Setting Claim Rule Conditions

Claim Rule Conditions create criteria for a claim to meet that instruct the system to apply a change. A good claim rule has three components: If/Then statements, And statements, and Any statements.

Let's review each component together! 

• 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.
  
  Example:  If the claim type is institutional, delivered electronically, and the current sequence behavioral carve-out payer is BCBS Florida, the system will create the claim using the Facility NPI as the billing provider.

• When selecting multiple conditions, it's important to note the rule will only apply when all the conditions are met.

  Example: If the claim type is institutional, delivered electronically, has a bill-type prefix of 86, and the current sequence behavioral carve-out payer is BCBS Florida, the rule applies only to claims that meet all 4 selections/conditions.

  

• There may be multiple choices within each condition; it's important to note the rule will only apply when all the sub-conditions are met

  Example: When selecting Current Sequence Behavioral Carve-Out, there is an option to select multiple payers (e.g., Aetna, Cigna, BCBS Florida) to which the rule will apply. The rule will apply if any of the payers selected are in the patient’s profile as long as the other conditions have been met.

  

Rule Conditions 

Each set of claim rules has conditions the system looks for when identifying which claims the rule should be applied to. Let's review each set together! 

• 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 Carve-Out	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 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 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 delivered to the secondary or tertiary.	All payers from Practice Admin > Payers
  Current Sequence Behavioral Carve-Out	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, the secondary payer if this is a secondary claim, and the 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, the secondary payer if this is a secondary claim, and the 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 matches one of the selected condition payers. The condition references the primary payer if this is a primary claim, the secondary payer if this is a secondary claim, and the tertiary payer if this is a tertiary claim.	All payers from Practice Admin > Payers
  Places of Service	The rule behaviors will apply whenever the selected place of service is set.	Manually selected value
  Bill-Type Prefixes	The rule behaviors will apply whenever the selected bill-type prefix is set.	Manually input value
  Facility	The rule behaviors will apply whenever the selected facility is set.	Manually selected value

• 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 Care-Out	This condition is met when the primary behavioral payer is the destination payer, regardless of whether the claim is 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 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 delivered to the secondary or tertiary.	All payers from Practice Admin > Payers
  Current Sequence Behavioral Carve-Out	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, the secondary payer if this is a secondary claim, and the 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, the secondary payer if this is a secondary claim, and the 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 selected home plan payer matches the home plan payer in the patient's insurance tab. The condition references the primary payer if this is a primary claim, the secondary payer if this is a secondary claim, and the 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 service date, 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

• Condition	Definition	Options
  Claim Method	The rule will affect services or treatments marked for the selected claim submission method, which is Electronic or Paper.	Electronic Paper
  Primary Behavioral Carve-Out	This condition is met when the primary behavioral payer is the destination payer, regardless of whether the claim is 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 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 delivered to the secondary or tertiary.	All payers from Practice Admin > Payers
  Current Sequence Behavioral Carve-Out	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, the secondary payer if this is a secondary claim, and the 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, the secondary payer if this is a secondary claim, and the 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 selected home plan payer matches the home plan payer in the patient's insurance tab. The condition references the primary payer if this is a primary claim, the secondary payer if this is a secondary claim, and the 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 corrected, i.e. XX7 bill type or 07 resubmission code.	Yes No
  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 only applies the claim rule to 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 payers from Practice Admin > Payers
  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 payers from Practice Admin > Payers
  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 with the benefits assignments set with this condition.	Yes No
  Facility	The rule behaviors will apply whenever the selected facility is set.	Manually selected value