Adding and Configuring Payer Rules

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

This article goes over how to setup and manage Payer Rules. If you need help taking the initial steps to add Payer Details or Payer Plans, visit our help articles linked above..

Payer rules in NikoHealth let you turn each Payer’s requirements and internal workflows into consistent, automated system behavior. When set up thoughtfully, these rules help ensure claims are built correctly the first time, reduce manual checks, and give your team a predictable billing process across payers.

You can set up Payer rules for a variety or reasons and needs.

Below, we explore each Payer Rule option further.

Creating a prior authorization rule in NikoHealth helps ensure that the system automatically validates whether a prior authorization is required for specific services or products. This process can be applied to individual Payers or specific Payer Plans, and is designed to automate the tracking and handling of authorizations during the Order process and the Invoice (claims) process. Learn more about creating Payer rules for prior authorization.

A CMN (Certificate of Medical Necessity) Payer rule let's the system know exactly which HCPCS codes, and for which Payer/Plan, require a CMN, and can enforce that automatically. When a CMN rule is in place, NikoHealth will:

By default, when automatically creating an Invoice, the system puts each unique item delivered on its own service line.

The Combine Line Items Payer rule tells NikoHealth to roll up multiple Invoice lines with the same HCPCS code into a single service line on the Invoice/claim, summing the units (and associated charge) at the Invoice level. This is typically used for Payers that don’t want separate lines for each fill/delivery, and instead expect one consolidated line per code for the billing period. (ex: monthly supply billing where all E1390 lines should appear as a single E1390 line with total units).

This rule can be set for all codes or for specific HCPCS codes where the Payer requires combined billing.

The Compliance Payer Rule is used mainly for PAP (CPAP/BiPAP) therapy, and it tells NikoHealth to automatically check whether a Patient has met the Payer’s usage/compliance requirements before letting an Invoice go through.

The Compliance rule can be tied to a Payer/Plan and specific HCPCS codes (e.g., PAP devices/supplies). You'll define the thresholds the Payer requires, including Evaluation Period, Best Usage Period, Minimum Usage Per Day, and Percentage. NikoHealth then uses the Patient’s therapy/usage data to decide if they are compliant. If not, the related Invoice is automatically placed on hold for non-compliance instead of being billed and denied later.

The Deductible Hold Payer Rule lets you tell NikoHealth: “For this Payer/Plan, don’t let Invoices go out until the Patient has met at least X amount of their deductible.”

When configuring the rule, you'll set a deductible threshold amount. When an Order/Invoice is created for this Payer, and the Patient has not met the threshold, NikoHealth puts the Invoice into a "Deductible Hold" status instead of sending it on to billing/EDI.

Once the Patient’s deductible is considered met for this Payer (based on updated eligibility/benefits and your rule), Invoices on "Deductible Hold" can be automatically released to a billable status. This way, your team doesn't have to manually track “is it time to start billing yet?”

This Payer rule is mainly used for Payers like Medicare, or high-deductible commercial plans, where you want to intentionally delay billing until the Payer-side deductible is satisfied. NikoHealth can enforce that policy consistently instead of relying on someone to remember who’s “still in deductible season.”

The HCPCS Substitution Payer Rule lets you tell NikoHealth, “For this Payer/Plan, bill with a different HCPCS code than the one tied to the Product/Order.”

You'll choose the original HCPCS code, and then designate a substitution, telling the system: "when you see {Original HCPCS}, substitute {HCPCS Substitution} for this Payer/Plan.

You can also choose to apply the rule only at the Invoice/claim level, so that the Product and Order can still use your original HCPCS internally, while the outgoing claim shows the payer-specific code.

This is especially useful when a secondary Payer requires a different HCPCS than the primary Payer. It's also useful when a Payer wants a legacy/alternate code, so that you don’t need duplicate products or manual recoding— NikoHealth does the swap for you.

Assigning a Playbook Rule to a Payer. Once you have created a playbook template you will need to assign the playbook rule to a payer. For more information, visit our help article on Assigning a Playbook Rule to a Payer. If you're new to Playbooks, start with our help article on Creating Playbook templates.

It is safe to assume that all products/services require a prescription no matter what insurance the patient has, however there could be some exceptions.

Prescription rules are for HCPCS that don’t require an actual prescription. Once you add the appropriate HCPCS and save, your invoice will not flag the item if no prescription is entered/received.

Some Payers require a separate rendering provider for billing based on the HCPCS code. When a new invoice is generated, if there is no Rendering Provider listed the system will flag the invoice as such.

By system default if you were to deliver two items on the same date of service that were both designated with a rental price option, upon completion of the order a single invoice would automatically create with both items on separate service lines.

In certain cases, you may want to split the rental items delivered on two separate invoices.

For example if you delivered oxygen and a ventilator to a patient but did not want to hold the entire invoice from being submitted due to documentation requirements such as a CMN outstanding, you could create a rental rule for a specific payer indicating which HCPCS codes cannot be combined with other items on an invoice.

In this case, when the system generates the invoice it will create two invoices with the individual item on each.

If you are supplying patients with ongoing disposable supplies creating resupply payer rules will help streamline your resupply order workflow and reduce denials for frequency limitations.

The frequency of when a payer may reimburse for supplies varies according to the product dispensed. Many payers do follow Medicares replacement schedule however it is always recommended you verify coverage criteria with your payer.

By creating a resupply rule, you can tell the system how often specific HCPCS can be supplied. You can make this rule payer and or plan specific.

If a resupply rule is defined, it will reflect the eligibility in the patients resupply program for those HCPCS. In addition if an order is created with an item that exceeds the frequency eligibility for the patient, the order will automatically be tagged with "resupply limit" indicating to the user that further review must be taken.

For more information, visit our help article on how to Setup Payer Rules for Resupply.

By default, the Service Location on an Order is used as the "facility address" that gets populated on claims (Box 32 on the CMS-1500 and in the 837P EDI file). The Service Location Payer Rule allows you to change this default behavior at the Payer level, and control which address NikoHealth sends as the service facility for a specific Payer.

The rule allows you to choose between:

Always Report NPI Option

It's important to note that this Payer Rule affects how information is reported on the claim only. It does not change the Service Location stored on the Order, or in your Corporate Setup.

If you delivered a specific quantity of a single product by default, when NikoHealth automatically creates the Invoice, it puts the item delivered with the total quantity on a single service line. With this "Split Line Payer Rule" enabled, you can split the total item count delivered with the same HCPC code on multiple service lines with a quantity of 1.

For example, if you delivered a quantity of 5 of an item, the Invoice will generate with 5 separate service lines.