Payers

A payer is anyone who pays for care: Medicare, a Medicaid plan, a commercial insurer, workers' compensation, an auto insurer, a school or agency, or the patient. Open Setup > Billing setup > Payers to see them all, with each payer's type, how claims are sent, its payer ID and its fee schedule. Anyone with access to Setup can see the list; only people whose role can manage payers can add or change them.

Every clinic starts with a Self-pay payer for patients who pay for their own care. It is built in: you can edit its contact details and rules, but you cannot delete it, deactivate it or change its type.

Add a payer#

1. Click New Payer. The new payer opens in a dialog.
2. Under Details, enter the name and choose the Payer type. NeatPractice fills in the usual Claim filing indicator for that type, such as CI for commercial or MB for Medicare Part B; change it if the payer asks for another code.
3. Fill in the Electronic and Paper sections as described below.
4. Click Create Payer.

A new Medicare or Medicare Advantage payer starts with the Medicare billing rules, and a new Medicaid or Medicaid managed care payer starts with the Medicaid rules. Every other payer starts with the standard rules. The dialog tells you which one applies before you save, and you can change any rule afterward.

To change a payer later, click its name or choose Edit from the menu on its row. The payer opens in a dialog with the same tabs; make your changes and click Save Changes.

Details#

Add the address where paper claims go, the payer's phone number and its provider portal (a full https:// address), plus any notes for your billing staff. Turn off Active for a payer you no longer bill; inactive payers stay on past records but leave pickers.

Electronic#

• Send claims is Electronic for payers you bill through the clearinghouse, or Paper for payers that only take printed claim forms.
• Payer ID is the clearinghouse ID for this payer, such as EXHP01. Electronic claims and eligibility checks need it. Click Find next to it to search the clearinghouse payer directory by name or ID, then click Use: NeatPractice fills in the payer ID and the switches below from the directory. Check them before you save.
• Turn on what the payer supports (eligibility checks, electronic remittances) and which transactions need enrollment before you can use them.

Claim form#

• Print on plain paper prints the claim form grid along with your data, for payers that accept plain paper instead of red forms.
• Accept assignment means the payer pays your clinic directly.
• Signature on file in box 31 prints SIGNATURE ON FILE in box 31 instead of the rendering provider's name.
• Leave boxes 24I, 24J and 33b blank without a payer number stops claims from reporting the taxonomy (qualifier ZZ) in those boxes, for payers that reject it there. A payer-specific provider number still prints.
• Group provider number is the number this payer assigned your group, with its qualifier (such as G2 or 1D). Claims send it in box 33b ahead of a location's Medicaid provider number.
• Box 19 default text starts every new claim to this payer with that text in box 19. You can still change it on each claim.
• No-response follow-up days replaces the clinic's follow-up days for this payer's claims: how long a sent claim can go unanswered before it joins the No response list.

Where each claim box comes from#

NeatPractice fills the claim boxes from your setup, so there are no per-claim box overrides to maintain:

Who renders a supervised service follows the payer's supervised services rules, and modifiers follow your modifier rules. To see where a value on one claim came from, open the claim's Form Map tab (see Claims).

Aliases#

Some payers go by more than one name, such as a local plan sold under its own brand, or use a second payer ID. Open the payer and pick the Aliases tab, then click New Alias to add another name and, if it has one, the payer ID it uses under that name.

• Searching the payer list by an alias's name or payer ID finds the payer, and the list shows how many aliases each payer has (hover the badge to read them).
• A remittance that arrives under an alias's payer ID posts to this payer. A payer's own payer ID always wins over another payer's alias.
• Claims always carry the payer's own name and payer ID, never an alias.

Billing rules#

The Rule sets tab holds the billing rules for this payer. Rules change over time, so they are kept in versions: each version applies to dates of service from its Effective from date until the next version starts. The version that covers today is marked In effect today. A charge always uses the rules for its date of service, and keeps them even if you edit the rules later.

To start a new version, for example when a contract renews:

1. Click New Version from Current. The form opens with a copy of the version in effect today, and its description names the dates that version covers.
2. Set Effective from to the first date of service the new rules apply to.
3. Change the rules that are different and click Create Version.

Open a version's row menu and click Edit to change it, or Delete to remove it. A payer always keeps at least one version; when you delete one, the dates it covered fall back to the version before it.

Each version covers:

Unit rounding#

A timed code bills one unit for each full unit of minutes. The leftover minutes count as one more unit by the rule you pick:

New payers start with the CMS 8-minute rule. Pick the method your payer's manual names; a visit keeps the method that applied when it was created.

Payer week and reauthorization reports#

Two settings under Authorization and referral shape how authorizations from this payer are tracked:

• Work week starts on: the first day of the payer's week. Weekly limits and weekly caps on an authorization, and the pace shown in its utilization, count weeks from this day. New payers start on Sunday.
• Reauthorization report (days before end): how many days before an authorization ends the progress report for its renewal is due, for example 30. On that day a treatment approval with no renewal requested yet shows a due item named Reauthorization report due for the providers on the patient's care team. Leave it blank when this payer asks for no report. Once the progress report for that authorization is signed, the item clears.

Blackout days#

Under Authorization and referral, No services on weekends and No services on clinic holidays stop booking a visit this payer covers on those days. Someone with the authorization override permission can book past it with a reason, and an authorization with Allow blackout dates turned on skips it. Add other dates under Blackout dates.

Notes#

• Longest note (hours): the most time one note may cover for this payer. A longer visit shows a warning to split the session into several notes. Leave it blank for no cap.
• Time format on notes: signed notes, and claim line notes that carry times, print the start and end time in 12-hour (2:30 PM) or 24-hour (14:30) time.

Visit verification#

With the EVV add-on, turn on Medicaid EVV payer when your state's EVV program covers this payer's visits. Pick the EVV aggregator the visits go to and, if your clinic connects to that aggregator in more than one state, the EVV state. Their open EVV exceptions can then hold charges, and the visits can be sent from EVV submissions. See EVV settings.

Caregiver signs reports#

Turn on Caregiver signs reports when this payer wants the caregiver's signature on evaluation, progress and discharge reports. New payer reports on its authorizations then go to caregiver review, and the provider can sign only after the caregiver has signed.

Billable condition#

By default a session can bill once its note is signed (and co-signed when that is required). In Billable condition you can add:

• Caregiver signature required to bill: the caregiver signs on a clinic device that the session took place. The visit offers the signature even after the note is signed.
• Analyst review required to bill: a supervising analyst reviews the note first.

Until the condition is met, the charges wait in charge review with the Billable condition not met hold, which lifts on its own once the condition is met.

An approved note review of one of the visit's notes counts as the analyst's review.

QA and audit holds#

Two more switches in Billable condition tie this payer's billing to documentation quality:

• QA approval required to bill: when a QA rule sends one of the visit's notes to the QA queue, its charges wait with the Awaiting QA review hold until a reviewer approves the note. Notes no rule picks bill as usual.
• Hold charges with open audit findings: while one of the visit's notes has open audit findings, its charges wait with the Audit findings open hold. It lifts once the findings resolve, for example after the author corrects the note with an addendum.

A biller can release either hold with a reason.

Supervised services and claims#

• Bill under picks the rendering provider for services a technician, assistant or student delivered: the delivering provider, the coverage's case lead, the visit's supervisor, the group NPI, or the clinic default.
• Claim batch days limit Create claims to those weekdays for this payer; leave empty for every day.
• Line start and stop times in line notes puts each line's start and stop times in its claim line note (the shaded line on the CMS-1500 and the line note of an electronic claim), in the rule set's Time format on notes.

See Supervised and concurrent services.

Code rules#

The Code rules tab holds how this payer treats individual codes. Like rule sets, each code rule covers dates of service from Effective from through Effective to (or onward when empty), and versions of one code never overlap.

1. Click New Code Rule.
2. Enter your clinic's Code and the dates.
3. Fill in only what this payer does differently, then click Create Rule.

Charges already created keep the code they billed; a new or changed rule applies to charges created after it.

Below the code rules, Concurrency rules say what this payer does when two codes for one patient overlap in time: allow it, carve the overlap out of the concurrent line, or split it off as non-billable time (see overlapping services).

Authorization templates#

The Authorizations tab holds this payer's usual approvals. Click New Template, give it a name, the discipline, kind, usual length in months, and the code lines with their limits, then click Add Template. On a new authorization for this payer, Use Template fills them in.

Blackout dates#

Also on the Authorizations tab, Blackout dates lists ranges of dates this payer will not pay for, such as a plan year changeover. Click New Blackout Date, enter a name and the first and last date, and click Add Blackout Date. Booking a visit this payer covers on those dates is stopped the same way as the blackout days.

Ready to bill#

The Billing column shows Ready to bill when a payer has what claims need: a Payer ID for electronic claims or a full claims address for paper claims, and a billing rule set in force today. Otherwise it shows Not ready to bill; point at the badge to see what is missing. The setup checklist counts payers that are not ready.

Move patients to another payer#

When every patient on one payer moves to another from a set date, for example a plan that a different insurer takes over, move them in one step instead of changing each chart. You need roles that can manage coverage and authorizations for all patients.

1. On Payers, open the page menu and click Move Patients.
2. Choose the payer patients Move patients from, the payer they move To, and the Cut-off date: the first date of service billed to the new payer.
3. Choose what happens to approvals that run past the cut-off: Transfer what is left to the new payer, or End it, new approval to follow.
4. Turn on Only one plan to move only the coverages with a given plan name, and New plan name to name the plan on the new coverages. Otherwise each coverage keeps its own plan name. Member ids and group numbers carry over.
5. The Patients table lists every coverage on the payer still in effect on the cut-off date, with its last billed visit and how many appointments, unbilled visits and approvals would move. A patient who cannot move shows why: a visit on or after the cut-off is already billed, the coverage starts on or after the cut-off (edit its payer instead), or the new payer needs a member id the coverage lacks. Uncheck anyone who should stay.
6. Click Move Patients. A message confirms how many moved and how many stayed. A move of more than 500 patients runs in the background instead: the dialog says so before you click, and you can keep working while it runs.

Each patient moves exactly as Change insurance would move them: the old coverage ends the day before the cut-off, a new one starts on it, billed visits never change, and unbilled visits and upcoming appointments move. A patient whose upcoming visits would be left without an authorization the new payer requires stays on the old payer, and the rest still move. One move takes up to 5,000 patients; run it again for more.

A background move checks each patient again when their turn comes, so a coverage that was edited, ended or billed in the meantime stays put with its reason. Follow it under Background jobs at the top of the page or in Payer Moves, where its status shows how many patients it has checked. Only one background move runs at a time; start the next one when it finishes. If it stops partway, the patients already moved keep their new coverage and the row says how far it got.

To see past moves, open the page menu and click Payer Moves. Each row shows the payers, cut-off date, status and how many patients moved or stayed. Download Audit File from the row menu saves a CSV file listing every patient: who moved, with what moved for them, and who stayed, with the reason. Downloading it needs permission to export patient records.

Import, export and print#

Click Export CSV to download every payer with its type, claim settings, address and status. Click Import CSV to add payers from a file in the same format; payers whose name you already use are skipped, and each new payer starts with its type's billing rules. Click Print for a PDF of the list, or open a payer and click Print for a PDF of that payer's details. See Import, export and print.

Delete or deactivate a payer#

You can delete a payer only while nothing uses it. A payer on a fee schedule, named by a posting rule, on a patient's coverage or on any visit, charge, claim, payment, deposit, remittance or refund is in use: NeatPractice tells you what still uses it, and you can turn off Active instead. Its rule sets go with it when it is deleted.