Payers, participation, and rates

Where payers come from

When you add insurance to a patient or pick a payer on a claim, the list is the live clearinghouse directory. A payer you can select is one Sefton can reach electronically; there is nothing to set up per payer beyond enrollment (Electronic claims).

Payer rules

Each payer carries rules Sefton maintains: authorization requirements by service, accepted modifiers, timely filing limit, telehealth place-of-service expectations, and attachment support. The Payer Rules Engine validates every claim against them before submission, and a blocked claim shows which rule it tripped so you can fix the visit or the booking. Practice-specific exceptions (a contract that allows a modifier the default rule blocks) go to support with the contract language and are added for your practice.

Payer participation

Settings > Payer participation records whether each provider is in-network, out-of-network, or pending credentialing with each payer. Sefton uses it to route a visit to a superbill (out-of-network) or a claim (in-network) and to flag scheduling a patient with a payer the provider cannot bill.

Rates

Settings > Rates is the fee schedule: your charge per CPT® code, with per-payer contracted rates where you have them. Rates print on superbills and populate the claim’s charge line; Good Faith Estimates use them too.

Payer intelligence

Insights > Payer intelligence shows denial rates, turnaround, and reimbursement by payer from your own claims, which is where you find the payer worth a contract renegotiation.