Payer Rules: MAT Dosing

The Payer Rules tab allows users to create billing rules specific to each payer. This article is focused on MAT Dosing rules.

Required Permissions: You must be a Super Admin to add and edit payer and billing rules.

Creating a Billing Rule

Before you begin, you must create a payer rule. For detailed instructions, click here.

Note: MAT dosing payer rules are not designed to be used in conjunction with other billing rules. Adding more than one billing rule will result in payer rules not working correctly.

Once you've created a payer rule, click on the + Add Billing Rule button.
Select MAT Dosing from the Billing Rule Type drop-down.
There are essentially two ways to set up MAT Billing rules: Medicare and Non-Medicare (Medicaid, Commercial, Other Billing Types), where each of the Non-Medicare options functions the same.

Medicare

Let's review how to configure a MAT Billing rule for Medicare.
1. Select Medicare from the MAT Billing Type drop-down.
2. Next, search for the Codes that should be replaced and bundled.
3. Select your desired Billing Week. By default, this field is set to Mon - Sun.
4. Provider Type, Billing Period, and Minimum/Maximum Days cannot be edited to comply with Medicare MAT Billing Requirements.
5. After adding the Codes, add the following:
  1. Window Bundle Code: This is the code that will be billed instead of the original code when at least one window dose is billed for the patient.
    1. Choose First Day of Billing Week (Dispense) or Last Day of Billing Week (Dispense) from the Date of Service drop-down depending on your facility and state requirements
  2. Take Out Bundle Code: This is the code that will be billed instead of the original code when at least one take out dose is billed for the patient during that week and no window dose was billed.
    1. You make the date of service the first day of billing week by dosage date or the first day of the billing week by dispense date.
6. Included Codes: You can add ancillary codes that will be included with this billing rule. When the system looks at these codes, it will look for the services matching these codes from the whole week.
7. Click Update to save the billing rule.
8. You can add additional billing rules by clicking on the + Add Billing Rule again. To delete a billing rule, click on the red x next to the rule.

Non-Medicare (Medicaid, Commercial, and Other Billing Types)

Let's review how to configure a MAT Billing rule for non-Medicare payers. This includes Medicaid, Commercial, and Other Billing Types.

Choose MAT Billing Type, Codes, and billing information, and minimum/maximum days.
1. Select Medicaid, Commercial, or Other Billing Types from the MAT Billing Type drop-down.
2. Next, search for the Codes that should be included.
3. Next, select the Billing Period to Daily, Weekly, or Monthly. Daily is the most commonly used for non-Medicare MAT Billing.
4. When the Billing Period is set to weekly, select your desired Billing Week. By default, this field is set to Mon - Sun.
5. You will also need to set the Minimum Days the patient needs to be billed for before the bundle code will be triggered. For example: If you set this field to 2, the patient would need to be billed for at least two doses within the Billing Week to trigger the payer rule for bundling.
Next, set the bundle information.
1. Set the Bundle Window Code. This is the code that will be billed instead of the original code when at least one window dose is billed for the patient and the minimum days requirement is satisfied for the week. You can add up to 4 modifiers, as needed.
  1. Date of Service: When you choose Weekly and set your billing week, you can use the Date of Service field to indicate whether you want the date of service to be the first day of the billing week, or the dispense date.
2. You can also add a Bundle Take Out Code. This is the code that will be billed instead of the original code when at least one take out dose is billed for the patient during that week and no window dose was billed. You can add modifiers as well.
  1. Date of Service: The date of service will always be the first day of the billing week, but you can choose between the date that the take out doses were actually dispensed, or the first day of the billing week that the takeout dosages are for. If, for example, you dispensed take out doses for three weeks, choosing First Day of Billing Week (Dosage) would result in three dates of service corresponding to the first day of each billing week.
3. Next, set the Unbundled Window Code. This is the code that will be billed instead of the original code for window doses that do not meet the bundling requirements.
  1. Date of Service: As this date of service will always be the dispense date, edits to the Date of Service field are not possible.
4. Check the Do Not Generate Unbundled Take Out Doses box to prevent unbundled charges for take outs from generating on the billing audit tool report.
5. If you want to generate unbundled take out charges, you can specify which code should appear on the billing report using the Unbundled Take Out Code field. This is the code that will be billed instead of the original code for take out doses.
  1. Date of Service: If a you set a minimum days amount when you choose a weekly billing period, unbundled takeout codes will be applied if you have a patient whose number of take outs does not meet the minimum number of days. For example, if your minimum is five days and the patient only needs three take out doses, this is the code that will be billed. As in the Bundle Take Out Code example, Dosage Date would be the date each dose is meant to be taken, and Dispense Date would be the date that the take out medications were dispensed.
  2. If you choose Dispense Date, you will see checkboxes for Aggregate Unbundled Take Out Doses and Single Take Out Unit.
    - Aggregate Unbundled Take Out Doses will combine all the unbundled take out doses and sum the units.
    - Single Take Out Unit will aggregate and only display one unit.
If needed, add the included codes for ancillary services.
1. Included Codes: You can add codes for ancillary services that shouldn't generate separate billable items in the report.
If you have created a Daily billing code, there will be fewer fields.
1. When the billing period is set to Daily, you will only have Window and Take Out Code fields to complete.
Follow these instructions to enable Medication Quantity Billing.
1. You can also enable medication quantity billing by clicking on this checkmark.
2. Next, click + Add Medication.
3. Type in the name of the medication or scroll until you locate the correct medication. If you have selected the Enable Medication Quantity Billing checkbox, this list will only display medications that include a billing code and are from an enabled location.
4. Check the Replace Code box if needed, choose the replacement medication code and add a modifier if necessary.
5. Choose the correct type from the Quantity Type drop-down.
6. Calculated: If you select this option, the system will calculate the units based on the quantity that must be dispensed to make up 1 unit. Liquid medications will be calculated using mg dispensed. Non-liquid will be calculated using the dosage amount that was dispensed rather than the medication strength.
  - Enter the desired Dispensed Quantity/Unit and choose whether and how you wish units to be rounded.
    1. No Rounding: Units will not be rounded.
    2. Round Up: Units will always be rounded up to the nearest integer.
    3. Round Down: Units will always be rounded down to the nearest integer.
    4. Standard: Units will be rounded up or down to the nearest integer (e.g. 1-4 will be rounded up, 5-9 will be rounded up).
7. Dispensed: The system will apply units based on amounts dispensed. Liquid and tablets/capsules/dispersibles/etc. will be treated differently.
8. Choose whether and how you wish units to be rounded.
  1. No Rounding: Units will not be rounded.
  2. Round Up: Units will always be rounded up to the nearest integer.
  3. Round Down: Units will always be rounded down to the nearest integer.
  4. Standard: Units will be rounded up or down to the nearest integer (e.g. 1-4 will be rounded up, 5-9 will be rounded up).
9. Fixed: Regardless of the Medication Inventory Transactions dose strength/tablets, the system will apply the Units in the Quantity field to each dose line item and calculate the units in the bundle.
Save, add, and delete billing rules.
1. Click Update to save the billing rule.
2. You can add additional billing rules by clicking on the + Add Billing Rule again. To delete a billing rule, click on the red x next to the rule.