Setting Up Payment Rules for Electronic Remittances

To simplify the remittance posting process, you can create company-level insurance payment rules to automatically adjust or write off underpaid claims. When a remittance is downloaded to Eyefinity Practice Management, the payment rule created for its carrier is applied to any underpaid claims in the remittance, which the system then automatically adjusts or writes off according to the rule. For more information on the Electronic Remittance Advice feature in Eyefinity Practice Management, see Processing and Posting Electronic Remittance Payments (ERA).

  • Each carrier can be associated with only one payment rule.
  • Payment rules are applied to remittances only when the remittance is initially downloaded.
  • Payment rules are not applied to the following:
    • External claims
    • Manually processed claims
    • Overpaid claims
    • Remittance adjustments
    • Line items with nonpayable statuses such as On Hold, Ready to Bill, Bill to Patient, and Canceled

  • You can review claims adjusted by insurance payment rules in the following locations in Claims Management:

This section includes the following topics:

Creating Insurance Payment Rules

  1. From the menu, select Billing & MVC and then Payment Rule Setup.
  2. Click Add Rule.
  3. In the Add New Rule window, select the Carrier.
  4. Select whether the rule applies to an entire claim or only to a claim line item.

    If you select Claim:

    • If any line item is overpaid, the payment rule is not applied to the claim.

    • If multiple line items have the same procedure code (such as V2799 for miscellaneous items), the payment rule is not applied to the claim.

    If you select Line:

    • If a claim has overpaid and underpaid line items, the payment rule is applied only to the underpaid items.

  5. Enter a dollar range for the outstanding balance (for example, 0.00–5.00). The first value in the range must be less than the second value.

  6. Select whether the rule creates an adjustment or a write-off, and select the reason for the adjustment or write-off from the associated drop-down list.

  7. Click Save.

    The new rule appears in the Active Rules table.

Searching for Active Payment Rules

  1. From the menu, select Billing & MVC and then Payment Rule Setup.

  2. If you know the carrier associated with the rule you want to find, select it from the Carrier drop-down list to filter your search results.

    If you do not specify a carrier, the search returns all the active payment rules.

  3. Click Search.

    The active payment rules that match your search criteria are listed in the Active Rules table.

Editing a Payment Rule

To change a payment rule, click the rule's Edit icon in the Actions column of the Active Rules table.

  • If the rule was used, it is inactivated, and the edited version becomes active. The inactive version is not removed from claims to which it was applied; the active version is applied only to remittances downloaded after it was saved.
  • If the rule was not used, your edits apply to the current version, which remains active.

Deleting a Payment Rule

To delete a payment rule, click the rule's Delete icon in the Actions column of the Active Rules table.

  • If the rule was used, it is inactivated but not removed.

  • If the rule was not used, it is removed.

Copying a Payment Rule

You can copy active payment rules from one carrier to create new rules for other carriers.

  1. From the menu, select Billing & MVC and then Payment Rule Setup.

  2. Find the rule you want to copy. See Searching for Active Payment Rules.

  3. In the Actions column of the Active Rules table, click the Copy icon for the rule you want to copy.
  4. In the Copy Payment Rule window, select the carrier to which you want to copy the payment rule. You can select multiple carriers.
    Carriers with active rules do not appear in the To drop-down list. You cannot copy a payment rule to a carrier that already has an active rule. Delete the active rule before proceeding. See Deleting a Payment Rule
  5. Click Save.

    The rule is added to the Active Rules table for each carrier you selected.

Viewing Active and Inactive Rules in the Payment Rules History

All payment rules are active by default. They become inactive if you try to edit or delete them after they have been used. You cannot directly change a rule from active to inactive.
  1. From the menu, select Billing & MVC and then Payment Rule Setup.
  2. If you know the carrier whose rule history you want to find, select it from the Carrier drop-down list to filter your search results.
  3. Click the History link above the rules table.

    The payment rules table is updated. If you specified a carrier, the table lists all the active and inactive insurance payment rules for that carrier. Otherwise, it lists all the active and inactive insurance payment rules.