Adding and Configuring Payer Details

For each Payer you add to NikoHealth, you can configure:

This article goes over how to setup and manage Payer Details. If you need help taking the initial steps to add a Payer, visit our help article on this topic.

After adding a new Payer, you can configure the following Payer Details.

NikoHealth integrates with multiple clearinghouses. To start, choose the clearinghouse you work with and acquire the Payer ID for that clearinghouse. Once you add your Payers, please notify our team to begin the enrollment process by sending an email to payerenrollment@nikohealth.com.

This is the unique identifier your clearinghouse or payer assigns to your organization as the sender of electronic claims (and other EDI transactions). The Submitter ID is what gets populated in the EDI envelope to tell the clearinghouse “this file is coming from Provider X".

The Submitter ID identifies who is sending the claim and the Payer ID identifies where the claim is going.

Pricing Groups are basically labels that group your Payers/Plans under a shared pricing strategy so that the system knows which price option to use when it prices Orders and Invoices. Instead of building separate prices for every single Payer, you assign Payers to Pricing Groups (e.g., Medicare, Medicaid, Commercial, Retail) and then maintain your product/HCPCS pricing by group, which the pricing engine and pricing reports use to drive and analyze reimbursement.

Before you can add a Payer to a Pricing Group, you'll need to create the Pricing Group in Billing Setup. For more information, visit our help article on Pricing Groups.

You can store your own general ledger code for a Payer so that charges and AR tied to that Payer can be grouped correctly in accounting/Reporting (e.g., 1200-AR-MEDICARE, 1305-AR-COMMERCIAL). It doesn’t affect claim routing or EDI. It’s purely an accounting/finance identifier that shows up on Reports/exports (like Invoice Detail or Payer-based reports) so that finance can tie NikoHealth activity back to the correct GL buckets in your external system.

This is not required, but should be used if you're printing/mailing 1500 claim form as the address will appear on the document when printed.

Toggle Electronic Claims "ON" if this Payer will be enrolled in electronic claims. Be sure to add:

Payers set up to accept electronic claims are easily identifiable in your Billing/Invoice queue and on each specific Invoice. For more information, visit our help article on Submitting Invoices Electronically.

Toggle Electronic Eligibility "ON" if you can verify benefits for this Payer electronically via NikoHealth. The Electronic Eligibility ID is used for electronic insurance eligibility and should be the ID defined by the clearinghouse. In most cases, this ID will be the same as the Payer ID.

This applies to workman's comp claims. For those payers that accept electronic document attachments, the Attachment ID is used to electronically route the 275 attachment. For more information, visit our help article on Electronic Medical Attachments.

This setting applies to recurring rentals. If you have a rental in the system that is generating every month, you can toggle this preference "ON" and the system will auto submit the recurring rental Invoices.

When this is toggled "ON", NikoHealth automatically creates payments as soon as the ERA comes in. When it's toggled "OFF", the ERA comes in to the EOB/ERA queue with a status of "New", and waits for someone on your team to review and manually post the payment.

For more information on remittances in NikoHealth, visit our help article on EOB/ERA Remittances.

You can set the preference to transfer a remaining Invoice balance to the patient by toggling it on/off.

Select the appropriate payer type from the drop down selection. This must be properly defined to avoid any clearinghouse rejections.

Medicaid Carrier Code is a special, state-Medicaid-specific carrier ID that you store at the Payer level and use when Medicaid tells you they require a carrier code / Payer ID for coordination of benefits. Not all states require the use of a carrier code.

For more information, visit our help article on Medicaid as Secondary- Carrier Codes.

This is situational and should only be used when required by the Payer as an additional identifier.

Select the appropriate setting from the drop down. This is used to populate BOX 1 of the CMS 1500 form when printed.