Payer Contracts
What each payer agreed to pay for the procedures you bill. Once an ERA posts, each of its lines is compared with the contract in force on the line’s service date. A line paid short goes to the Underpayments work queue and a line paid over to the Overpayments queue. Posting is never held.
This is not the Fee Schedule. The fee schedule is what the practice charges everyone; a payer contract is what one payer allows.
Who Can See It
Section titled “Who Can See It”Administrator and User, once a client is selected: the Payer Contracts tab of Pricing, under Setup in the sidebar. An Administrator also sees the Fee Schedule tab, which a User does not. An Administrator edits contracts; a User reads them and can Test a Rate. It needs the Remittances module.
The List
Section titled “The List”| Column | What it shows |
|---|---|
| Name | The contract |
| Applies To | The payer groups and plans it covers, and how many plans that reaches |
| Current Version | The version in force today and its dates, or the next one with the day it starts |
| Status | Where it stands, below |
| Rates | How many rates the current version holds |
| Tolerance | How far a payment may differ from the contract before it counts |
| Updated | When it last changed, and by whom |
| Status | What it means |
|---|---|
| Draft | It has no version or covers no plan yet, so it compares nothing |
| Scheduled | Assigned, but every version starts after today |
| Active | Assigned, with a version in force |
| Expired | Past its termination date. Lines dated before then are still compared |
The Insurance Plans and Payer Groups lists show a Contract column once a contract is assigned, naming the contract each plan or group follows; a plan covered through its group says “via group”.
The Contract Page
Section titled “The Contract Page”The Terms card holds:
| Term | What it does |
|---|---|
| Lesser of Charge | When the billed charge is below the rate, the charge is expected instead. Most contracts pay the lesser of the two |
| Tolerance | A line counts as underpaid or overpaid only beyond this margin: the amount, or the percent of expected, whichever is larger. New contracts start at $1.00 and 0% |
| Terminates | Lines with service dates after this day aren’t compared |
| Notes | Free text |
An Administrator edits the terms in place and saves them from the bar that appears.
Applies To lists the payer groups, with the plans each one brings, and the plans assigned directly. A plan assigned directly takes this contract even when its group has another. A plan in the group that follows a different contract is named, with a link to it.
Versions lists the contract’s dated rate sheets. The version a line uses is the latest one starting on or before its service date.
The Version Page
Section titled “The Version Page”| Column | What it shows |
|---|---|
| Procedure | The procedure code and its description |
| Modifier · Rendering Provider · Location · POS | What the rate is for, or Any |
| Rate | The amount the payer allows |
| Basis | Per unit (rate × units billed) or Per line (the rate, whatever the units) |
| Source | Manual, Imported or Copied |
When several rates match a line, the most specific one wins, the same way the Fee Schedule picks a price. Export… and Import… in the table menu move a version’s rates as a CSV file with the columns Code, Modifier, Provider NPI, Location, POS, Rate and Basis.
Actions
Section titled “Actions”| Action | What it does | When it is offered |
|---|---|---|
| New Contract | Creates a contract with a first version named for this year, optionally copying another contract’s current rates | Administrator only |
| Edit Terms | Moves to the Terms card so you can change it in place | Administrator only |
| Assign Plans and Groups… | Chooses what the contract covers. A plan or group another contract already holds is greyed, with Follows ‘{contract}’ naming it | Administrator only |
| New Version | Creates a version, empty or copied from another with Change Rates By (%) | Administrator only |
| Edit Version | Renames a version, or changes its start date while it is Upcoming | Administrator only |
| Add Rate · Edit · Delete | Manages the rates of a version | Administrator only |
| Delete Version | Deletes a version | Administrator only, and only while the version is Upcoming |
| Export… · Import… | Moves a version’s rates as a CSV file | Export for everyone who can see the page; Import for an Administrator |
| Test a Rate | Shows what the contract expects for a plan, date, code and units, and why | Everyone who can see the page |
| Delete Contract | Deletes a contract | Administrator only. Refused once an ERA line was compared with it; set a termination date instead |
On a Remittance
Section titled “On a Remittance”After a remittance posts, each Service Lines row shows a second line under Allowed: −$27.00 vs contract, +$42.18 vs contract, at contract, no rate, no contract or not compared. Select it to see how the expected amount was found: the contract and how the plan matched it, the version, the rate and the rows that lost, the units, the lesser-of check, what the payer allowed and the tolerance. Denied lines, secondary payers, reversals, capitated and self-pay plans are not compared.
The Two Queues
Section titled “The Two Queues”Underpayments holds one item per posted ERA with a line paid short. Choose Accept with a reason, or Request Reprocessing or Appeal Underpayment with a date to check back. No money moves: the payer’s adjustment stays posted, and a corrected ERA that pays the contract closes the item as Recovered. When other items in the same queue were short-paid the same way, a notice offers Show All, which filters the queue to that plan and code so you can act on them together. Items in other days’ queues are not counted.
Overpayments holds one item per posted ERA with a line paid over. Choose the outcome under Resolution, then select Resolve; the likely one is already chosen. Record Refund records the money returned and its matching adjustment, so the claim stays at $0.00: enter Amount, Method, Reference and Refunded On in the bar. Paid by check or EFT it needs a reference. Offset on a later ERA needs none and posts nothing: the payer’s later ERA takes the money back and posts the recovery. Await Takeback waits for the payer to recoup it until Check Back On, and is unavailable with fewer than 14 days left. Keep closes it with a reason. For Medicare and Medicaid the item shows Refund By, 60 days after the overpayment was identified; Start Investigation pauses that clock for up to 180 days while you look for related overpayments, and Finish Investigation resumes it with the days that were left.
States
Section titled “States”- No Payer Contracts Yet on an empty list, with New Contract for an Administrator.
- No rates in this version yet. on an empty version.
- Couldn’t load payer contracts. or Couldn’t load these rates. with a retry.
- Blocked - without the Remittances module the screen is not in the sidebar, and a saved link to it says the module is not part of your plan.
Related: Fee Schedule · The Remittance Page · Work Queues