Payor plan

  • The definition of 'Plan' in EMR-Bear is a specific "benefit plan" offered by the Payor that a given client might be associated with. Most Payors offer several benefit plans, and each of them might have a different set of benefits for different clients enrolled in that plan (i.e., some plans may cover certain procedures, others might not, or reimbursements may differ from plan to plan).
  • Many times the billing address that receives claims for a given plan is different from that of another plan for the same Payor. For these reasons, one Payor may have several plans associated with them. EMR-Bear provides a transparent way to define your client's insurance companies to the correct Payor and (benefit) Plan under that Payor.
  • On the Payor's list, click Edit Plan or Add Plan

Payor plan

  • Plan name: the name for this plan (required)
  • Fee Schedule: the Fee Schedule associated with this plan.(add link to fee schedule)
  • Effective since and Effective until will be pre-populated, however, if these plans reflect a specific contract term, you can use these fields to keep track of the contract's end date
  • .Billing mode: You can choose a billing mode from the drop down menu. System default mode can be used if you are going the setup in the billing configuration. Organization billing mode can be used bill for the whole organization, individual provider can be used to bill separately for all the individual provider and individual provider for a location can be used to bill individual provider to each location.
  • Billing policies: allows u to restrict which diagnosis is allowed for which proc code. There will list of proc for diagnosis. The billing policies enable extra set of rules for billing.
  • Payor type: choose the payor type from the drop down.
  • Address: Enter the address here.
  • Timely filing : How many days after the date of service must claims be filed to receive payment.
  • Fax: Enter the fax number here
  • Billing policies: Billing policies can be used to apply extra set of rules to the billing. You will enter the billing code there.

Billing policies

They need to be defined here and assigned to the specific Payor Plan. Whenever a superbill is created using such plan, if a current billing policy is linked to that plan, then the system will run its validation and approve or not the superbill based on those rules. Each Billing Policy can have several Policy Sets.

Policy Sets have a collection of procedures and a collection of diagnosis codes. If a procedure on a superbill matches one set, then the set rules will be applied. A plan can take one or more Billing Policies, and each billing policy can have more than one policy set. A billing policy will pass the validation if all matching policy sets pass. A policy will only validate a set for which there's a matching diagnosis. The "Policy Procedures" is a different repository than that of your fees. It is an abstraction that has one single entry per each combination of procedure code and modifiers, regardless of the fee schedule. Meaning that if you have the same procedure code several times in different fee schedules, you only will have it once in the policy procedures repository. The system offers a feature to mass process and create policy procedures from your fee schedules.