Set up a payor
RehabAlpha is still under active development. It is not yet HIPAA compliant and should only be used with dummy data.
A payor is the person, company, plan, or program responsible for paying for all or part of a patient's care. Payors are used when you add patient coverages, set up billing episodes, track authorizations, and review billing information.
Before you start
You need:
- An organization. See Set up an organization.
- For manual setup, Owner or Admin access, or Custom access with Create permission for Payors. File imports require Owner or Admin access. PointClickCare refresh also permits managers of the selected facility.
Medicare Part A and Medicare Part B are pre-loaded in new organizations, so you do not need to create them manually.
Choose a payor setup workflow
There are three ways to set up a new payor in RehabAlpha:
- Manual setup: Add the payor directly in RehabAlpha. Use this workflow when you are entering one payor or want full control over the payor name and type as you create the record.
- Import: Upload one or more files with payor information using the import tool. This is explained in Import data.
- PointClickCare refresh: Import supported payors from patient coverage information through a facility integration.
The steps below explain the manual setup workflow.
Manually create a payor
- Open Payors.
- Click New payor.
- Enter the payor Name.
- Select the payor Type.
- Select the Payment model.
- Review the required Yes or No answers under Payor rules. Add AI compliance guidance, tags, or notes when helpful.
- Click Save.
RehabAlpha creates the payor and adds it to the organization's payor list.
The payment model type defines one reimbursement or benefit lane:
- PDPM case-mix per diem uses a daily case-mix calculation.
- Custom fee schedule uses an uploaded organization fee schedule.
- Duration-based payment pays a configured amount per minute for each discipline.
- Medicare Part B MPFS uses the CMS Medicare Physician Fee Schedule.
RehabAlpha initially selects PDPM case-mix per diem for Medicare Part A and Managed Care Part A payor types and Medicare Part B MPFS for Medicare Part B and Managed Care Part B. It initially selects Custom fee schedule for every other payor type, including Hospice. You can change that selection before creating the payor. Imported payors use the same defaults when the source data does not specify a payment model type. These are defaults only; every payor type supports every payment model.
Choose carefully. The payment model type cannot be changed after the payor is created. If the same carrier offers both types of reimbursement, create a separate payor record for each benefit lane.
Import payors from PointClickCare
From a configured facility's Details → Integration, select Refresh as an Owner, Admin, or manager of that facility. As each patient is processed, RehabAlpha reads the patient's PointClickCare coverages to identify payors and import supported patient coverages.
PointClickCare payors use these types and payment models:
| PointClickCare type | RehabAlpha type | Payment model |
|---|---|---|
medicareA | Medicare Part A | PDPM case-mix per diem |
medicareB | Medicare Part B | Medicare Part B MPFS |
medicaid | Medicaid | Custom fee schedule |
private | Private Pay | Custom fee schedule |
Managed care, outpatient, other, Medicare Part D, and unrecognized payor types are excluded from organization payor imports. Patient coverage imports also exclude entries ranked Informational; managed care, outpatient, other, and unrecognized coverage types produce a coverage issue for review. RehabAlpha does not infer a type from a payor name. Missing or invalid required fields on a payor that enters import appear in View issues.
An unknown PointClickCare payor identifier creates a separate payor, even if a manual or pre-loaded payor has the same name or type. Later refreshes find it by its saved identifier. There is no automatic name matching or control to associate another identifier with an existing payor. If several identifiers are already mapped to one payor, only its active source updates the name; other mapped sources leave the payor unchanged. The first source stays active, with no automatic promotion or source-selection control.
New payors receive the rule defaults described below. Later refreshes update only the name from the active source. Type is locked for a linked payor; a different type supplied by its active source is skipped and reported in View issues. Payment model, rules, AI compliance guidance, tags, and notes keep their saved values.
The facility's Details → Integration shows PointClickCare payor records with processed and discovered totals and created, updated, unchanged, skipped, and failed outcomes. Repeated payor appearances can be counted across patients, but each identifier is processed once per refresh. Unsupported types do not add to these counts. Payor and coverage collection issues describe a patient's coverage lookup or response problem; PointClickCare payor issues describe a particular payor. Review these issues before using imported payors for billing. Facility and patient refreshes also import supported patient coverages, with separate coverage outcomes and issues.
Refresh a payor from PointClickCare
Open a linked payor's Details → Integration to see its PCC payor IDs, source organization and facility information available to you, Last attempt, and Last successful refresh. Supplies updates identifies the active source. The section is absent for unlinked payors and while editing.
Select Refresh to update only this payor from the source marked Supplies updates. It can update the name, with the same type and billing restrictions described above. It does not create or update patient coverages, and it does not switch the active source.
Anyone with access to the payor can view the section. Refresh requires Owner, Admin, or manager access for an associated source facility with an enabled, configured integration. If Refresh is unavailable, the section explains why, including when another refresh is using that facility. Use the facility's Details → Integration to cancel an active refresh.
If PCC no longer exposes the payor through the saved source relationship, the payor stays unchanged. Select Refresh again if available; another associated facility may provide the same source. Otherwise, refresh the associated facility integration to rediscover the relationship.
Choose the payor type
Choose the Type that best describes how the payor should be handled in billing and reporting workflows.
- Use Commercial Insurance for standard commercial plans.
- Use Hospice for hospice payors.
- Use Managed Care Part A or Managed Care Part B for managed Medicare plans.
- Use Medicaid for Medicaid payors.
- Use Medicare Part A or Medicare Part B only when you need a separate Medicare-related payor record beyond the pre-loaded options.
- Use Private Pay when the patient or another private party is responsible.
- Use Workers' Compensation for workers' compensation coverage.
The payor type helps RehabAlpha apply billing rules and group payors for reporting.
Review payor rules
Each payor rule requires Yes or No. New payors start with the following answers based on their exact Type, including imported payors and the Medicare payors pre-loaded in new organizations:
| Payor type | Authorization required? | Concurrent treatment allowed? | Group treatment allowed? | Student treatment allowed? |
|---|---|---|---|---|
| Medicare Part A | No | Yes | Yes | Yes |
| Medicare Part B | No | No | Yes | No |
| Private Pay | No | No | No | No |
| All other types | Yes | No | No | No |
These are editable starting values. Review each answer against the payor's policy before using the payor. Managed Care Part A and Managed Care Part B use the All other types defaults. Choosing a Medicare payment model does not apply Medicare rule defaults to another payor type.
While creating a payor, selecting a Type updates only the rule answers you have not changed yourself. Clearing Type leaves the current answers intact until you select another type. Changing the type of an existing payor keeps its saved rule answers.
- Authorization required? refers to payor approval for treatment. It is separate from certification of a treatment plan; No does not remove certification requirements.
- Concurrent treatment allowed? refers to the distinct concurrent treatment mode used in SNF care. Under Medicare Part B, simultaneous treatment of multiple patients may be group treatment, even when they perform different activities. The Medicare Part B default of No for concurrent treatment does not prohibit covered group treatment. See CMS guidance on individual and group treatment.
- Group treatment allowed? indicates whether the payor permits group treatment, subject to its coverage and billing requirements. For Medicare Part A SNF stays, concurrent and group therapy together are limited to 25% of therapy minutes for each discipline. See CMS Medicare payment systems.
- Student treatment allowed? indicates whether student-delivered treatment time may be counted without a qualified practitioner attending the full session, subject to applicable supervision requirements. No does not prohibit supervised student participation in a qualified practitioner's service. Medicare Part B pays for the qualified practitioner's service, with specific requirements for student participation. See CMS guidance on therapy students, chapter 15, section 230.
These rules guide AI compliance reviews. They do not directly block billing or determine whether a claim will be paid. Add relevant limits and supervision requirements in AI compliance guidance.
Understand payors and coverages
A payor record identifies who may pay. A patient coverage record describes when that payor applies to a specific patient and what benefit details are available.
Keep the payor record focused on the payor's identity, rules, and documentation guidance. Enter patient-specific details on the patient's coverage, such as:
- coverage start and end dates
- deductible
- copay
- coinsurance
- out-of-pocket maximum
- authorizations
Add the payor to a patient coverage
After the payor exists, use it on the patient's coverage record.
- Open the patient.
- Click Coverages.
- Click New coverage.
- Select the payor.
- Enter the coverage start date and end date when known.
- Add deductible, copay, coinsurance, out-of-pocket maximum, or authorization details when needed.
- Click Save.
Manage payor details
With Custom access, you need Update permission for Payors to change these details.
- Open Payors.
- Find the payor in the list.
- Click the payor name.
- Click Details.
- Click Edit.
- Update the payor name, type when available, rules, AI compliance guidance, tags, or notes.
- Click Save.
The payment model type is read-only after creation. Existing billing episodes retain the payor name, type, and payment model type that were saved with the episode.
For a PointClickCare-linked payor, Type is also read-only. You can edit its name, but a refresh of its active source can replace that name. Deleting an imported payor removes its external links, and a later refresh may create it again.
In Metadata, the read-only Created and Last updated rows show the available date and time, responsible user, and source, including Via PointClickCare for an integration write. These rows are also visible while editing.
Add AI compliance guidance
In the payor's Details, click Edit and find AI compliance guidance under Payor rules. Enter requirements from the payor's documentation policy, such as how to justify skilled therapy or which treatment-plan styles are permitted, then click Save.
RehabAlpha uses this guidance when the payor is the primary payor for a reviewed clinical document. Changes queue affected reviews for another check, including those in closed cases. Leave patient-specific information out of this field. If you leave it blank, the review uses the other available payor rules and clinical documentation.
See Review AI compliance findings to interpret concerns, risk levels, and review status.
Add a payor arrangement
With Custom access, you need Read and Create permissions for Payor arrangements. Read is off for new members. Creating or editing an arrangement that uses Custom fee schedule also requires Read for Fee schedules. To edit an existing arrangement, you need Read and Update for Payor arrangements.
- Open the payor.
- Click Arrangements.
- Click New payor arrangement.
- Choose whether the arrangement applies to All billing providers or Specific billing providers. If you choose specific providers, select one or more.
- Enter the inclusive start and end dates. Turn on Way back when the arrangement has no practical start date, or Indefinite when it has no end date.
- Configure the payment model shown for this payor:
- For PDPM case-mix per diem, choose whether to include wage index and variable per diem adjustments.
- For Custom fee schedule, select an uploaded fee schedule, choose custom or Medicare units, enter the adjustment percent, and choose whether to apply assistant reductions. For custom units, configure Minutes per unit, rounding, and Pool minutes by.
- For Medicare Part B MPFS, configure MPPR, assistant reductions, and sequestration.
- For Duration-based payment, enter the dollars-per-minute rate for each covered discipline.
- Add notes or tags when helpful.
- Click Save.
Use All billing providers when the same reimbursement terms apply broadly. The selection also covers billing providers added later. Use Specific billing providers when different, non-overlapping groups of providers need different arrangements. During any date range, each billing provider can belong to only one arrangement for the payor. An all-provider arrangement therefore cannot overlap another arrangement for that payor. Every arrangement automatically uses the payor's payment model type.
For custom units in a custom-fee-schedule arrangement, RehabAlpha adds the minutes in each selected pool and rounds the total once before allocating whole units to its services in a consistent, deterministic order. New custom-unit definitions initially use Patient, service date, discipline, and HCPCS code. Pools remain separate for each billing provider and payor arrangement.
You should know
Owners and Admins can add or delete payors. Custom access can do so with the matching Create or Delete permission for Payors.
Medicare Part A and Medicare Part B are pre-loaded in new organizations.
Do not delete a payor if it is still needed for patient coverages, billing episodes, authorizations, or reporting.
Do not create a separate payor for each patient unless the payor itself is actually different. Use patient coverages for patient-specific policy periods and benefit details.
Frequently asked questions
Do I need to create Medicare Part A or Medicare Part B?
No. Medicare Part A and Medicare Part B are pre-loaded in new organizations.
Where do I enter deductible, copay, coinsurance, or authorization details?
Enter those details on the patient's coverage. The payor record stores the payor name and type. The coverage stores patient-specific dates, benefits, and authorization limits.
Can I import payors instead of entering them manually?
Yes. Use Import for source files, or use a facility's PointClickCare Refresh to import supported payors and patient coverages from PCC's current coverage trees. Review imported payors and any coverage issues before using them for billing episodes, authorizations, or reporting.
Can I change a payor type later?
For a payor that is not linked to PointClickCare, open Details, click Edit, update Type, and save. Review related coverages and billing setup if the type change affects how your organization expects to use that payor. PointClickCare-linked payors keep their imported type; Type is read-only.
Can I change a payor's payment model type later?
No. Create a new payor for the new reimbursement lane. End the prior arrangement and billing episode at the cutoff, then create the replacement arrangement and billing episode with the new payor.
Can reimbursement differ by billing provider?
Yes. Add a payor arrangement for each payor and billing-provider combination that uses different rates or settings. When arrangements overlap in time, their selected billing-provider groups must be disjoint. Use effective dates when the terms change.
Can I use one payor for multiple patients?
Yes. Create one payor record for the payor organization or responsible party, then use that payor on each patient's coverage as needed.
What to do next
After creating the payor, configure its payor arrangements and the facility's billing-provider mappings. Then select the primary payor on billing episodes; RehabAlpha uses that payor's payment model type. Add the payor to patient coverages separately when you need to track patient-specific dates, benefits, or authorizations.