You can configure billing rules for SIM codes that are valid for specific payers, and are therefore considered invalid or non-coordinated for other payers on the Non-Coordinated SIM Maintenance window. The rules can be configured in a way that ensures a non-coordinated SIM code is billed only to a valid payer. The rules can also be configured to ensure that services rendered by a provider with a specific credential are billed only to a valid payer. You can define additional rules for balance control, auto-adjustments, and claims.
- In File Maintenance, select Libraries, and then select Non-Coordinated SIM Library.
The Non-Coordinated SIM List window opens.
- Double-click a library.
The Non-Coordinated Service Item Library Maintenance window opens.
- In the Payer SIM Configuration section, do one of the following:
- To create a new SIM configuration or row, select open menu
and then select New.
- To modify an existing SIM configuration, select the row, select open menu and then select Open.
The Non-Coordinated SIM Maintenance window opens.
- Enter the effective date and expiration date for the SIM configuration.
- Enter the description for the SIM configuration.
- To select one or more Non-Coordinated SIM codes to be billed to specific payers, select open folder
.
The
Service Items window opens.
In the
Service Items window, do the following:
- Select the Search for keyphrase anywhere in this field check box to refine the search.
- Select a search method.
- Enter a value in the Available field to filter the list of SIMs.
- Move the required SIM to the Included section and select OK.
- To add a provider credential, select open folder .
The
Credentialing Type window opens.
In the Credentialing Type window, move the required credential type to the Included section and select OK.
To use the provider credentialing in a SIM configuration, the following additional setup is required:
- Select the Enable Provider Credential Billing check box on the General tab of the Enterprise Preferences window.
- Credentialing Types are created in the Credentialing master list.
- Link the credentialing types to the appropriate rendering providers on the Credentialing tab in the Providers master file .
Note: You cannot use the Provider Credentialing and Only for Selected Prior Payers parameters together in a SIM configuration.
- To add payers, select open folder .
The
Payers window opens.
In the Payers window, move the required payers to the Included section and select OK.
- Select the Only for Selected Prior Payers check box and select the open folder to add prior payers, if applicable.
If no payers are selected here (blank), the SIM configuration applies when any payer is prior to a valid payer on the encounter. If one or more payers are selected here, the SIM configuration applies only when a payer selected here is prior to a valid payer on the encounter.
Note: The Provider Credentialing and Only for Selected Prior Payers parameters cannot be used together in a SIM configuration. If credentials are populated, this section is disabled.
- Set up the Non-Coordinated SIM Rules.
For more information on each field, see Setting Up Non-Coordinated SIM Rules.
- To save changes and close the window, select OK.
