Partner Services
Partner Services governs system business logic related with how to calculate pricing and claims requirements based on patient contract and sponsor (customer) information.
Field | Description | Acceptable Values | Notes |
partnerLookupID | The payer entry in 20190803/partner/lookup. | Determines what Partner Lookup record will be used by mapping to PartnerLookup.partnerLookupID. | |
contractID | The sponsor/customer contractID from the AMT. | Numeric | |
hasClaims | boolean for whether or not sends claims to this payer for this contract. | True, False | |
hasDeductibleAwareness | boolean for whether or not checks accumulator/deductible for this payer for this contract. | True, False | |
inNetworkDefault | When hasDeductibleAwarness = TRUE if they system reads from in-or out-of network values in the accumulator/deductible check. | True, False | If TRUE, the application will use the In-Network accumulator to calculate visit fees. If the value is FALSE, the system will use the Out -of-Network accumulators to calculate visit fees. |
coinsurancePercentageDefault | When hasDeductibleAwarness = TRUE and plan is HSA the fallback coinsurance % applied to a per-visit cost when a participant has met their deductible. | Numeric | For participants with a HDHP with HSA, the percentage of patient responsibility for the contracted rate when the participant is in their coinsurance phase (has met their deductible), expressed as a decimal. |
Relevant Process
Use the payerID to find a matching partnerLookup record.
Relevant Configuration
Refer to the Partner Services section within the Account Management Tool for more information.
Multiple PayerIds in the same Contract/Eligibility File
Configuration exists to support instances where one contract/EF contains multiple payerIDs to support claims submission.
Example:
The customer 98point6 Bakery contractID 111 submits an eligibility file that contains both BCBS (payerID 222) and Aetna (payerID 333) HSA members. To support claims submission to both Payers associated to this contract/EF:
Create a Partner Services record for contractID 111.
Create an associated PartnerLookup record associated with payerID 222.
Create a Partner Services record for contractID 111.
Create an associated Partner Lookup record associated with payerID 333.
Example Partner Services Record: