Claim Rule: Setting Claim Rule Conditions

Understanding Claim Rule Conditions

"If/Then" Statements

Claim rules are constructed as "if-then" statements, where conditions are the "if", i.e. if the following conditions are met, "then" the selected behaviors will occur. See below for the three different types of claim rules and the conditions each offers.

"And" Statements

When selecting multiple conditions, please note that the rule will only apply when all the conditions are met.

Example: When selecting Primary Behavioral Payer and Bill Type Prefix, the rule will only apply to claims that meet both selections for Primary Behavioral Payer and Bill Type Prefix.

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"Any" Statements

Within each condition, there may be a list of multiple choices. Please note that when any of the sub-conditions are met, the rule will apply.

Example: When selecting Primary Behavioral Payer, there is an option to select multiple payers (i.e. Aetna, Cigna, Beacon Health Options) that the rule will apply to. If any of the payers selected are in the patient’s profile, the rule will apply.

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Service Grouping Rule

Condition Definition Options
Claim Type The rule will affect treatments set up with the selected claim form. 
  • Institutional
  • Professional
Claim Method The rule will affect treatments marked as the selected claim submission method. 
  • Electronic
  • Paper
Billing Provider

The rule will affect treatments set to the selected billing provider.

These values are set in the Attendance Standalone Service Editor and Treatment Episode Utilization Plan.

  • Practice
  • Rendering Provider
Primary Behavioral Payers

The rule will affect treatments set to the selected billing provider.

This condition is met when the primary behavioral payer is the destination payer regardless of whether the claim is being delivered to the secondary or tertiary.

All payers from Practice Admin > Payers

Primary Medical Payers This condition is met when the primary medical payer is the destination payer regardless of whether the claim is being delivered to the secondary or tertiary. All payers from Practice Admin > Payers
Primary Home Plan Payers This condition is met when the primary home plan payer selected matches the Home Plan payer in the patient's insurance tab, regardless of whether the claim is being delivered to the secondary or tertiary. All payers from Practice Admin > Payers
Current Sequence Behavioral Payers This condition is met when the current behavioral claim payer matches one of the selected condition payers. The condition references the primary payer if this is a primary claim, secondary payer if this is a secondary claim, and tertiary payer if this is a tertiary claim. All payers from Practice Admin > Payers
Current Sequence Medical Payers This condition is met when the current medical claim payer matches one of the selected condition payers. The condition references the primary payer if this is a primary claim, secondary payer if this is a secondary claim, and tertiary payer if this is a tertiary claim. All payers from Practice Admin > Payers
Bill Type Prefixes The rule behaviors will apply whenever the selected bill type prefix is set. Manually input value
Places of Service The rule will apply whenever the selected place of service is set. Manually selected value

 

Claim Line Item Rule

Condition Definition Options
Service Billing Profile Selecting a specific service billing profile as a condition will set the claim rule to only affect the chosen billing profile. 

All billing profiles from Practice Admin > Services 

Primary Behavioral Payers This condition is met when the primary behavioral payer is the destination payer regardless of whether the claim is being delivered to the secondary or tertiary.

All payers from Practice Admin > Payers.

Primary Medical Payers This condition is met when the primary medical payer is the destination payer regardless of whether the claim is being delivered to the secondary or tertiary.

All payers from Practice Admin > Payers.

Primary Home Plan Payers This condition is met when the primary home plan payer selected matches the Home Plan payer in the patient's insurance tab, regardless of whether the claim is being delivered to the secondary or tertiary.

All payers from Practice Admin > Payers.

Current Sequence Behavioral Payers This condition is met when the current behavioral claim payer matches one of the selected condition payers. The condition references the primary payer if this is a primary claim, secondary payer if this is a secondary claim, and tertiary payer if this is a tertiary claim.

All payers from Practice Admin > Payers.

Current Sequence Medical Payers This condition is met when the current medical claim payer matches one of the selected condition payers. The condition references the primary payer if this is a primary claim, secondary payer if this is a secondary claim, and tertiary payer if this is a tertiary claim.

All payers from Practice Admin > Payers.

Current Sequence Home Plan Payers This condition is met when the current home plan payer selected matches the Home Plan payer in the patient's insurance tab. The condition references the primary payer if this is a primary claim, secondary payer if this is a secondary claim, and tertiary payer if this is a tertiary claim.

All payers from Practice Admin > Payers.

Revenue Codes Entering a specific revenue code applies the claim rule to only that revenue code.

Manually input value.

HCPCS/CPT Codes Entering a specific HCPCS/CPT code applies the claim rule to only that HCPCS/CPT code. 

Manually input value.

Claim Line Number Of the numbered line items on an institutional claim, the claim rule will only apply to the selection.
  • Equals
  • Greater than or equal to
  • Less than or equal to

Manually input value

Same-Day Line Number Of the numbered line items on an institutional claim for the same date of service, the claim rule will only apply to the selection.
  • Equals
  • Greater than or equal to
  • Less than or equal to

Manually input value

Code Appears First (Per Date of Service) Of the codes on each line item per date of service, the claim rule will apply to the first or subsequent appearances of the code.
  • First Appearance
  • Subsequent Appearance 
Code Appears First (Per Claim Form) Of the codes on each line item, the claim rule will apply to the first or subsequent appearances of the code. 
  • First Appearance
  • Subsequent Appearance 
Professional Service Line Of the numbered line items on a professional claim, the claim rule will only apply to the selection.
  • Equals
  • Greater than or equal to
  • Less than or equal to

Manually input value

 

Claim Form Rule

Condition Definition Options
Claim Method The rule will affect services or treatments marked for the selected claim submission method. The options are Electronic and Paper.
  • Electronic
  • Paper
Primary Behavioral Payers This condition is met when the primary behavioral payer is the destination payer regardless of whether the claim is being delivered to the secondary or tertiary.

All payers from Practice Admin > Payers.

Primary Medical Payers This condition is met when the primary medical payer is the destination payer regardless of whether the claim is being delivered to the secondary or tertiary.

All payers from Practice Admin > Payers.

Primary Home Plan Payers This condition is met when the primary home plan payer selected matches the Home Plan payer in the patient's insurance tab, regardless of whether the claim is being delivered to the secondary or tertiary.

All payers from Practice Admin > Payers.

Current Sequence Behavioral Payers This condition is met when the current behavioral claim payer matches one of the selected condition payers. The condition references the primary payer if this is a primary claim, secondary payer, if this is a secondary claim, and tertiary payer if this is a tertiary claim.

All payers from Practice Admin > Payers.

Current Sequence Medical Payers This condition is met when the current medical claim payer matches one of the selected condition payers. The condition references the primary payer if this is a primary claim, secondary payer, if this is a secondary claim, and tertiary payer if this is a tertiary claim.

All payers from Practice Admin > Payers.

Current Sequence Home Plan Payers This condition is met when the current home plan payer selected matches the Home Plan payer in the patient's insurance tab. The condition references the primary payer if this is a primary claim, secondary payer if this is a secondary claim, and tertiary payer if this is a tertiary claim.

All payers from Practice Admin > Payers.

Treatment Episode Discharge Date The claim rule will apply only to claims that meet the discharge date selection. 
  • Discharge Date Not Set
  • Discharged on Claim Service End Date
  • Discharged 1 day after Claim Service End Date
  • Discharged more than 1 Day After Claim Service End Date
Bill Type Prefixes The rule behaviors will apply whenever the selected bill type prefix is set.

Manually input value.

Is Corrected Claim The rule will apply if the claim is marked as a corrected claim, i.e. XX7 bill type or 07 resubmission code.
  • Yes
  • No
Claim Contains Revenue Code Entering a specific revenue code applies the claim rule to only that revenue code.
  • Manually input value.
Claim Contains HCPCS/CPT Code Entering a specific HCPCS/CPT code applies the claim rule to only that HCPCS/CPT code. 
  • Manually input value.
Claim Contains First Episode DOS for Services The rule will apply if the claim contains the first date of service for a specific service billed from the treatment episode.

All services from Practice Admin > Services.

Claim Contains Last Episode DOS for Services  The rule will apply if the claim contains the last date of service for a specific service billed from the treatment episode.

All services from Practice Admin > Services.

Claim Contains First DOS in Episode  The rule will apply if the claim contains the first date of service, regardless of service, billed from the treatment episode.
  • Yes
  • No
Benefits Assignment The rule will apply only to patients that have the benefits assignments set with this condition. 
  • Yes
  • No

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