Creating Payer Rules

Creating Payer Rules

Overview   

ICANotes+ empowers billers to manage payer rules, allowing users to handle custom business rules for their practice with greater ease and flexibility. This feature allows users to define and manage the specific rules required by payers for proper claim processing, ensuring compliance and improving the success rate of claim submissions. 


Enable the Payer Rule Feature   

To enable the payer rule feature, reach out to our training/implementation team.


Notes
Our training/implementation team will assist you to enable this feature and configure the payer rules for your practice. Once the rules are configured, you can modify them according to your practice needs.

Step 1: Assign Permission to Create Payer Rules   

Ensure that the biller has permission to access the payer rule section.


To assign access to create payer rules:
  1. Navigate to Settings > Practice Settings > Roles & Permissions.
  2. Click the Create New Role or the Edit button.
  3. Expand the Payer Rules section.
  4. Select the Access Payer Rules checkbox.

 

 


 

 

 

Step 2: Create Payer Rules   

Once the permission is assigned, the authorized billers can create payer rules.

To create a payer rule:
  1. Navigate to Settings > Revenue Cycle Management > Payer Rules.
  2. Click the Create Payer Rule button.


 

 

 

The Create Payer Rule screen appears as shown below, allowing you to define rules according to your practice's needs.


For example, you can create a rule to replace the rendering provider's last name with "Doe" for all claims where the payer is AARP Medicare, the rendering provider is John Smith, and the rule applies to all service locations. You can set this up by selecting the appropriate options in the IF and THEN sections of the screen.

 

 

 

IF section

This is the section where you can configure the condition to apply the rule.

 

  • Payer: This dropdown will display all the payers you have configured in the system. Select the desired payer to apply the rule. If you want to apply the rule for all the payers, select Any option in this field.

 

  • Rendering Provider: This dropdown will display all the providers you have configured in the system. Select the desired provider to apply the rule. If you want to apply the rule for all the providers, select Any option in this field.

 

  • Service Location: This dropdown will display all the sites you have configured in the system. Select the desired site to apply the rule. If you want to apply the rule for all the sites, select Any option in this field.

 

 

 

THEN section

This is the section where you can configure the outcome for the condition you have set in the IF section.

 

  • Action: This dropdown will display the following options:
    • Include: 
    • Omit
    • Replace

 

  • Object/Field: This dropdown will display a list of objects and fields that you may want to include, omit, or replace while submitting the claim. You can include or omit both objects and fields, but for replacements, only fields can be replaced. 

 

Expanding the Object/Field dropdown will display the following objects that you can include or omit.

 

 

 

Expanding the object will reveal the corresponding fields that you can include, omit, or replace. For example, when you expand the Billing object, it will display the associated fields as shown below: 

 

 

 

  • New Value: Enter the new value for the selected object/field. When you submit the claim, the value entered in this field will be considered in the claim.

 

Step 3: Modify Payer Rules   

After creating a payer rule, you can modify it as needed.

To modify a payer rule:
  1. Navigate to Settings > Revenue Cycle Management > Payer Rules.
  2. Click the Edit button.

The same modal that appears when creating a new payer rule will open. Make the necessary changes, and then click Save.


Step 4: Delete Payer Rules   

If a payer rule is no longer in use, you can delete it.

To delete a payer rule:
  1. Navigate to Settings > Revenue Cycle Management > Payer Rules.
  2. Click the Delete button.



A confirmation message appears when you click Delete. If you confirm, the payer rule will be deleted.





FAQs 

You can find the Frequently Asked Questions (FAQs) on our Knowledge Base page.


Click here for quick access to the FAQs.

 

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Need additional assistance?

Phone: 443-203-5857 

Text: 866-301-0085

Email: ticket@icanotes.com

Chat: http://app.icanotes.com 

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Proprietary Notice Information: This article is provided for informational purposes only, and the information herein is subject to change without notice. While every effort has been made to ensure that the information contained within this article is accurate, ICANotes cannot and does not accept any type of liability for errors in, or omissions arising from the use of this information.

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