Skilled Nursing Facilities

Managing Payer Rules at the Facility Level

Payer Rules define contractual requirements such as deductibles, liability, coverage limits, and coinsurance specific to a Payer.

Payer Rules can be edited if the incorrect options are selected. 

Note

Before configuring Payer Rules, Payers must be setup and a rate line created in Payer Rules and Rates to activate the Payer. 

  1. From facility > Admin > Setup > Payer Rules & Rate Schedules. 

  2. Click edit payer rules.

  • Does the Payer Cover Deductibles?- Select Yes or No.

  • Does payer have a Deductible/Liability? - Select Yes if the Payer reduces payment for a deductible or liability amount and complete the additional fields, otherwise select No.

    • Default Amount: - Type the amount if the amount is the same for all residents for the Payer. The default amount populates the same amount for all resident's for the payer in the resident's census. If resident's have a different amount, leave the field blank and you can type the resident specific amount in census entries.

    • Disallow Override of Amount - Select if you typed a Default Amount and do not want the amount to be overridden in resident census and rates.

    • Frequency: - Select from the list.

    • Method: - Select from the list.

    • Include Ancillaries in deductible: - Select the option if the Payer includes ancillaries when calculating the deductible/liability.

  • Does payer have a Coverage Limit? - Select Yes if the Payer covers a maximum amount and complete the additional fields, otherwise select No.

    • Default Amt./Pct.: - Type the amount.

    • Disallow Override of Amount - Select if you typed a Default Amt./Pct amount and do not want the amount to be overridden in resident census and rates.

    • Frequency: - Select from the list.

    • Once Reached:

      • Pass to next Payer  - Select this option to split the billing between payers.

      • Write-off to:  -  Select the account from the list if a portion of the bill is not to be collected from the resident. For example, to reduce the charge for a subsidy.

    • Include Ancillaries in coverage limit: - Select to include ancillaries if the payer includes ancillaries in coverage limit.

    • Default Amt./Pct.:  - Type the coinsurance amount.

    • Disallow Override of Amount - Select if you typed a default amount and do not want the amount to be overridden in resident census.

    • Frequency: - Select from the list.

    • Select Valid Coinsurance Payers: - Select all of the valid coinsurance payers for the Payer.

    • Percentage:  - Type the percentage amount.

    • Account:  - Select the account to apply the reduction.

  • If Apply reduction to net reimbursement is selected, the reduction is applied to room and board when you generate transactions and ancillary charges within a batch.