual Adjustment on Invoice
Remove CC Info From Generic - Remove the Credit Card Info from Remit portion of Generic Invoice
Remove shading on Invoice - Remove shading on Invoice
Mark 11d No when no other insured exist - Mark 11d No when no other insured exist

HCFA

Print Accident Date Box 14 - Prints accient date in Box 14
Print additional Diagnosis codes - Print additional Diagnosis Codes
Print Associate License# - Print Associate License
Print Associate NPI - Print Associate NPI
Print Associate Taxonomy in Box 24j - Print Associate Taxonomy in Box 24j
Print diagnosis description - Print diagnosis description
Print No and 0 amount in Box 20 - Print No and 0 amount in Box 20
Print Other Insured Info in Box 9 - Print Other Insured Info in Box 9
Print Palliative Care in Box 19 - Print Palliative Care in Box 19
Print Service From/To Dates on HCFA1500 - Print Service From/To Dates on HCFA1500
Print Start of Care Date in Box 12 - Print Start of Care Date in Box 12
Print Start of Care Date in Box 14 - Print Start of Care Date in Box 14
Print System Date in Box 12 - Print System Date in Box 12
Print Taxonomy on Hcfa1500 - Print Agency Taxonomy on Hcfa1500
Print Taxonomy on Hcfa1500 - Print Agency Taxonomy on Hcfa1500 33B
Select Group Health Plan on Hcfa1500 - Select Group Health Plan on HCFA1500 1
Split by Associate NPI - Split/Break by Associate NPI
Use Agency Address In Box 32 - Use Agency Address in Box 32
Use Associate NPI in 2310b loop - Use Associate NPI in 2310b loop
Use Patient Address In Box 32 When POS is home - Use Patient Address in Box 32 when place of service is home
Use Place of Service from Payer/Service mapping - Use Place of Service from Payer/Service mapping
Apply Certifying+Ordering Physician - Apply Certifying+Ordering Physician for claims after start date

Invoicing

Apply Place of Service Transaction - Apply Place of Service Transaction
Atypical Provider - do not use NPI - Atypical Provider - do not use NPI
Automated Routine Care Adjustment - Automated Routine Care Adjustment
Automated Service Intensity Add-On - Automated Service Intensity Add-On Adjustment
Default Units to 1 when equal to 0 - Default Units to 1 when equal to 0
Demand Bill - not simultaneous - Demand Bill - not simultaneous
Demand Bill - simultaneous - Demand Bill - simultaneous
Do not send medical record #. - Do not send medical record #.
Do not send more than 1 decimal position for units - Do not send more than 1 decimal position for units
Do not send Payer secondary identifiers. - Do not send Payer secondary identifiers.
Do not send physician secondary identifiers. - Do not send physician secondary identifiers.
Do not send preceding zeros in GS06/GE02 segment - Do not send preceding zeros in GS06/GE02 segment
Do not send trailing blanks in diagnosis codes - Do not send trailing blanks in diagnosis codes
EDI - Admission date/hour - do not send hour - EDI - Admission date/hour - do not send hour
EDI - Remove Punctuation from Patient ID - EDI - Remove Punctuation from Patient Identifier
EDI - send accident date - EDI - send accident date
EDI - Send Loop 2010AB (remit to) - EDI - Send Loop 2010AB (remit to)
EDI - send payer bill to address - EDI - send payer address
EDI - Send Service Facility Medicaid # - EDI - Send Service Facility Medicaid # (2310e)
EDI - send/print physician taxonomy along with NPI - EDI - send/print physician taxonomy along with NPI
EDI ? send physician and NPI at detail level - EDI ? 873P - send/print physician and NPI at detail level
EVV inclusion of data elements for 837p - EVV inclusion of data elements for 837p
Include Multiple Auth on form - Include Multiple Auth on form
PDGM - Use 30 Day Concept Based On Start Date
Prevent Supplies from being 1st Billable - Prevent Non-routine services (supplies) from being 1st billable item
Print MRN instead of Invoice# - Prints Medical Record Number instead of Invoice#
Print Physician License# - Print Physician License Number
Print zero balance invoices - Print zero balance invoices
Print zero balance line items - Print zero balance line items
Print/Send Oasis Matching Key And Authorization As Referring
Secondary Payer Rules - Secondary Payer Rules
Split by Authorization# - Split/Break by Authorization#
Split by Service Category - Split/Break by Service Category
Split by Service Month - Split/Break by Service Month
Summarize by HCPC/Revenue Code - Summarize by HCPC/Revenue Code/Service Date
Summarize by HCPC/Revenue Code - use 1st rate - Summarize by HCPC/Revenue Code/Service Date - use 1st rate
Time Conversion - Convert Billing Units to 15 minute increments
Time Conversion (special) - Convert Billing Units to 15 minute increments (special under 35 minutes)
Use Agency/Payer Tax Id - Use Agency/Payer Tax Id instead of Agency Tax Id
Use alternate agency billing address - Use alternate agency billing address
Use alternate agency remit address - Use alternate agency remit address
Weekly invoices - split - Weekly invoices - split ICD9 and 10 during cut over
Physician Face2Face Requirement - Check Orders for Face2Face >= the Start date

Orders

Charge Rate - Set Charge rate to Payer Rate
Scheduling Authorization Required - Scheduling Authorization Required

Scheduling

Scheduling Authorization Warning - Scheduling Authorization Warning
Scheduling Bypass Authorization - Scheduling Bypass Authorization check
Use Telephony - Use Telephony
Apply LOC for Discharged Patients with no Service - Apply Level of Care for Discharged Patients with no Services

Services

Authorization Warning - Authorization check is a warning only
Apply Billing Qnty of UOM=Day to Value Code List - Apply Billing Quantity of UOM=Day to Value Code List
Auto-Verify Services Regardless of Note - Auto-Verify scheduled service regardless of service note.
Auto-Verify Services that have a Completed Note - Auto-Verify scheduled services that have a completed service note.
Billable Routine Service requires service note - Verification-Billable Routine Service requires service note
Bypass Authorization - Bypass Authorization check
Diagnosis Pointer - Ability to connect multiple diagnosis codes to a service
EVV transmit data - EVV transmit data
Late Billing - Apply late time slips to initial bill
Late Billing - Default to rebill - Apply late time slips to initial bill-default to rebill
Mass/Auto -Time must be between defined minutes - Mass/Auto -Service Time must be between defined minutes
PDGM - Warn User If Moving Service Outside 30 Day

UB04

Apply Service Facility Name to Remarks - Apply Service Facility Name to Remarks
Apply value code 85 and FIPS code - Apply value code 85 and FIPS state and county code - PPS invoices
Apply value code 85 and FIPS code to all - Apply value code 85 and FIPS state and county code to all
Condition Code - apply A6 - Condition Code - appy A6
Do not print Admitting Diagnosis code - Do not print Admitting Diagnosis code
Insured Address - Print Insured Address in Box 38
Payer name and address - Print Payer Name and Address in Box 38
Print 27 and SOC in locator 31 - Print 27 and SOC date in locator 31
Print 52 and Certification Date in locator 31 - Print 52 and Certification date in locator 31
Print 55 and death date in locator 31 - Print 55 and death date in locator 31
Print 61 and CBSA code in locator 39 - Print 61 and CBSA code in locator 39
Print 9/0 in box - Prints a 9/0 on UB04 locator 66
Print Agency zip+4 on UB04 - Print Agency Zip+4 on UB04 Locator 81b
Print Diagnosis code+description in Remarks - Print Diagnosis code+description in Remarks
Print Facility Hold Dates - Print Facility Hold Dates
Print first/last service dates - Print first/last service dates on Ub in header
Print HCPC and Rate on UB - Print HCPC and Rate on UB
Print HCPC on UB - Print HCPC on UB
Print Name- Last, First MI - Print Name- Last Name, First Name MI
Print Payer ID in box 57 - Print Payer ID# in UB04 box 57
Print Payer Name And Address In Box 38 - When activated, this rule will skip all the edits required to bill a RAP (Request for Anticipated Payment) and will use all other payer rules/requirements to bill the final claim(s) to the payment source.
Print Service Facility NPI and name in locator 77 - Print/Send Service Facility NPI and name in loc 77/2310E
Print Taxonomy on UB04 - Print Agency Taxonomy on UB04 Locator 81
Print units as whole numbers - Print units as whole number - no decimals
Send Admitting Dx code always - Send Admitting Dx code even when it matches primary
Send Primary Dx Code As Reason For Visit - You have a new Organization payer rule that, when activated, will include the reason for the patient’s visit (patient’s primary diagnosis populates a specific field for EDI payers).
Set Charge amount to 0.01 on RAP - Set Charge amount to 0.01 on RAP
Set UOM to DA for Routine care, respite and Gen In - Set UOM to DA for Routine care, respite and general in patient
Type of Bill - Set 1st 2 digits to 34
Type of Bill - Set TOB to 333
Type of Bill - Set 1st 2 digits to 26 - Type of Bill - Set 1st 2 digits to 26
Type of Bill - Set 2nd digit to 3 - Type of Bill - Set 2nd digit to 3
Type of Bill - Set 3rd digit to 1 - Type of Bill - Set 3rd digit to 1
Type of Bill - Set 3rd digit to 3 - Type of Bill - Set 3rd digit to 3
Use Locator 1 for Locator 2 - Use Locator 1-Agency Address for Locator 2-Pay to Address
Use Primary Physician in 2310b and 2310c loops - Use Primary Physician in 2310b and 2310c loops
Include Clinical Lab. Improvement Amendment # - Include Clinical Laboratory Improvement Amendment #