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Commercial payer onboarding

Outcome​

A tenant can bill a commercial payer: the payer exists in master with its lines of business, plans and submission capabilities, and the tenant has a contract, a fee schedule and a program setting for it.

No seeded payers

Environments no longer come up with commercial payers. The RM-12 bulk seed that installed a UHC / Anthem / Aetna / Cigna / Humana roster was retired in #7029, and master migration 157 purged the seeded payers (#7025). Every payer is set up by hand, in the two screens below.

Prerequisites​

  • The tenant is provisioned and has at least one billing entity.
  • The program the payer will bill under exists in master (ADM → Master data → Programs).

Steps​

  1. Create the payer in master. In ADM → Master data → Payers, add the payer, open it, then add its lines of business and plans, and on the Submission tab its submission capabilities (claim type, method, trading partner, timely filing). See Configure a new payer.

  2. Add the tenant's contract and fee schedule. In RCM, add the payer contract anchored to the billing entity and its contract-owned fee schedule. See Payer contract registry and Managing fee schedules.

  3. Add the program setting for the payer. Under Configuration → Programs, add the payer's setting (auth workflow, billing NPI type, timely filing days). A payer of the program with no setting, and no program-level setting to fall back on, is blocked at scrub with PROGRAM_CONFIG_MISSING. See Onboarding program settings, payers and contracts.

  4. Payer-scoped modifier overrides, if the payer needs any: see Payer-scoped modifier overrides.

Validation​

-- The tenant's contracts for commercial payers
SELECT p.short_name, c.contract_number, c.effective_from
  FROM billing.payer_contract c
  JOIN rcm_master.payer p ON p.payer_id = c.payer_id
 WHERE p.payer_type = 'COMMERCIAL'
 ORDER BY p.short_name;

Then run a single pricing call through CodeResolver.resolveCodes against a charge for that payer and confirm rate_source_ref begins with CONTRACT: — the end-to-end proof that the contract tier is lit up.

Cross-references​

Next​

4.5 — Managing fee schedules