Payer Rules Setup

Payer Rules are a set of instructions for RevFlow to follow when Electronic Remittance Advices (ERAs) are released and claims are posted. They include the payment code, adjustment code, and transfer rules. When you release a payment and the line turns red, this indicates the payer rules have not been setup. Check out the Payer Rules Setup chapter of the Release ERAs video.  Payer rules must be established in RevFlow for each payer prior to releasing the first ERA. Sometimes an already-established payer will submit payment with a different Payer ID; you will need to add the new payer ID for that payer.

Accessing Add/Edit Payer Rules

Open the Payment menu and select Add/Edit Payer Rules.

EOB Payer Rules - Upper Section

The EOB Payer Rules page is divided into two sections. In this section, you make your selections for the payer rules using the drop-down menus. 

  1. Payer: You must make a selection from the Payer drop-down list. You will not be able to establish payer rules for a payer until you receive your first ERA from that payer, allowing RevFlow to assign them a payer number. Each payer that sends you an ERA will appear on this list.
  2. Description: This field is optional. Type a description for the payer payment rules.
  3. Ins. Class: Select the appropriate insurance class for the payer.
  4. PayCode: Select the payment code that will be used for auto-posted payments.
    1. For most payers, select PCON.
    2. For Medicare, select PMCR.
    3. For Medicaid, select PMCD.
    4. For Worker's Compensation, select PWCI.
  5. AdjCode: Select an adjustment code that will be used for auto-posted adjustments.
    1. For most payers, select AIWO.
    2. For Medicare, select AMCR.
    3. For Medicaid, select AMCD.
    4. For Worker's Compensation, select AWCA.
  6. Transfer Check Boxes: Select what should be done with the remaining balances for claims processed by this payer. For most payers, select Transfer to Next Payer.

EOB Payer Rules, Lower Section

The lower section of the page displays payer rules already created. When you click on  Edit, the information related to that payer ID displays in the upper section of the EOB Payer Rules page. You can then make any changes necessary and click Save.

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