Getting Started
What is Payer Mapping and Why Is It Important?
When you upload claims into the OneSpot Claim Scrubber, the system first applies general rules to all claims. These rules ensure that each claim meets basic requirements, like having diagnosis codes for every line item.
However, payer-specific rules are just as important. These rules make sure that each payer's claims are processed correctly and according to their own unique guidelines. For example, you wouldn’t want Humana claims to be scrubbed using Blue Cross Blue Shield rules—and that’s where payer mapping comes in.
How Payer Mapping Works
In OneSpot, you’ll see an option to select a Mapped Payer for each of your payers. This selection is key to applying all payer-specific rules to the claims for that payer.
Once a Mapped Payer is selected, the option to further select Sub-Level Payers may appear. Sub-Level Payers allow the Claim Scrubber to apply additional scrubbing rules that are based on factors like your location, the plan type, or both.
Payer Mapping Example: Medicare
- When Medicare claims are uploaded, they are first scrubbed using general rules that apply to all claims.
- After your Medicare Payer is linked to our Medicare Mapped Payer, the system will apply payer-specific rules to your claims, like verifying that the Medicare Beneficiary Identifier format is correct—something that only applies to Medicare claims.
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If a Sub-Level Payer is selected the system will apply additional payer-specific rules that are unique to your jurisdiction, as determined by your Medicare Administrative Contractor.
Which Payers Should be Mapped?
You should map any payer whose claims you want to be processed using payer-specific rules. Mapping ensures that each payer’s claims are scrubbed correctly according to their unique requirements.
Payers in Your PMS vs. OneSpot Payer Directory
- Payers in Your PMS (Practice Management System): These are managed within your own system and basic payer details are uploaded to OneSpot through an Aging File or nightly sync.
- OneSpot Payer Directory: The OneSpot Payer Directory is managed by us; this directory includes both Mapped Payers and Sub-Level Payers. The directory is used for mapping purposes, ensuring that the right scrubbing rules are applied. Each payer in the directory is carefully researched, and specific rules are created just for them.