Payer Contract Management

1. Selection: Click 'Add New Contract'. Select the specific Insurance Company (Payer) and the corresponding Plan (Product Line) with which the contract is being established. 2. Term Definition: Define the contractual Start Date and End Date. 3. Service Categorization: Select the relevant Category (e.g., Inpatient, Outpatient, Diagnostics) from the dropdown menu to group services for initial configuration. 4. Rate Configuration (Service Management): Proceed to systematically select individual Services (or service codes) within the chosen category and define the following crucial financial parameters for each: * Patient Copayment/Responsibility: The specific amount or percentage designated as the patient's financial obligation. * Payer Reimbursement: The contracted rate or methodology for the Payer's liability for the service. 5. Finalization: Upon completion of service-level data entry, the contract is formally created, establishing the defined rates for the selected Payer and Plan.

Clicking on an individual contract provides granular detail, displaying the following core data points:

* Service Name: The nomenclature for the specific medical service. * Plan: The Payer's specific insurance product to which the contract terms apply. * Contract Tracking Identifier: A unique code or number shared between the Provider and the Payer upon mutual approval of the agreement, serving as a formal reference. * Approval Information: Status and specific details indicating formal ratification of the contract by the Payer. (Further functionality related to this is managed within the Payer Enrollment module.) * Payment Structure: The detailed, configured breakdown of Patient Copayment and Payer Reimbursement rates as entered during the configuration stage.

1. Template Selection: Choose the Reference Plan (the source contract) to use as the template. 2. Percentage Change Definition: Specify a Percentage Change (positive or negative) to be applied uniformly across all service rates in the new contract. 3. Application Scope: Define the recipient of the adjustment: * Apply to Both (Patient Responsibility and Payer Reimbursement). * Apply to Patient Responsibility Only. * Apply to Payer Reimbursement Only. 4. Data Persistence: Choose whether to apply the changes to the current page only or propagate the adjustments across all pages of the service list within the contract being created.

Import Procedure: The Entity Manager can download the structured data template, populate it with the required code translations, and upload the completed file. This process automatically generates the corresponding service contracts based on the mapped data.

Permissible Use Cases for Custom/Internal Code Mapping:

The import utility is designed for two specific, enterprise-level scenarios:

1. Custom Service Definition: The addition of a new, non-standard medical service not currently indexed within the core system database (a highly infrequent occurrence). 2. Systemic Internal Code Alignment: The bulk mapping of a comprehensive, existing Internal Code List to their equivalent Standard CPT Coding System counterparts, ensuring a seamless interface between the provider's operational coding and the payer's required claim codes.

Mandatory Precaution: Prior to all data uploads, users are required to meticulously review the embedded instructions and template structure to prevent processing errors and ensure data integrity.