SPECIFIC PAYER SETUP

Payer Standard Rules

Invoice Type	Invoice Cycle	Group Codes	Rule Descriptions
UB04	PPS	Editing	Diagnosis Code Required
		Editing	Admission Type Needed
		Invoicing	Print zero balance invoices
		Invoicing	Apply Place of Service Transaction (Q Codes)
		Invoicing	Prevent Non-routine services (supplies) from being 1st billable item
		Invoicing	Default Units to 1 when equal to 0
		Scheduling	Scheduling Authorization Warning (if Payer Requires Auth)
		Services	Apply late time slips to initial bill-default to rebill
		UB04	Prints a 9/0 on UB04 locator 66
		UB04	Apply value code 85 and FIPS code to all
		UB04	Do not print Admitting Diagnosis code
		UB04	Print Payer Name and Address in Box 38
		UB04	Print HCPC on UB
		UB04	Print Name- Last Name, First Name MI
		UB04	Set Charge amount to 0.01 on RAP
Invoice Type	Invoice Cycle	Group Codes	Rule Descriptions
UB04	Weekly	Editing	HCPC required for routine services
		Editing	Payer Provider# not required (Only for Commercial Payers)
		Editing	Diagnosis Code Required
		Editing	Admission Type Needed
		Invoicing	Print zero balance invoices (allows you to print $0.00 balance Invoices)
		Invoicing	Prevent Non-routine services (supplies) from being 1st billable item
		Invoicing	Split/Break by Service Month
		Scheduling	Scheduling Authorization Warning (if Payer Requires Auth)
		Services	Apply late time slips to initial bill-default to rebill
		UB04	Prints a 9/0 on UB04 locator 66
		UB04	Do not print Admitting Diagnosis code
		UB04	Print Payer Name and Address in Box 38
		UB04	Print HCPC on UB
		UB04	Print Name- Last Name, First Name MI
Invoice Type	Invoice Cycle	Group Codes	Rule Descriptions
UB04	Bi-Weekly	Editing	HCPC required for routine services
	ONLY FOR MA PLANS	Editing	Payer Provider# not required
		Editing	Diagnosis Code Required
		Editing	Admission Type Needed
		Editing	Apply and Edit PPS Data elements on Non-PPS invoices
		Invoicing	Print zero balance invoices
		Invoicing	Convert Units to 15 minute incrememts (only if Required)
		Invoicing	Prevent Non-routine services (supplies) from being 1st billable item
		Invoicing	Apply Place of Service Transaction (Q Codes)
		Scheduling	Scheduling Authorization Warning (if Payer Requires Auth)
		Services	Apply late time slips to initial bill-default to rebill
		UB04	Prints a 9/0 on UB04 locator 66
		UB04	Apply value code 85 and FIPS code to all
		UB04	Do not print Admitting Diagnosis code
		UB04	Print Payer Name and Address in Box 38
		UB04	Print HCPC on UB
		UB04	Convert Units to 15 minute incrememts (only if Required)
		UB04	Print Name- Last Name, First Name MI
		UB04	Print 27 and SOC date in locator 31
		UB04	Print 61 and CBSA code in locator 39
		UB04	Print Agency Taxonomy on UB04 Locator 81 (If Required)
Invoice Type	Invoice Cycle	Group Codes	Rule Descriptions
UB04	Monthly	Editing	HCPC required for routine services
	ONLY FOR MA PLANS	Editing	Payer Provider# not required
		Editing	Diagnosis Code Required
		Editing	Admission Type Needed
		Editing	Apply and Edit PPS Data elements on Non-PPS invoices
		Invoicing	Print zero balance invoices
		Invoicing	Convert Units to 15 minute incrememts (only if Required)
		Invoicing	Prevent Non-routine services (supplies) from being 1st billable item
		Invoicing	Apply Place of Service Transaction (Q Codes)
		Scheduling	Scheduling Authorization Warning (if Payer Requires Auth)
		Services	Apply late time slips to initial bill-default to rebill
		UB04	Prints a 9/0 on UB04 locator 66
		UB04	Apply value code 85 and FIPS code to all
		UB04	Do not print Admitting Diagnosis code
		UB04	Print Payer Name and Address in Box 38
		UB04	Print HCPC on UB
		UB04	Convert Units to 15 minute incrememts (only if Required)
		UB04	Print Name- Last Name, First Name MI
		UB04	Print 27 and SOC date in locator 31
		UB04	Print 61 and CBSA code in locator 39
		UB04	Print Agency Taxonomy on UB04 Locator 81 (If Required)
Invoice Type	Invoice Cycle	Group Codes	Rule Descriptions
HCFA-1500	Weekly	Editing	HCPC required for routine services
		Editing	Payer Provider# not required
		Editing	Diagnosis Code Required
		HCFA	Print Other Insured Info in Box 9
		HCFA	Print Service From/To Dates on HCFA1500
		HCFA	Print Start of Care Date in Box 12
		HCFA	Use Patient Address in Box 32 when place of service is home
		HCFA	Print additional Diagnosis Codes
		Invoicing	Print zero balance invoices
		Invoicing	Split/Break by Service Month
		Scheduling	Scheduling Authorization Warning (if Payer Requires Auth)
		Services	Apply late time slips to initial bill-default to rebill
Invoice Type	Invoice Cycle	Group Codes	Rule Descriptions
HCFA-1500	Bi-Weekly	Editing	HCPC required for routine services
		Editing	Payer Provider# not required
		Editing	Diagnosis Code Required
		HCFA	Print Other Insured Info in Box 9
		HCFA	Print Service From/To Dates on HCFA1500
		HCFA	Print Start of Care Date in Box 12
		HCFA	Use Patient Address in Box 32 when place of service is home
		HCFA	Print additional Diagnosis Codes
		Invoicing	Print zero balance invoices
		Scheduling	Scheduling Authorization Warning (if Payer Requires Auth)
		Services	Apply late time slips to initial bill-default to rebill
Invoice Type	Invoice Cycle	Group Codes	Rule Descriptions
HCFA-1500	Monthly	Editing	HCPC required for routine services
		Editing	Payer Provider# not required
		Editing	Diagnosis Code Required
		HCFA	Print Other Insured Info in Box 9
		HCFA	Print Service From/To Dates on HCFA1500
		HCFA	Print Start of Care Date in Box 12
		HCFA	Use Patient Address in Box 32 when place of service is home
		HCFA	Print additional Diagnosis Codes
		Invoicing	Print zero balance invoices
		Scheduling	Scheduling Authorization Warning (if Payer Requires Auth)
		Services	Apply late time slips to initial bill-default to rebill
Invoice Type	Invoice Cycle	Group Codes	Rule Descriptions
Generic	Weekly	Editing	Payer Provider# not required
		Generic	Reflect Contractual Adjustment on Invoice
Invoice Type	Invoice Cycle	Group Codes	Rule Descriptions
EDI 837I	PPS	Editing	Admission Type Needed
		Editing	Payer Identifier# required
		Editing	HCPC required for routine services
		Invoicing	Apply Place of Service Transaction
		Invoicing	Prevent Non-routine services (supplies) from being 1st billable item
		Invoicing	Print zero balance invoices
		Invoicing	Convert Billing Units to 15 minute increments
		Invoicing	Apply Certifying+Ordering Physician for claims after start date
		Invoicing	Default Units to 1 when equal to 0
		Invoicing	Do not send medical record #.
		Invoicing	Do not send Payer secondary identifiers.
		Invoicing	Do not send physician secondary identifiers.
		Invoicing	Do not send preceding zeros in GS06/GE02 segment
		Optional Rules	Rule Description
		Orders	Check Orders for Face2Face >= the Start date
		Services	Auto-Verify scheduled services that have a completed service note
		Services	Apply late time slips to initial bill-default to rebill
		UB04	Apply value code 85 and FIPS state and county code - PPS invoices
		UB04	Print 55 and death date in locator 31
Invoice Type	Invoice Cycle	Group Codes	Rule Descriptions
EDI 837I	Hospice	Editing	Admission Type Needed
		Editing	Apply and Edit Level of Care service codes
		Editing	Apply M2 Occurrence Span and Edit Respite care>5 days
		Editing	HCPC required for routine services
		Editing	Payer Identifier# required
		Editing	Previous Invoice must be Billed
		Editing	Service Facility NPI reporting required
		Invoicing	Print Physician License Number
		Invoicing	Print zero balance invoices
		Invoicing	Do not send medical record #.
		Invoicing	Do not send Payer secondary identifiers.
		Invoicing	Do not send physician secondary identifiers.
		Invoicing	Do not send preceding zeros in GS06/GE02 segment
		Optional Rules	Rule Description
		Services	Auto-Verify scheduled services that have a completed service note
		Services	Apply late time slips to initial bill-default to rebill
		UB04	Print 27 and SOC date in locator 31
		UB04	Print 55 and death date in locator 31
		UB04	Print 61 and CBSA code in locator 39
		UB04	Print HCPC on UB