This article describes how to set up a client Chart Items for waterfall billing if the first payer only partially pays or denies. For this to work for a client with a plan, both payers have to appear on identical services on the plan goals page. Note that only Admins or for folks with Admin Billing permissions will be able to make any changes related to Claim Items.
General ChartItem Setup
- Ensure both payers are active with current dates for the client, and with the priorities indicating the order that you want them to bill.
- Before approving a chart item for the client make sure both payers are listed at the bottom of the chart item in the desired order.
- The first payer will bill normally, and if it denies or is partially paid then you can use the "Next Payer" option from the claim item to bill the next payer.
- Whatever
the Due Amount is on the first claim item is the amount that will be
billed the second payer, so before you Next Payer you should add a
writeoff or adjustment claim item result if you want to change the amount billed the
second payer.
- If everything is working the claim item should show up immediately as a Posted claim item with the desired next payer listed on the new claim.
Troubleshooting
Q: What do I do if a chart item was approved before a second payer was listed at the bottom of the chart item?
A: To
fix this you have to go to each chart item, do an Update Payer, and verify
that the second payer shows up. Once both payers are listed on the
chart item, then Next Payer should work on the claim item. If everything
is working correctly then both payers should show up on the client's
chart items without you having to always Update Payer.
Q: OKHCA is always denying. What may fix this problem?
A: Current understanding is that OKHCA is a
payer of "last resort", which means if the client is eligible for
another payer you have to bill the other payer first and then OKHCA. If a client has more than one payer and you bill OKHCA first then it will always deny. To fix this, set the other payer to be billed first by changing the priority on the client payer to first, and the OKHCA payer priority to second.
Q: The secondary payer isn't paying. Am I missing something?
A: A secondary payer usually requires proof that the primary payer was billed first. Details may vary by payer, but usually you have to log into the secondary payer's website and upload a remittance advice, or something, for each claim to prove that you billed the primary first.
- See our video Adding a Service Plan for more information on service plans.
- For more information on ClaimItem write-offs and adjustments, see our article Manually Reconciling Claim Items.
- The Rebilling Claims Due to Client Payer Changes article will have more information for you on the Update Payer action.
- More information about working with Plan Goals can be found at Client Treatment Plan Modifications.