Configuring payor programs for multi-payor billing

If you need to bill more than one payor for a client’s services and premiums, you can create a payor program on the client’s profile. A payor program allows you to create a series of rules at the client level for determining which payors are invoiced for what portion of a client's billable items in a billing period.  

Each payor program for a client contains a set of informational fields and benefit rules referred to as a policy or contract, depending on the type. The benefit rules determine how much will be billed to the payor on the policy/contract. 

You can create different versions of the benefit rules on a policy or contract with different effective dates or start and end dates. The dates of different policy/contract versions cannot overlap with one another. 

The payor on the policy or contract is the bill-to party who will be invoiced for a portion of the billable items dictated by the rule set on the policy/contract. The guarantor is the bill-to party who will be invoiced for the remainder of the invoice balances after the program rules have been applied to the billable items. 

After you have created your payor program, you must attach it to any client services or billing premiums for which the rules on the program should apply. When adding a program to a service or client billing premium, you must also select a rating funder. This rating funder will use the associated bill codes to determine the rates that will be used to bill for the service or premium during the invoice generation process. 

Once items are approved and you begin the invoice generation process, the system will apply the rules on the payor program using the rates associated with the rating funder and generate the invoices for the different bill-to parties. 

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What types of payor programs are available?

There are different types of payor programs. The type determines the kinds of rules you can set to determine how to split an invoice during the billing process. The type that you select for a payor program will dictate which rule fields and informational fields will be available for completion when adding a policy or contract to a client’s profile.  

The following types of payor programs are available to enable upon request:

• Long-term care insurance
• Co-payment
• Split percentage
• Co-contribution
• Coordination of Benefits

The table below provides an overview of the major differences between the types of payor programs currently available in AlayaCare:

Type	Program characteristics
Long-term care insurance	Ability to set benefit rules using a term and limit on policies Term types available: amount or percentage Lifetime maximum available as term and limit frequencies More than policy can be added to a program and sequenced in the desired order Deductibles can set on policies (as an amount or number of calendar or service days) Premiums must be 100% covered by either the payor on a policy or the guarantor Funder selected as the guarantor must be client individual The program can be versioned
Co-payment	Ability to set benefit rules using a term and limit on contracts Term type available: amount Only one contract can be added to a program, but contracts can be deleted or versioned Deductibles can be set on contracts (as an amount or number of calendar or service days) Premiums must be 100% by either the payor on a contract or the guarantor Funder selected as the guarantor can be either funder individual or client individual The program can be versioned
Split percentage	Ability to split the cost of billable items based on the distribution percentage set for each payor on the contract Ability to set different guarantors at the program and contract levels Premiums can either be 100% covered by a payor or contract guarantor or split according to the distribution percentage set for each payor Funders selected as guarantors (contract and program level) can be client individual or funder individual The program can be versioned
Co-contribution	The co-contribution payor can either be the guarantor or a second payor Ability to create a service at any time using the program that is billed by a payor while billing the guarantor 100% of the client’s service costs Ability to set a limit on the payor contribution Selected premiums can either by covered in full by the payor or the guarantor Funder selected as the guarantor can be client individual or funder individual The program can be versioned

To learn how to set up a payor program for multi-payor billing, select a program type below:

• Configuring long-term care insurance payor programs
• Configuring co-payment payor programs
• Configuring split percentage payor programs
• Configuring co-contribution payor programs

After configuring a payor program, you will need to attach it to a service or billing premium. To learn more, see Setting a funder methodology for a service or a client billing premium.