Access and Set Up the Billing Matrix

Access the Billing Matrix

1. From the Facility Record, click Additional Information on the vertical toolbar; the Additional Information screen displays.
   
   

2. Ensure all Pricing Options are blank. The Facility/Unit Billing Matrix replaces the Pricing Options.

3. Click Billing Matrix on the vertical toolbar. The Billing Matrix screen displays.
   
   
   
   The Facility/Unit Billing Matrix has six columns. Payor, Price Plan, Charge Account, Exclusions, Exceptions and Continue. Click New to create a new entry. Click Edit to modify an existing entry.
   

   • Payor: Indicates the name of the payor established in the Facility Unit Payor List. Enables the user to select payor class by name rather than Price Plan.
     
   • Price Plan: This is the Price Plan assigned to this payor. The Price Plan sets parameters for calculating price, third party adjudication and drug order filling edits. This field can be left blank to use the third party on the patient's insurance record.
     
   • Charge Accounts: This is the charge account assigned to this particular payor. Establish charge accounts according to each Facility/Unit. Patient Records must be established for each charge account that will be used. The charge account field may be left blank on the Billing Matrix. The system will use the charge account listed on the Patient Record. If no charge account is listed on the Patient Record, the system will use the patient as the charge account.
     
   • Exclusions: A list of items that are excluded from coverage for this payor. Exclusions can be: Drug Description(s), NDC Number(s), Specific Therapeutic Class(es), Drug Categories (user Defined), Non-Medicaid items, Stock Supply and Hospice Drugs.
     
   • Exceptions: A list of exceptions to the exclusions list. For example, a payor does not cover OTC drugs except for Aspirin 81 mg. The best way to address this exception is to show the OTC drug category as the exclusion and the GCNSEQ# for Aspirin 81 mg. as the exception.
     
   • Continue: This identifies the next payor entry to be used in a coverage cascade. Add a New Payor to the Facility Payor List.

    

Add a New Payor to the Facility Payor List

1. From the Billing Matrix screen, click New. The Edit Billing Matrix Item window displays.
   
   

2. Click the Add Payor hyperlink; the Payor List displays.
   
   
   

3. Use the Next icon to proceed to the next page. Select a blank Payor field and type in the Payor Code and Payor Description.

4. Click Save. The system adds the new payor to the list.

5. To delete a payor from the payor list, click the Payor and Description fields and clear the information. Click Save.

Adding an Existing Payor to the Facility/Unit Billing Matrix

Key Functions

Price Plan: Price Plan to use; if left blank, the patient's Price Plan is used.
Charge Account: C-acct to use; if left blank, the patient's c-acct is used.
Exclusions: Items to be excluded from this payor.
Exceptions: Items that are exceptions to the exclusions; they stay on this payor.
Continue: The payor that the exclusions move to next.

1. From the Facility Billing Matrix, click New; the Edit Billing Matrix Item window displays.
   
   

2. Click the Add Payor hyperlink; the Payor List displays.
   
   

3. Press the corresponding function key to add the Payor. The Payor Description displays.
   
   

4. Add the Price Plan, Charge Account, Exclusions, Exceptions and Next Payor as needed. Click Save.

Return to Set up the Facility/Unit Billing Matrix