Service Rates track situations where expected or billed amounts deviate from the standard rate or when an agreement has been made with the payer or patient that requires us to override the usual rate for a service (these are called single-case agreements or SCAs).
Entering this information as a Service Rate in Avea gives users a reference so processed claims can be more easily reviewed and balanced.
Add a Service Rate
- Navigate to the Patient tab and click on the Patient name.
- Open the drop-down under Intake and click on the U/R quick link for the treatment episode in question.
- Click on the Service Rates tab.
- Click Add Service Rate.
- Complete the Add Service Rate fields.
- Service Rate Type: Select Insurance - Single Case Agreement, Standalone Authorization, or Private Pay. Private Pay is only an option for organizations with the Patient Billing feature enabled. The service rate type will impact which fields are included on this form.
- Start Date: Enter the date when the Service Rate starts. This is the first date the new rate can be billed.
- End Date: Enter the last date the specialty service rate can be billed.
- Facility: Set the facility. This determines which services are available.
- Service: Select the service that requires the special rate.
- Service Billing Profile: Select the service billing profile to which the service rate should apply.
- Payer: Select the Payer from the list of insurances added to the treatment episode. This field will be hidden for Private Pay service rate types.
- Override Facility Service Rate on Claims: Toggle On to use the Service Rate as the billed amount on the claim. Leave this toggled Off to update the expected allowed amount for calculating the claim balance to the Service Rate but bill the normal facility rate. Please review the Service Rate Override section for more information. This only applies to Insurance Service Rate Types.
- Rendering Provider: Select the provider rendering the service.
- Billing Provider: Choose whether you would like the Billing Provider to be the Practice or the Rendering Provider. The Rendering Provider can only be set as the Billing Provider if the Can Bill Insurance as Billing Provider toggle is enabled for the Rendering Provider profile.
- Unit Rate: The expected rate for a single unit of treatment.
- Notes: Optional for your reference.
- Click Add.
Service Rate Overrides
When a patient’s claims need to be billed with a non-standard charge amount for a service, use a Service Rate Override to dictate the new charge. Service Rate Overrides will only successfully set a claim charged amount if all the following conditions are met.
- Overrides Facility Service Rate on Claims is set to Yes in the Add Service Rate window.
- The Service Rate information must exactly match the utilization plan or attendance calendar configuration. This includes date range, facility, service, service billing profile, payer, rendering provider, and billing provider.
- If no information changes, one service rate override can be entered for multiple UR plans spanning different date ranges. The start date of the service rate would be the start date of the first UR plan for the service. The end date of the service rate would be the last date of the final UR plan for that service. If any information changes, the override will not occur for the service.
- Example: The rendering provider in the UR tab is Dr. Phillips. The rendering provider in the Service Rates tab is set as Dr. Smith. In this situation, this override will fail and the standard service rate will be charged.
- All rules impacting the claims agree with the information in the UR plan or attendance calendar and the Service Rates tab.
- Example: There is a claim rule set to change the billing profile to PHP - H0035 but the Service Rates tab and UR plan list the billing profile as PHP-H2036. This override will not occur for the service.
- The Unit Rate added in the Add Service Rate dialogue box must be greater than the rack rate (e.g., the unit rate is greater than the insurance contracted rate for the service). Rack rates are set within each billing profile in Practice Admin > Facilities. If the unit rate entered is lower than the rack rate, the override will fail.
- Tip: When service rate overrides are often needed for a particular service, make a new billing profile for this specific situation. The rate associated with the billing profile can be set to $1. This ensures that the rate set in the Add Service Rate dialogue will always be greater and the override will take. For assistance with this please see either, UR Required Services – Creating a New Billing Profile or Standalone Services – Creating a New Service for as Needed Changes depending on the service’s UR Classification.
How do Service Rates (Single Case Agreements) impact reporting?
- When a Service Rate is entered at the Patient-level (e.g., single case agreement), it will override the facility or payer rates in the Expected Amount field in reports such as the Claim Status Report (by Service Date or by Claim).
- In the Claim Status Report, you can use the filter Has Single-Case Agreement, so you can easily identify patients with a single-case agreement. This is useful to analyze whether the payer has paid what was agreed upon. Report results will display Yes or No, with Yes indicating the patient has a Service Rate (Single Case Agreement) added to their treatment episode.
- The Daily Census Report will also indicate if a patient has a single case agreement.