Payer Options ( Codes > Program Related Codes > Payer Codes )
Payer Basic Setup:
•Enter the Program Number and Payer Number
•Enter the Provider # (The provider number will be the identity number the payer gave you; or you may use your Tax ID Number)
- Provider#: Use the key phrase "24J=" and then type in what you want to show up on the 1500 24J field. Example: 24J=NPI or 24J=NONPAR.
485 Box 26:
•1=Home Health PPS or other insurance that requires homebound status;
•2=Medicaid or other insurance that does not require homebound status;
Type of Bill:
•For UB04: 32=PPS payer, 34=Medicare Flu Shots, 81=Hospice, 33=All Others (33 is no longer valid for Home Health)
•For 1500: C=Ohio Medicaid, D=NC CAP, E=NC PCS, F=NC Private Duty Nursing, G=NC Group Home
For PPS, RAP tob code should be 322
•for UB04: 32=PPS payer, 34=Medicare Flu Shots, 33=All Others;
•for 1500: C=Ohio Medicaid, D=NC CAP, E=NC PCS, F=NC Private Duty Nursing, G=NC Group Home
•5 for 1500 if the above don't work
•P = whole hour units (for 1500 form only)
Pay Class: (Please view KB Article: Payer Codes/Pay Class - for more options)
•H = Units to appear in 1/4 hour increments
•R = shows supply code 0272 on claim
•2 = pulls NPI and taxonomy from the employee on the visit rather than program/payer (use this for therapy services)
•5 = prints 1500
•6 = Units to appear in 1/4 hour increments (CMS1500)
•7 = prints 1500
•J or K will put the provider# into #51
•P = whole hour units (for UB04 only)
•Anything else is neither Medicare nor Medicaid
•Y or N
•If Hospice then Y or N; otherwise N
•Y or N (if Medicare or billed like Medicare, then Y)
Use Medicare HCPCS:
•Y or N
If Y then the HCPCS codes on the job code are ignored and replaced based on the revenue code
◦042X = G0151 PT
◦043X = G0152 OT
◦044X = G0153 ST
◦055X = G0154 RN
◦056X = G0155 MSW
◦057X = G0156 HHA
Hospice 60-day Certs Only
•Yes or No
Translate G0154 to G0299 and G0300
• Answer Yes for non PPS payers that require the new G codes
•Yes or No
Claim Requires ICD Codes
•Yes or No
Force revenue codes that end in 0 to end in 1:
•Each job code has an associated revenue code that is used for billing - job codes themselves do not appear on a claim
•Some agencies use revenue codes that end in 0, and that is accepted by most insurances;
•However, NC BCBS requires that the skill codes (see above) use revenue codes that end in 1, like 0551 for RN
Your options are to select No to ignore any changes to the revenue code; Just those that end in 0; All
Requires F2F – Choose one of the three options
•At SOC only (like Medicare)
•Hospice 60-day certs
Oasis M0150 Type - This will help automatically fill in an accurate OASIS answer on M0150.
Use 30-Day Episodes for PDGM - You can select which payer uses the 30 and 60 day PDGM episodes for billing purposes. If N is selected it will continue to use a 60 day episode. This option will only show up for payers with PPS Yes answered.
Contact Information: (Optional)
This is address of where you send the paper claims to. This will show up on the paper claim. The UB04 puts contact info in box 38. The 1500 puts it at the top middle.
Payment Posting Setup:
•Pay/Adj code to use when posting payments:
•Pay/Adj code to use when posting adjustments:
•When setting up payment and adjustment codes for A/R, some agencies use generic descriptions (PRIVATE INSURANCE PAYMENT) and use the same code for all private insurance payments; others set up a separate code for every insurance (BCBS NC PAYMENT).
•When posting payments from a paper Remittance Advice, to choose the claim being paid, you click on an Amount Billed line on the screen. That line contains a program and payer code. The screen that pops up that is used to enter the amount paid and optional amount adjusted will use these two codes.
•NOTE: If these codes are invalid or blank, then the posting process will generate an error message that the codes are unknown.
Electronic Claims Setup:
Fill in your agency information and Save. Make sure you enter your agencies physical address, along with the 9-digit zip code. FYI: You can select Save at the end of each screen.
•For PPS payers that are not Medicare, use Type of Bill 32, billing format Q, pay class Q, stat class X, hospice and perdiem no, pps and use mcare hcpcs yes.
•For claims to print increments in 15-minutes: Payclass=H, Format=Q, Type= UB04
•United Health Care: on 1500 = format Q, payclass U, statclass X
•For private insurance that will be billed per visit each month, use type of bill 33, billing format Q, pay class Q, stat class X, hospice, perdiem, pps = no, and use Medicare hcpcs can be either yes or no, depending on that insurance's billing instructions - if they want HCPCS codes that start with G on the claim, then it's yes; if they have other codes they want, then it's no.
• 1500 form needing doctor and NPI in field 17; and agency provider / NPI in field J = both format and payclass as J