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Payer Identification and Billing Services

This document provides a comprehensive analysis of payer identification and billing services in the PCC system, including reliable identifiers for payers and the billing/invoicing workflow.

Payer Data Structure​

The PCC system uses a multi-layered approach to track and manage payers:

Core Payer Tables​

  1. ar_lib_payers - Master library of payers

    • Contains the core payer information shared across facilities
    • Includes payer types, codes, and descriptions
    • Stores electronic submission parameters

  2. ar_payers - Facility-specific payer information

    • Contains facility-specific customizations for payers
    • Links to the master payer library
    • Includes facility-specific provider numbers and billing parameters

  3. ar_lib_payer_type - Payer type definitions

    • Defines standard payer categories (Medicare, Medicaid, Private, etc.)
    • Used for reporting and workflow management

Reliable Payer Identifiers​

Based on our analysis, the most reliable identifiers for payers in the PCC system are:

Primary Identifiers​

  1. payer_id

    • Unique numeric identifier
    • Used consistently across all tables
    • Most reliable for internal system references
    • Example: 4 for Medicare A

  2. payer_type + description

    • Combination of payer type and description
    • Provides clear identification of the payer's nature and name
    • Example: Medicare A with type Medicare A

  3. payer_code

    • Short alphanumeric code
    • Consistent across facilities
    • Example: MCA for Medicare A

Secondary Identifiers​

  1. provider_no

    • Facility's provider number with the payer
    • Varies by facility and may not be populated for all payers
    • Critical for claim submission

  2. submitter_id

    • Links to electronic claim submission configuration
    • Identifies how claims are submitted to the payer
    • May be shared across multiple payers

Payer Relationships​

The system tracks relationships between clients and payers through:

  1. ar_client_payer_info

    • Links clients to their payers
    • Includes policy numbers and effective dates
    • Supports multiple payers per client (primary, secondary, tertiary)

  2. ar_client_payer_authorization

    • Tracks service authorizations
    • Links to specific payers and includes authorization numbers
    • Includes date ranges for authorized services

Billing and Invoicing Services​

The PCC system includes comprehensive billing and invoicing capabilities:

Electronic Claim Submission​

The system supports electronic claim submission through:

  1. ar_lib_submitter

    • Defines electronic claim submitters
    • Contains information needed for electronic claim submission
    • Includes submitter IDs, receiver IDs, and other EDI parameters

  2. ar_invoice_claim

    • Stores claim data for submission
    • Contains all fields required for UB-04 and CMS-1500 claim forms
    • Supports electronic submission to clearinghouses

Clearinghouse Integration​

The system supports integration with several clearinghouses:

  • Waystar (formerly ZirMed)
  • Trizetto
  • Ability

These integrations allow for:

  • Electronic claim submission
  • Electronic remittance advice (ERA) processing
  • Claim status inquiries

Billing Workflow​

The billing process in PCC typically follows these steps:

  1. Charge Capture

    • Services are recorded as transactions in ar_transactions
    • Each transaction is linked to a client and payer

  2. Invoice Creation

    • Transactions are grouped into invoices in ar_invoice
    • Invoices are created by facility, client, and payer

  3. Claim Generation

    • Claims are created from invoices in ar_invoice_claim
    • Claim data includes all required fields for UB-04 or CMS-1500 forms

  4. Claim Submission

    • Claims are submitted to payers electronically
    • Submission is tracked through clearinghouse_exported_date

  5. Payment Posting

    • Payments are recorded as X or XR transactions
    • Payments are applied to invoices and reduce the balance due

  6. Adjustment Processing

    • Contractual adjustments are applied as CA transactions
    • Other adjustments may be applied as A transactions

  7. Secondary Billing

    • Remaining balances are billed to secondary payers
    • Secondary claims are created and submitted

  8. Patient Billing

    • Patient responsibility amounts are billed
    • Patient payments are tracked and applied

SQL Scripts for Payer and Billing Analysis​

We've created several SQL scripts to help analyze payer data and billing services:

  1. analyze_payer_data.sql: Queries to analyze payer data and identify reliable payer identifiers, including:

    • Payer type distribution
    • Payer code analysis
    • Provider number analysis
    • Payer usage in transactions
    • Client-payer relationships
    • Electronic claim submission analysis
    • Payer identifier consistency
    • Invoice and claim analysis by payer

  2. analyze_billing_services.sql: Queries to analyze billing and invoicing services, including:

    • Invoice analysis
    • Invoice transaction analysis
    • Electronic claim submitter analysis
    • Claim analysis
    • Billing calendar analysis
    • Clearinghouse export analysis
    • Billing service configuration analysis
    • Billing batch analysis

Recommendations for Payer Identification​

Based on our analysis, here are recommendations for effectively identifying and managing payers:

  1. Use payer_id for System Integration

    • When integrating with other systems, use payer_id as the primary identifier
    • This provides the most reliable and consistent reference

  2. Use payer_type + description for Reporting

    • For reporting and user interfaces, use the combination of payer type and description
    • This provides clear, human-readable identification

  3. Maintain Consistent Payer Codes

    • Ensure payer codes are consistently applied across facilities
    • Use standard codes like MCA for Medicare A, MCD for Medicaid, etc.

  4. Validate Provider Numbers

    • Regularly validate provider numbers for accuracy
    • Ensure provider numbers are properly formatted for each payer

  5. Monitor Payer-Client Relationships

    • Regularly audit client-payer relationships for accuracy
    • Ensure policy numbers and effective dates are current

Conclusion​

The PCC system provides robust capabilities for payer identification and billing services. By understanding the payer data structure and billing workflow, users can effectively manage their accounts receivable and optimize their revenue cycle.

The most reliable identifiers for payers are the payer_id, the combination of payer_type and description, and the payer_code. These identifiers can be used for system integration, reporting, and user interfaces.

The billing and invoicing services in PCC support the complete revenue cycle, from charge capture to payment posting, with electronic claim submission capabilities through various clearinghouses.