How do I create an electronic billing payor?

For visits to be included on electronic billing claims, the service must be funded by an electronic billing payor.

To set up an electronic billing payor, go to Accounting>Accounting settings>Electronic billing payors and select add electronic billing payor.

In the dialogue, complete the required fields in the summary section.

Note that all electronic billing payors require a city and a phone number. For payors of institutional claims, the first name and last name fields must also be filled out for the payor.

Under funder specific information, select professional or institutional as the claim type.

Select electronic or manual as the export type. You should select electronic if you will be sending 837 files to payors through a clearinghouse and manual if you will be exporting the files out of AlayaCare to send to payors directly. Note that you will still be able to download and view the contents of 837 files if you select electronic as the export type.

After selecting electronic as the export type, you will be able to select a claim destination system. Depending on the destination system, this field may be automatically filled out based on what you selected as the EVV destination system.

To export Electronic Visit Verification (EVV) data to a state aggregator, you must also select an EVV destination system. Depending on the destination system, this field may be automatically filled out based on what you selected as the claim destination system.

Next, select a claim grouping methodology. The claim group methodology determines how visits will be grouped in service lines when multiple visits with the same bill code on the same date of service. You can select from the following options:

• Details with no modifier: each visit in the claim will be sent as its own service line.
• Details with modifier: if a second visit on the same date of service the same bill code will contain a 76 modifier.
• Group by date: all visits on the same date of service using the same bill code will be sent as part of the same service line.

Per the above options, please note the following:

• The 76 modifier will be added to the second visit of the date of service, provided that the 2 visits were included on the same claim. To have this happen, the details with modifier option needs to be selected at the payor level.
• A 76 modifier will not be sent to the second same date of service visit that falls on a separate claim.

Finally, enter the maximum number of service lines that you wish to allow on a claim for this payor in the service line limit field. For professional claims sent through the clearinghouse, the limit should be set to 50. It is recommended that you do not set the service limit under 50. 

Complete the required and optional fields in the provider information section.

Enter the provider name, provider tax ID, atypical provider identifier, provider taxonomy code, payor code, payor name, payor electronic transmitter identifier, national provider identifier, and provider electronic transmitter identifier. Enter a national provider identifier (NPI) and/or atypical provider identifier (API or MMIS) to send as the provider code.

You can hover over the icon to view more information about the field where available.

If Tellus Rendered Services is selected as the claim destination system, you must also enter a plan ID, program ID, and delivery system (FFFS - Fee for Service, MCOR - Managed Care Organization). 

Under billing information, select a billing frequency.

You have the following options:

• No frequency: during claim generation, all visits for the same client and funder on or before the defined cut-off date will be grouped on the same claim.
• Per day: during claim generation, all visits for the same client and funder on or before the defined cut-off date will be grouped into different claims for each day.
• Per week: during claim generation, all visits for the same client and funder on or before the defined cut-off date will be grouped into different claims for each day. For this frequency, you will also need to select a day of the week as the end of week. You will only be able to generate claims on this day.
• Per calendar month: during claim generation, all visits for the same client and funder on or before the defined cut-off date will be grouped into different claims for each day. Note that you will only be able to generate claims for this funder on the last day of the month.

Check the use bank option if you want claims to use and contribute to banked time for each bill code/client. If use bank is unchecked, claims will be rounded down for billing. See the section understanding the time bank to learn more about using the bank.

If necessary, you can also select a timely filing window of 30, 60, 90, 120, 180, or 365 days from date of service or no timely filing deadline.

Under claim configuration options, select how you want to send the referring provider name. You will be able to select from the following options:

• Send agency as referring provider (claim): the agency will be sent as the referring provider at the claim level. Information will be pulled from Settings>Agency information.
• Send agency as referring provider (service line): the agency will be sent as the referring provider at the service line level (loop 2420F). Information will be pulled from Settings>Agency information.
• Send client contact as referring provider (claim): a client contact will be sent as the referring provider at the claim level. Provider information will be pulled from the client contact with referring provider set as the provider type on the contact’s profile.
• Send client contact as referring provider (service line): a client contact will be sent as the referring provider at the service line level. Provider information will be pulled from the client contact with referring provider set as the provider type on the contact’s profile.
• Do not send: referring provider will not be sent on the 837.

Select how you want to send the rendering provider name. You will be able to select from the following options:

• Send agency as rendering provider (claim): the agency will be sent as the rendering provider at the claim level. Information will be pulled from Settings>Agency information.
• Send agency as rendering provider (service line): the agency will be sent as the rendering provider at the service line level. Information will be pulled from Settings>Agency information.
• Send client contact as rendering provider (claim): a client contact will be sent as the rendering provider at the claim level. Provider information will be pulled from the client contact with rendering provider set as the provider type on the contact’s profile.
• Send client contact as rendering provider (service line): a client contact will be sent as the rendering provider at the service line level. Provider information will be pulled from the client contact with rendering provider set as the provider type on the contact’s profile.
• Send employee on the visit as rendering provider (service line): the employee assigned to the visit will be sent as the rendering provider at the service line level. Note that the employee must have a rendering provider NPI entered on their profile.
• Do not send: rendering provider will not be sent on the 837.

For professional claims, you will also have the option to enter a supervising provider name, ordering provider name, and service facility and check whether it requires ambulance pick-up and drop-off location (yes or no) or whether you wish to send date of injury (yes or no).

You can select how you wish to send the supervising provider name from the following options:

• Send client contact as supervising provider (claim): a client contact will be sent as the supervising provider at the claim level. Provider information will be pulled from the client contact with supervising provider set as the provider type on the contact’s profile.
• Send client contact as supervising provider (service line): a client contact will be sent as the supervising provider at the service line level. Provider information will be pulled from the client contact with supervising provider set as the provider type on the contact’s profile.
• Do not send: supervising provider will not be sent on the 837.

You can select how you wish to send the ordering provider name from the following options:

• Send agency as ordering provider (service line): the agency will be sent as the ordering provider at the service line level. Information will be pulled from Settings>Agency information.
• Send client contact as ordering provider (service line): a client contact will be sent as the ordering provider at the service line level. Provider information will be pulled from the client contact with ordering provider set as the provider type on the contact’s profile.
• Do not send: ordering provider will not be sent on the 837.

For professional claims, you can select how you wish to send the service facility from the following options:

• Send agency as service facility at the claim level: the agency will be sent as the service facility for this payor at the claim level.
• Send agency service facility at the service line level: the agency will be sent as the service facility for this payor at the service line level.
• Send client as service facility – claim level: the client will be sent as the service facility for this payor at the claim level.
• Send client as service facility – service line level: the client will be sent as the service facility for this payor at the service line level.
• Do not send: service facility will not be sent on the 837 for this payor.

For institutional claims, you will also be required to enter an operating provider name, attending provider name, and service facility.

You can select from the following options for operating provider name:

• Send agency as operating provider (claim): the agency will be sent as the operating provider at the claim level. Information will be pulled from Settings>Agency information.
• Send agency as operating provider (service line): the agency will be sent as the operating provider at the service line level. Information will be pulled from Settings>Agency information.
• Send client contact as rendering provider (claim): a client contact will be sent as the operating provider at the claim level. Provider information will be pulled from the client contact with operating provider set as the provider type on the contact’s profile.
• Send client contact as operating provider (service line): a client contact will be sent as the operating provider at the service line level. Provider information will be pulled from the client contact with operating provider set as the provider type on the contact’s profile.
• Do not send: operating provider will not be sent on the 837.

Select from the following options for attending provider name:

• Send agency as attending provider (claim): the agency will be sent as the attending provider at the claim level. Information will be pulled from Settings>Agency information.
• Send client contact as attending provider (claim): a client contact will be sent as the attending provider at the claim level. Provider information will be pulled from the client contact with attending provider set as the provider type on the contact’s profile.
• Do not send: attending provider will not be sent on the 837.

For institutional claims, select from the following options for service facility:

• Send agency as service facility at the claim level: the agency will be sent as the service facility for this payor at the claim level.
• Send client as service facility – claim level: the client will be sent as the service facility for this payor at the claim level.
• Do not send: service facility will not be sent on the 837 for this payor.

When you select professional as the claim type, you also have the option to attach documentation to claims for the payor.

In the attach claim documentation field, select yes or no. Select the attachment report type and a transmission method (available on request at the provider site, by mail, electronically only, email, file transfer, or by fax).

Under 837 interchange control header segment, enter a sender qualifier, sender ID, receiver qualifier, and receiver ID. Hover over the icon to see which segments of the 837 these details will be sent in.

• Sender qualifier: will populate Segment ISA05 in the 837.
• Receiver qualifier: will populate Segment ISA07 & GS03 in the 837.
• Sender ID: Insert: will populate Segment ISA07 & GS02 in the 837.
  • Always use the value entered as the provider electronic transmitter identifier.
• Receiver ID: will populate Segment ISA08.

When Waystar is selected as the claim destination system, the fields in the 837 interchange control header segment section will be auto-populated with the correct values for Waystar. The sender qualifier will be set to ZZ, the receiver qualifier will be set to ZZ, and the receiver ID will be set to ZIRMED. If a provider electronic transmitter identifier has been entered, the provider electronic transmitter identifier will be set as the sender ID.

When sending directly to a payor, the payor usually provides these values in the payor companion guide.

When you are finished, click save.

Note that when editing an electronic billing payor, you will not be able to edit the claim type, EVV destination system, or claim destination system.