FAQ: Payer Profiles and Services
These frequently asked questions will help provide guidance as you troubleshoot through the Payer section of Aloha.
What is the difference between a charge rate and a contract rate? What should I be charging?
Within your profile set-up there are two rates, charge rate and contract rate. The contract rate is fairly straightforward; it is the rate given to you by the payer within the fee schedule. The charge rate is the rate you set for yourself. No, these rates do not have to be the same! In fact, most billers recommend setting a standard charge rate about 20% higher than your highest payer for a few reasons.
1. From an ethics perspective, by setting a standard rate you are treating all clients as equals and not charging more for some rather than others.
2. From a business perspective, sometimes insurance companies raise their rates and they might fail to inform you. If the previous rate was $20/unit and you are charging $20/unit, when they raise their rates to $22/unit and you keep charging them $20/unit, they will keep paying you the old rate. However, if you've been charging them $24/unit, they will now reimburse at $22/unit rather than $20/unit.
When the insurance company cuts you a check, they will acknowledge your charge rate, but still pay the contract rate. Check out this example below from an actual remit:
There is no punishment for setting a higher charge rate, many providers do it!
For more information about updating your contract and charge rates, check out this article in the Knowledge Base about Changing Contract and Charge Rates.
What is a modifier and how do I know if I should use one?
A modifier is a common two-character alphabetical or numerical code that gives insurance companies more information about the claim. Not all payers use them; refer to your fee schedule to see if modifiers are included in the codes. Some modifiers help signify place of service, for example GT or 95 are used to indicate a service was provided via Telehealth. Others signify the educational level of the person who provided the service. For example HO often means that the provider has a Master's Degree. Often payers will reimburse at a different rate based on the modifier.
In the Billing Rules section of the payer, you can customize the modifiers to associate with specific qualifications or place of service based on your fee schedule.
You can add the modifiers with their own individual charge rate and contract rate using the 
next to the modifiers. From there, you can set a "default" modifier to show up on every session. "Highest credential" indicates that the modifier will match with the qualification of the person providing the service. For example, if you have staff member with a Bachelor's degree and highest credential is selected, it will pull the HN modifier every time they provide that service for that payer (based on the qualification modifiers set in the above example).
Claims can be denied if they are missing required modifiers!
If I use modifiers, what should my base service charge and contract rate be? When two rates are against each other the system will use the highest.
If a payer requires modifiers, Aloha still requires a base charge and contract rate should no modifier be selected. When there are two possible rates, the Aloha system will choose the higher rate. In this scenario, it is recommended to choose the lowest possible rate for your base rate.
I see a warning pop-up saying that I chose a payer not on the list.
This is not a big deal! This just means that you are choosing a payer that AlohaABA has not worked with before. Just go ahead and click "Proceed".
How do I choose my required credentials?
The required credentials for a service should be the minimum required, not all the possibilities. For example, if a BCaBA or a BCBA can perform 97155, just check BCaBA as the required credential. The system understands that a BCBA can do all the work a BCaBA can do and more! If there are multiple credentials required (e.g., CPR, LBA and BCBA), make sure to check them all.
If the required credential is greyed out and cannot be changed, this is because you already have appointments scheduled and/or completed in the schedule. Email support@alohaaba.com to have your credentials changed on the back end.
Why can't I add the same service name twice?
In Settings > Services, make sure you have a service name added for each of the billable services that you provide. Most of the time, modifiers will indicate different rates for different education levels of providers. For example, payers may indicate that an HO modifier should be used if a BCBA bills 97153 and pay at a higher rate than the HN or HM modifier for the same service provided by an RBT.
However, if modifiers aren't used and payer reimburse at a different rate for BCBAs and RBTs providing the same service, you will need to create two services. For example, you may want to create two services called Direct- RBT and Direct-BCBA to indicate different rates for 97153 without modifiers.
It is always recommended to name services with a description rather than a billing code. For example, use "Assessment" rather than "97151". Some insurance companies still use H or T codes. You will attach a specific billing code when you add the service to the individual payer.
What is concurrent billing?
Concurrent billing is when a payer does not allow the simultaneous billing of two services with the same client at the same time. For example, some payers do not allow 97153 (direct) and 97155 (supervision) to be billed at the same time. This is indicated in your contract/fee schedule with the payer. If this is not stated, don't worry about it!
If there are concurrent billing rules, follow these steps to set your system to automatically zero out sessions that cannot be billed concurrently.
1. Go to the Payer Profile and click on the Billing Rules tab
2. Under Concurrent Billing select "not allowed"
3. Use the 
to create a new rule. For example, "if Direct and Supervision are overlapped, bill Supervision" will zero out the billing minutes for the direct session and only bill out the supervision session. Create as many rules as necessary to reflect your fee schedule/contract with the payer.
What should I put as a unit size?
The majority of insurance payers bill in units, or 15 minute increments. It is recommended to use units as the unit size and "AMA" as the rounding rule for the majority of services/payers. If the payer fee schedule indicates a different unit size, you can select it in the dropdown.
What is the difference between "Flat" and "Appointment" in unit size?
Flat rate lets you set the appointment one time. For example, if you are completing an assessment and will only be billing the payer one time (e.g., you will be receiving $2000 for the completion of the assessment) you can enter the service as a flat rate.
Appointments are set as many times as the authorization allows, but the charge rate will be the same regardless of the duration. If you charge the same amount for a session no matter how long the session goes (e.g, a speech session is charged $50 whether it lasts 45 min or 75 minutes), you will use appointments.
What rounding rule should I use?
The majority of insurance payers want you to use the AMA rounding rule. This is the "8 minute" rule in which the time will round up to 15 minute if the session is verified at least 8 minutes into a 15 minute interval. It will round down if the session is verified less than 7 minutes into a 15 minute interval. For example, if a session is verified from 4:07pm-6:00pm, 8 units (15 minute intervals) will be billed. If a session is verified at 4:08pm-6:00pm, 7 units will be billed.
By selecting not allowed, you will indicate that the exact number of verified minutes will be billed. A session from 4pm-4:39pm will bill 39 minutes.
By selected round to nearest quarter, the system will round to the nearest 15 minute interval.
Down will round down to the nearest unit; if a session is verified from 4:00pm-4:44pm and the unit size is 15 minute, it will round down to 4:00pm-4:30pm or two units.
Up will round up to the nearest unit; if a session is verified from 4:00pm-4:33pm and the unit size is 15 minute, it will round up to 4:00pm-4:45pm or three units.
Nearest will round to the nearest unit; if a session is verified from 4:00pm-4:35pm and the unit size is 15 minute, it will round to the nearest 15 minute interval, 4:00pm-4:30pm or two units.
If choosing "flat" or "appointment", no rounding is necessary since the charge will not be based on the duration of session.
I have private pay clients. What payer type should I use?
For families that use private pay, there are two options for "payer type" when setting up the payer profile:
1. "Others": This is for families that will pay you directly for services
2. "Insurance": Use this payer type if the family plans to generate a "superbill" for reimbursement for services from their insurance company.
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