Setting Claim Rule Conditions

Claim Rule Conditions define the criteria a claim must meet, instructing 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; note that the rule applies only when all sub-conditions are met.

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

  

• The Order number of a rule determines when it will be applied if all conditions have been met. 
  
  Example: If three rules have the same three conditions, the order in which they will be used is determined by the order number assigned to them. The rule in the #1 position will be applied first, the rule in the #2 position will be used second, and the rule in the #3 position will be applied last.
  

Available Conditions

Each set of claim rules has conditions that the system checks when determining which claims the rule should apply to. Let's review each set together!

Condition	Category	Definition	Options
Claim Type	Service Grouping	Criteria based on the claim form type.	Institutional · Professional
Claim Method	Service GroupingLine ItemClaim Form	Criteria based on the delivery method of the claim.	Electronic · Paper
Primary Behavioral Carve-Out	Service GroupingLine ItemClaim Form	Criteria based on the identity of the claim's primary behavioral carve-out payer.	All payers from Practice Admin > Payers
Primary Behavioral Carve-Out — Plans	Service GroupingLine ItemClaim Form	Criteria based on the plan associated with the primary behavioral carve-out payer.	Manually selected; all plan names are configured in the payer profile
Primary Medical Payers	Service GroupingLine ItemClaim Form	Met when the primary medical payer is the destination payer, regardless of whether the claim is submitted to the secondary or tertiary payer.	All payers from Practice Admin > Payers
Primary Medical Payers — Plans	Service GroupingLine ItemClaim Form	Criteria based on the payer's plan for the claim's primary medical plan.	Manually selected; all plan names are configured in the payer profile
Primary Home Plan Payers	Service GroupingLine ItemClaim Form	Met when the primary home plan payer matches the Home Plan payer on the patient's insurance tab, regardless of whether the claim is delivered to the secondary or tertiary payer.	All payers from Practice Admin > Payers
Current Sequence Behavioral Carve-Out	Service GroupingLine ItemClaim Form	Met when the current behavioral claim payer matches one of the selected condition payers. References the primary payer for a primary claim, secondary for a secondary claim, and tertiary for a tertiary claim.	All payers from Practice Admin > Payers
Current Sequence Behavioral Carve-Out — Plans	Service GroupingLine ItemClaim Form	Criteria based on the plan associated with the claim's current sequence (primary, secondary, etc.) and the behavioral carve-out payer.	Manually selected; all plan names are configured in the payer profile
Current Sequence Medical Payers	Service GroupingLine ItemClaim Form	Met when the current medical claim payer matches one of the selected condition payers. References the primary, secondary, or tertiary payer to match the claim sequence.	All payers from Practice Admin > Payers
Current Sequence Medical Payers — Plans	Service GroupingLine ItemClaim Form	Criteria based on the plan associated with the claim's current sequence medical payer.	Manually selected; all plan names are configured in the payer profile
Current Sequence Home Plan Payers	Service GroupingLine ItemClaim Form	Met when the current home plan payer matches one of the selected condition payers. References the primary, secondary, or tertiary payer to match the claim sequence.	All payers from Practice Admin > Payers
Billing Provider	Service Grouping	Affects treatments set to the selected billing provider. Values are set in the Attendance Standalone Service Editor and Treatment Episode Utilization Plan.	Practice · Rendering Provider
Places of Service	Service Grouping	Uses the place of service on a claim to determine whether to apply the rule.	Manually selected
Bill-Type Prefixes	Service GroupingClaim Form	Uses the bill-type prefix of a claim to determine whether to apply the rule.	Manually input
Facility	Service GroupingClaim Form	Uses the claim's facility to determine whether to apply the rule.	Manually selected; all facilities in Practice Admin > Services
Service Billing Profile	Line Item	Limits the claim rule to only affect the chosen billing profile.	All billing profiles from Practice Admin > Services
Revenue Codes	Line ItemClaim Form	Applying a specific revenue code limits the claim rule to only that code.	Manually input
HCPCS/CPT Codes	Line ItemClaim Form	Applying a specific HCPCS/CPT code limits the claim rule to only that code.	Manually input
Claim Line Number	Line Item	Of the numbered line items on an institutional claim, the rule applies only to the selection.	Equals · ≥ · ≤ (manually input)
Same-Day Line Number	Line Item	Of the numbered line items on an institutional claim for the same service date, the rule applies only to the selection.	Equals · ≥ · ≤ (manually input)
Code Appears First (Per Date of Service)	Line Item	For each line item per date of service, the rule applies to the first or subsequent occurrences of the code.	First Appearance · Subsequent Appearance
Code Appears First (Per Claim Form)	Line Item	Of the codes on each line item, the rule applies to the first or subsequent appearances of the code.	First Appearance · Subsequent Appearance
Professional Service Line	Line Item	Only displayed when Claim Type is Professional. Of the numbered line items on a professional claim, the rule applies only to the selection.	Equals · ≥ · ≤ (manually input)
Treatment Episode Discharge Date	Claim Form	The rule applies only to claims that meet the specified discharge date criteria.	Discharge Date Not Set · Discharged on Claim Service End Date · Discharged 1 day after · Discharged more than 1 day after
Is Corrected Claim	Claim Form	The rule applies if the claim is marked as corrected (XX7 bill type or 07 resubmission code).	Yes · No
Claim Contains First Episode DOS for Services	Claim Form	The rule applies if the claim contains the first date of service for a specific service billed from the treatment episode.	All services in Practice Admin > Services
Claim Contains Last Episode DOS for Services	Claim Form	The rule applies if the claim contains the last date of service for a specific service billed from the treatment episode.	All services in Practice Admin > Services
Claim Contains First DOS in Episode	Claim Form	The rule applies if the claim contains the first date of service (any service type) billed from the treatment episode.	Yes · No
Benefits Assignment	Claim Form	The rule applies only to patients with benefit assignments that include this condition.	Yes · No
Rendering Provider	Claim Form	Criteria based on the claim's rendering provider.	All providers from Practice Admin > Rendering Providers