When billing for DME, pricing models can become quite complex due to a variety of factors including insurance requirements, rental versus purchase options, and various payer-specific rules. The NikoHealth system lets you to create Price Options that allow your system to automatically select the most appropriate pricing for items dispensed.

We will walk you through how to set up Price Options in NikoHealth.

Note: Prior to setting up your Price Options, it's important that you understand how different pricing models work in DME and how to best streamline your pricing process. We strongly suggest you review our article on Pricing Models in Billing for DME prior to setting up your Price Options.

There are 3 different TYPES of Price Options you can create in NikoHealth:

Each Price Option type can be based on HCPCS codes, products, and/or payers.

By properly configuring these options, the system will be able to automatically select the most relevant pricing based on location, payer, product, and default settings, streamlining your billing process.

To create a price option, go to the Management section and navigate to:

Management > Billing Setup > Pricing

From here, you can either edit an existing price option or add a new one. Please note that you must have the necessary user permissions to perform this action.

To create a new Price Option, click the blue plus sign. The Pricing Details screen will open.

Each price option must be linked to an HCPCS code (Healthcare Common Procedure Coding System) that corresponds to the item or service you are pricing.

You can assign a Pricing Group to your price option that allows you to apply the same price across multiple payers, creating a one-to-many relationship between pricing options and payer plans. Pricing groups can be a powerful tool when you want to consolidate your price options and simplify your billing process. By linking payers and price options under a single pricing group, you can simplify your workflow and avoid creating individual price options for each payer. Once set up, the system will automatically apply the appropriate price option based on the criteria you define, saving time and reducing errors in billing. For more information on Pricing Groups, please visit our help article.

If you have multiple locations with different pricing, you can set location-specific pricing by selecting the location where the price will apply. When a location is selected, the system will apply only the location-specific price options for that location. This feature is useful if your organization has different pricing at different locations (e.g., different regions, branches, or departments).

You can create price options tailored for specific payers or payer plans. This is useful for customized pricing based on insurance plans or specific agreements.

While you can set generalized pricing for a HCPCS code, you can also specify a product-specific price if desired. This allows for more granular control over pricing for particular items.

The charge field is used to specify the billed amount, which will appear as the total billed on an invoice or claim.

The allowed field is used to specify the expected or contracted amount with a payer. This amount will appear on the invoice/claim and can be included in revenue reports to track anticipated reimbursements.

You can add any relevant modifiers to be applied when using this price option for billing. These modifiers will automatically be appended to the billed charges on the claim whenever this price option is used. Learn more about modifiers here: Modifiers in DME Billing

This field specifies the date when this price option becomes effective. If a future effective date is entered, the price will not apply to any services provided before that date.

This field indicates the expiration date of the price option. Once expired, the price option will no longer apply to any services provided after this date.

This field specifies the number of billable units to be applied for this price option. In most cases, this value will be 1. However, if the billed charge applies to a quantity of 2, you can enter the appropriate value here. Learn more about Billable Units here: Price Option Billable Units

When this option is enabled for a price option, the system will apply the allowable Medicare reimbursement rates based on the current Medicare Fee Schedule, and it will also take into account several specific conditions for calculating the appropriate rates. These conditions include factors such as former Competitive Bidding Area (CBA) status, rural vs. non-rural areas, capped rental items, and the KJ modifier.

If your business needs to collect sales tax on products or services sold, our automated sales tax functionality calculates sales tax based on your customer's state, county, city, and even district tax rates. For fully taxable products you can choose to enable sales tax calculation by selecting the sales tax check box on the individual price option. When sales tax is enabled, if this price option is selected the customers delivery address is used to calculate appropriate state, county, city and district taxes.

Once you've completed all the necessary fields, Save the new price option. Your new price option will appear in the Pricing section of NikoHealth. You can review the pricing details and make any necessary edits by selecting the price option and making updates directly in the system.

Rental Price Options

Modifiers

Billable Units

Medicare Fee Schedule

Sales Tax

Bulk Import of Price Options