Claims
Payer rules
There is no payer rules engine. ArkCloud records a small set of facts per payer, and enforces three of them: whether the payer requires prior authorization, what it pays per code, and the claim filing indicator its claims are sent under. Everything else payer-specific is caught by the clearinghouse or the payer.
Written for: Billing and RCM teams · Practice administrators
What is recorded per payer
ArkCloud RCM → Insurance → Payers
| Field or control | What it means |
|---|---|
| Payer id, name, trading partner id | The payer id is what goes in the 837P and what 835s are matched against. |
| Contact details, EDI submitter id, vendors | Reference information. |
| Timely filing days | Stored and shown on the payer. Not enforced: the scrub report warns at a fixed 90 days whatever this says. |
| Appeal time limit | Stored and shown. Not used to set appeal deadlines (those default to 60 days). |
| Active | An inactive payer cannot be linked to new coverage. |
| Payer type, claim filing indicator | The payer type (for example Medicare, Medicaid, commercial) implies the claim filing indicator sent in the 837P (SBR09); an explicit filing indicator overrides it. Edited on Settings → Payers. |
Creating, editing, importing and deleting payers needs the edit_settings permission (administrators).
Insurance → Payers. Each payer's identifiers and limits; the timely-filing figure shown here is reference, not a rule the product applies.
/dashboard/insurance/payers
What is enforced
| Field or control | What it means |
|---|---|
| Prior authorization policy | Each payer records whether it requires prior authorization; unknown is treated as required. Episodes follow their payer unless an explicit per-episode choice overrides it, and changing the policy re-checks every episode that follows it. The billing-readiness gate holds a service when authorization is required and none is on file, or the one on file is not approved, expired, outside its dates, used up, or does not cover the service or its level of care (hold codes AUTH_REQUIRED, AUTH_NOT_APPROVED, AUTH_EXPIRED, AUTH_OUTSIDE_DATES, AUTH_EXHAUSTED, AUTH_SERVICE_NOT_COVERED, AUTH_LEVEL_OF_CARE_NOT_COVERED). Set by Rehab administrators from an episode's Billing setup panel. |
| Claim filing indicator | A claim whose payer has no filing indicator, and whose payer type implies none, is refused at submission (MISSING_FILING_INDICATOR). It is never defaulted to commercial. |
| Rates | Rates per code, per payer or as an organisation default, by effective date (fee schedules). A Rehab charge cannot be posted without one. |