The Secondary Encounter Rate and Tertiary Encounter Rate tabs on the Encounter Rate Billing Library Maintenance window contain billing rules that apply when the ER payer is the secondary or tertiary payer on the encounter.
- Open the Encounter Rate Billing library.
The Encounter Rate Billing Library Maintenance window opens.
- Select the Secondary Encounter Rate or Tertiary Encounter Rate tab.
- Select the Secondary Calculations when Medicare is the primary payer or Tertiary Calculations when Medicare is the primary payer settings for calculating the encounter rate when Medicare is the primary payer.
The options are:
- Encounter Rate amount is equal to the: Select one of the following options to determine the calculation for the encounter rate of the secondary or tertiary payer when Medicare is the primary insurance.
- Encounter Rate minus Medicare allowed
- Medicare allowed minus Medicare paid
- Encounter Rate amount minus Medicare paid
- Medicare paid minus Encounter Rate amount
- Encounter Rate amount
- 20% of original charges
- Do not insert ER SIM if the ER amount is less than primary paid: Select this option to suppress ER billing and ER SIM insertion if the encounter rate amount is less than the primary paid amount.
- Do not insert ER SIM if the ER amount is equal to primary paid: Select this option to suppress ER billing and ER SIM insertion if the encounter rate amount is equal to the primary paid amount.
- Select the Secondary Calculations when Non-Medicare is the primary payer or Tertiary Calculations when Non-Medicare is the primary payer settings for calculating the encounter rate when primary payer is not Medicare.
The options are:
- Encounter Rate amount is equal to the: Select one of the following options to determine the calculation for the encounter rate of the secondary or tertiary payer when a non-Medicare payer is the primary insurance.
On the
Secondary tab:
- Primary allowed minus primary paid
- Encounter Rate amount minus primary paid
- Encounter Rate minus primary (paid + adjustments)
- Primary paid minus Encounter Rate amount
- Encounter Rate
- ER - prim paid, or Line Item Balance (if lower)
On the
Tertiary tab:
- Previous allowed minus previous paid
- Encounter Rate amount minus previous paid
- Encounter Rate minus previous (paid + adjustments)
- Previous paid minus Encounter Rate amount
- Encounter Rate
- Do not insert ER SIM if the ER amount is less than primary/previous paid: Select this option to suppress ER billing and ER SIM insertion if the encounter rate amount is less than the primary paid amount for secondary calculations or the previous paid amount for tertiary calculations.
- Do not insert ER SIM if the ER amount is equal to primary/previous paid: Select this option to suppress ER billing and ER SIM insertion if the encounter rate amount is equal to the:
- Primary paid amount (for secondary calculations).
- or -
- Previous paid amount of the primary and secondary payers (for tertiary calculations).
- Select the Suppress Claim Creation settings to suppress claim creation for non-encounter rate claims for the secondary and tertiary payers.
The options are:
- Suppress claim for multiple same-day encounters (Multi-Yes only): Select this option to suppress the creation of a claim for the encounter if there are multiple encounters on the same day.
- Suppress zero dollar claims: Select this option to suppress the claim when the encounter rate SIM amount is $0 (zero dollars). For example, this option could be used when setting up PAC billing, which does not require a claim when reimbursement is determined to be zero dollars for secondary claims.
- Select the Auto Adjustments settings that apply to the secondary and tertiary payers. These settings have no impact on alternate payer charge lines.
The option is:
- Adjust remaining balance of changes for ER billed encounter: Select one of the following options for adjusting charges included in encounter rate:
- Only adjust line items if ER SIM is inserted
- Always adjust line items
- Never adjust line items
If
Only adjust line items if ER SIM is inserted or
Always adjust line items is selected, two additional options appear in the
Auto Adjustments section, as shown below. These settings are required.
- Complete the Auto Adjustments settings.
The options are:
- Adjust charges for non-ER billed encounters: This option applies only when multiple encounters per patient/payer/date of service exist. Selecting this option adjusts all charges to zero for the encounters not chosen for encounter rate billing (Multi-No). This option should be used when other encounters cannot be billed to the Encounter Rate payer.
- Use one of these methods for encounter rate adjustments: 20% to next bucket and FIFO, 20% to next bucket and weighted, 20% & adjust first line to ER amount, FIFO, Weighted, Adjust first line item to the ER amount and adjust other lines off, Adjust line items to $0.
Note: If an encounter rate adjustment or reversal occurs after the charge date, then the transaction date is still set to the same date as the charge date. The first three options are designed specifically for Medicare Part A to account for patient coinsurance.
- Select an adjustment code to use for automatic adjustments. This code, which provides greater reporting capability, is used for the automatic adjustments referenced above.
Note: The adjustment codes are created in the Transaction Codes master file.
- Select the Payment Verification settings to ignore payment verification.
The option is:
- Allow ER SIM to insert without previous payments: Select this option to ignore the encounter rate billing functionality that verifies all line items on the encounter have payments from a previous payer. This option enables the insertion of the encounter rate SIM code even though the previous payer has not paid yet on all charge lines. It is common for payment to be made on some line items, but not all. This option also allows insertion when there are no previous payments. It is commonly used for WRAP payers.
- To save changes and close the window, select OK.
