Pay Control – Payers tab

Date

Specify the pay control date for the patient since which the pay control became active. You can select only the prior or today's date. Future dates are not available.

Pri

Select the primary pay source. If the insurance is inactive for the selected date, the cell is highlighted in pink.

CSP

This field shows a contingent secondary pay sources. Select the appropriate pay sources from the Select CSP Pointers window. In this window, define the order of billing for the CSP payers if there is more than one CSP pointer.

A contingent secondary payer is a payer or insurance that pays only after the primary insurance either paid a portion of the bill or denied it completely. "Contingency" means that the contingent secondary payer cannot bill until the primary insurance has done something. For more information, see CSP Claims.

For a payer listed in this field, the system generates a claim for the CSP when a complete denial or partial payment has been received from the primary payer and you post an adjustment for the not covered dollar amount. The adjustment codes that trigger CSP are those defined in Administration > Financial > Adjustment Types (the CSP Deduction check box must be clear).

Eligible CSP

Select the eligible contingent secondary pay sources in the Select Eligible SCP Pointers window. All payers that currently are not defined in other columns: Pri, Elig, CoIns, and R&B with the exception of CSP are displayed in this window.

An Eligible CSP is a payer that must be billed only after the eligible payer either made a partial payment or denied the claim completely.

When a payer is listed in this field, the system automatically generates a claim for the eligible CSP when a complete denial or partial payment was received from the eligible payer, and you post an adjustment for the dollar amount that is not covered.

Eligible

Select the pay sources eligible for the specified services in the Select Eligible Pointers window.

An eligible payer is essentially a dual primary payer. The system can bill both this and the primary payer if both are primary payers. If an eligible payer is identified, you must indicate which payer should be billed at the time of scheduling the visit in TimeLog or Contract Invoices.

For example, a home health aide visits a patient Monday through Friday. Medicare will pay for the aide's services three days a week: Monday, Wednesday, and Friday. Medicaid is willing to pay for the services on Tuesday and Thursday. In this case, the user indicates that the services should be billed to Medicaid for the Tuesday and Thursday visits.

Eligible are defined to allow billing specific services to this payer or the primary.

CoIns

Select coinsurance pay sources in the Select CoInsurance Pointers window.

The co-insurance payer will be billed the difference between the gross rate and the net rate for that particular service code. To define the amount that will be billed to the co-insurance pay source, select the billing rate attached to the service code in Administration > Financial > Billing Rates. The co-insurance payer will be billed the difference between the gross and the net rate for the primary pay source.

R&B

Select the needed room and board pay source option.

This field is available when the patient has a payer that has the potential for billing room and board.

You can set a particular insurance code to be a room and board pay source. Go to Administration > Financial > Insurance Codes, select a benefit insurance type, and on the Per Diem tab, select whether to bill the patient at the rate defined by the insurance or the rate defined by the facility. Only payers that are Benefit (per diem) or Hybrid can have room and board settings defined.

ID

Select the facility to which this room and board pay source applies.

This field will be available only if the option to bill at the nursing home rates was selected on the Per Diem tab in Administration > Financial > Insurance Codes.

Facility

This field displays the facility description.

Rate

Select the room and board bill rate code.

Liability

Select this check box to activate the Liability tab. Once activated, patient liability parameters can be defined on this tab. The SpendDown, To, and From fields on the Payers tab become inactive.

Spend Down

Enter the Spend Down amount for this pay source.

The SpendDown column is used in relation to Medicaid and the dollar amount the patient is responsible to pay to be eligible for services. This amount is usually applied to services monthly. Other names for Spend Down include Patient Share of Cost and Patient Liability.

Settings related to this field are located on the General and Print Variations tabs in Administration > Financial > Insurance Codes.

From

Select the pay source to which the SpendDown amount is applied.

This field identifies from which payer to deduct the dollar amount indicated in the SpendDown field for billing purposes. The only payer type that is available in From is a Medicaid insurance code type.

To

Select the pay source from which the application subtracts the SpendDown amount.

This field identifies the payer to be billed for the dollar amount indicated in the SpendDown field. The valid payer type for this field is a payer with a Self-pay insurance code type.