Payer specific Billing Rules
Prolis Payer Management is equipped with the payer specific billing Rules Tab where the biller can define exceptions to the conventional laboratory billing.
For example a billable group setup to be billed to Insurances, can be defined to break in to its constituent for a specific payer. Conventionally setup CPT codes in the dictionary, can be defined to be replaced with other payer specific codes, etc.
Following billing elements can be changed during synchronization if defined in the Payer Specific Billing Rules;
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Billable component (Single or Composite) A single Group or Profile can be broken on the fly (while synchronization), in to its constituents or multiple billable components (Composite) can be bundled in to a single billable component. Both the original and the target components are required to exist in the dictionary. For example, most of the payers bundle CBC (85025), CMP (80053) and TSH (84443) in to a Health Profile, CPT code (80050).
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CPT Code The CPT code of certain billable components can be changed for specific payers, by defining them in the Payer Management, Payer specific Billing Rules. For example, most commercial payers accept toxicology claims with conventional CPT codes but the Medicare accepts the same with G codes.
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POS Code The Place of Service (POS) code can also be changed while synchronizing the billing data. For example the conventional POS code for a laboratory is 81 but some payers have decided to accept the claims using the point of specimen collection as the POS code, requiring the laboratory to use the code 12 instead of the conventional laboratory code 81. You may configure this code swap from 81 to 12 or what ever code is needed, for the specific payer, in the Payer Specific Billing Rules.
Check the Payer Management documentation for more information about the Payer Specific Billing Rules.