How do hospital billing rules differ between Medicare and a private payer in Resolute?

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The key idea is that payer-specific rules drive hospital billing in Resolute. Medicare and private payers operate under different coverage policies, payment methodologies, and rate structures, so the system must apply distinct edits and CMS-specific requirements for each payer. Medicare uses its own frameworks (like IPPS with MS-DRGs, bundled services, and particular CMS claim fields and documentation needs), while private payers rely on negotiated rates, their own coverage determinations, and their own bundling/unbundling and claim-edit rules. Because of these fundamental differences, Resolute needs separate payer-specific configurations to bill correctly and avoid denials. Codes matter, but they don’t reconcile the differing payer requirements on their own; the payer rules determine eligibility, coverage, and payment.