Configuring payers and billing codes

Billing configuration lives under Configuration → Billing. It covers the payers you bill, the fee schedules per payer, the authorization rules the system enforces, and the EDI / Office Ally submission settings.

1. Payers

A payer is whoever pays for services — a commercial insurance company, a state Medicaid plan, a private-pay parent. Every claim has a payer; every authorization has a payer.

Each payer row has:

• Name — what shows up on dropdowns and on claims.
• Type — Commercial, Medicaid, Medicare, or Private Pay. The type controls a few defaults (Medicaid claims include taxonomy; private-pay flips claims toward the invoice path instead of EDI submission).
• Payer ID — the EDI / clearinghouse identifier. Office Ally needs this to route the claim. Get it from the payer’s provider portal or your clearinghouse’s payer list.
• Address — used on paper claims and parent-facing invoices.
• Submission method — EDI 837P, Paper, or Manual (you handle it externally). EDI is the default for most commercial / Medicaid plans.

Adding a payer

Click Add Payer. Fill in name, type, payer ID, and address. Save, and the payer is immediately available on client insurance forms and authorization dialogs. You can flip a payer to Inactive later — historical claims keep working but the payer drops off new-record dropdowns.

2. Fee schedules per payer

Every payer needs a fee schedule — the rate (per unit) you bill each CPT code. Open a payer and go to its Rates tab.

A fee schedule entry has:

• Service code — 97153, 97155, 97156, 0362T, etc.
• Modifier — HO, HM, U1–U9, depending on the payer’s contract.
• Rate — dollars per unit (a unit is 15 minutes for most ABA codes).
• Effective dates — when this rate is in force. Most payers reset rates annually; keeping historical rates lets the system bill the right amount for an old session even after a contract update.

When a session is finalized, the system looks up (payer × code × modifier × date-of-service) and uses the matching rate. If no match is found, the claim is flagged for manual review rather than billed at $0.

3. Authorization Limits

The Auth Limits panel sets the defaults the system enforces when a new authorization is created.

For each service code:

• Default units per period — what most payers approve for a 6-month auth. Pre-fills the auth dialog so billers aren’t typing the same number every time.
• Hard cap — the maximum the system will allow on a single auth, regardless of what’s typed. Use this to catch accidental data-entry errors.
• Warning threshold — % of approved units after which the auth badges Expiring / High utilization.

These are practice-wide defaults; an individual auth on a client can still override them when the payer letter is unusual.

4. Office Ally / EDI submission settings

Configuration → Billing → Office Ally Submission is where you plug in the credentials the system uses to send 837P claim files electronically:

• Sender ID / Receiver ID — the trading partner identifiers Office Ally gave you when you signed up.
• Submission endpoint — the SFTP host or HTTPS URL.
• Username / password (encrypted at rest) — the credentials.
• Test mode — when on, claims are validated and previewed but not actually sent. Leave this on while you’re verifying setup.

Practices on a different clearinghouse (Availity, Change Healthcare, etc.) typically run the EDI generator and upload the file manually from the Billing → Submissions page rather than wiring up automated submission. The 837P output is standards-compliant either way.

5. Invoice settings

For private-pay billing, Invoice Settings controls:

• Invoice number prefix and starting number — invoices display as INV-001, INV-002, etc. Set the prefix and the starting number to mesh with your accounting system.
• Default payment terms — Net 30, Net 15, Due on receipt, etc.
• Late fee policy — flat fee or percentage, applied N days past due.
• Invoice footer text — bank routing for ACH, “Make checks payable to…” instructions, etc. Appears on every printed invoice.

6. Default billing rules per client

These set practice-wide defaults for new clients; per-client overrides happen on the client’s Demographics / Insurance tab.

• Bill-to mode — Insurance (claim → payer), Client (private invoice), or Hybrid (insurance first, balance to client). Most practices set Insurance as the default and override case by case.
• Place of service — POS code applied to claims when the session location is “clinic” (default 11), “home” (12), “school” (03), “telehealth” (02 or 10).
• Default rendering provider — usually the client’s assigned BCBA. Override per session if a different staff member ran it.

A practical setup order

If you’re configuring billing for the first time:

1. Service Types (under Sessions & Notes) — every CPT code you bill, with default rates as a starting point.
2. Payers — every commercial / Medicaid payer + private-pay.
3. Fee schedules per payer — the real rate per payer × code, overriding the service-type default.
4. Authorization Limits — defaults for what the dialog pre-fills.
5. Invoice Settings — once you have one private-pay client.
6. Office Ally Submission — last; this is the connector to your clearinghouse.

Once these are in place, the rest of billing — generating claims, running submissions, recording payments — is largely automated by the session-finalize flow.