Claim Rule Overview and Ordering

Audience: This document is for Managing Organization Administrators or Users that will be responsible for the claim rules for an organization.

Permissions: AveaOffice Managing Organization Users must have "Manage Claim Rules" permissions. Managing Organization Admins have this permission as a default.

Path: Management Center > Claim Rules

Preface

Claim Rule Ordering

Claim Rules are processed in order, from 1 to X. If many rules use the same behavior type, the behavior will be overridden by the last rule.

Example:

• Rule 1 states that if a service has bill type prefix 83, then we want to change the bill type prefix to 11.
• Rule 2 states that if a claim is set to send to Aetna, then we want to change the bill type to 13.
• For a claim that is set to Aetna with a service that has bill type prefix 83, the Rule 1 will change the bill type prefix to 11, but Rule 2 will change the bill type prefix to 13. Therefore, the Aetna claim will reach the payer with a a bill type prefix of 13.

Multiple Conditions

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.

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, BCBS, Value Options) that the rule will apply to. If any of the payers selected are in the patient’s profile, the rule will apply.

Service Grouping Rules – Specific Services

 

The goal of service grouping rules is focused on "grouping". Set indicators that ensure services with the same Claim Type, Claim Method, Bill-Type Prefix (Institutional) / Place of Service (Professional) are placed on the same claim. If any of these details differ between two services rendered for the same patient, those services will be split into separate claims.

Condition Types – When these criteria are met, the claim rules will perform the chosen behaviors.

• Claim Type: The rule will affect services flagged to use the selected claim form type. The options are Institutional and Professional.
• Claim Method: The rule will affect services or treatments marked for the selected claim submission method. The options are Electronic and Paper.
• Billing Provider: This condition is met when a given treatment maps to the selected billing provider. These values are set in the Attendance Standalone Service Editor and Treatment Episode Utilization Plan The options are Rendering Provider and Practice.
• 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.
• Primary Medical Payer: 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.
• 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.
• 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 is this is a secondary claim, and tertiary payer if this is a tertiary claim.
• 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 is this is a secondary claim, and tertiary payer if this is a tertiary claim.
• 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 is this is a secondary claim, and tertiary payer if this is a tertiary claim.
• Bill Type Prefixes: The rule behaviors will apply whenever the selected bill type prefix is set.
• Places of Service: The rule will apply whenever the selected place of service is set.

Behavior Types

• Set Service Billing Profile will always select the chosen billing profile for services that match the conditions of the rule.

Example

 BCBS wants Drug Screenings on a CMS-1500, but all other payers want Drug Screenings on UB04s. There are two ways to accomplish this:

1. Create two billing profiles (one billing profile set to professional claim form and one billing profile set to institutional claim form). Then create a claim rule that states when Primary Behavioral Payer is BCBS, select the service billing profile set to professional claim forms.
2. We use the Set Values Using the example above, when Primary Behavioral Payer is BCBS, we want to Set Claim Type to Professional.

• Use the Set Values logic above for Set Claim Method, Set Bill Type Prefix, Set Place of Service, and Set Condition Codes.

Claim Line Item Rule

Use a Claim Line Item Rule when specific information needs to be altered at the line-item level.

Condition Types – When these criteria are met, the claim rules will perform the chosen behaviors.

• Service Billing Profile: The rule will affect line items flagged to use the selected service billing profile.
• 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. 
• 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. 
• 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.
• 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 is this is a secondary claim, and tertiary payer if this is a tertiary claim.  
• 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 is this is a secondary claim, and tertiary payer if this is a tertiary claim.  
• 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 is this is a secondary claim, and tertiary payer if this is a tertiary claim.
• Revenue Codes: The rule will affect line items flagged to use the selected revenue codes.
• HCPCS/CPT Codes: The rule will affect line items flagged to use the selected HCPCS/CPT codes.
• Claim Line Number: The rule will affect specific line items, depending on the selection.
• Same Day Line Number: The rule will affect specific line items only if they are on the same day, depending on the selection.
• Professional Service Line Number: The rule will affect specific professional service line items, depending on the selection.

Behavior Types

• Add Modifier to Institutional or Professional claims for a certain line item number or a certain revenue or HCPCS/CPT code.

Example

Aetna wants to add a modifier to line items that contain the revenue code 0906 and HCPCS H0015.

1. Create a Claim Line Item Rule that states when the Current Sequence Payer is Aetna, the Revenue Code is set to 0906, and the HCPCS/CPT Code is set to H0015, Add Modifier 59 to the claim line item.

• Set Rendering Provider Name and NPI to either the Practice’s Billing NPI and Name, or the Rendering Provider’s NPI and Name. This can come in handy when the claim needs to have the practice’s NPI and Name on the line item.
• Set Secondary Provider ID can be set when certain payers require the provider’s location number, UPIN, Taxonomy, Provider Commercial Number, or State License Number on claims.

Claim Form Rule

The Claim Form Rule is the simplest and most common type of claim rule that will require or omit information on a claim.

Condition Types – When these criteria are met, the claim rules will perform the chosen behaviors.

• Claim Method: The rule will affect claims flagged for the selected claim submission method. The options are Electronic and 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. 
• 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. 
• 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.
• 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 is this is a secondary claim, and tertiary payer if this is a tertiary claim.  
• 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 is this is a secondary claim, and tertiary payer if this is a tertiary claim.  
• 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 is this is a secondary claim, and tertiary payer if this is a tertiary claim.
• Bill Type Prefixes: The rule will affect claims whenever the selected bill type prefix is set.
• Is Corrected Claim: The rule will only affect corrected claims with bill type suffix “7”.
• Claim Contains Revenue Code: The rule will affect claims where the selected revenue code is present.
• Claim Contains HCPCS/CPT Code: The rule will affect claims where the selected HCPCS/CPT Codes are present.

Behavior Types

The behaviors shown above can be

• required and written to claim,
• written to claim if present,
• or omitted from claim. 

Naming Convention for Rules

A good naming convention can make it easy to determine what a rule does without having to consider the details of the rule. See below for an example:

Payer Name - Service - What field is changing (Different Claim Form, Billing Profile Changing) to what.

Common Claim Rules

Example

UB04/Box 1 - To set the billing address as the facility address:

1. Select Create Claim Form Rule
2. Select your practice
3. Title your rule “All Payers – Institutional – Billing Provider Address as Facility Address”
4. Choose Claim Method: Electronic
5. Set Is Active to Yes
6. Set Order to 1
7. Set Claim Type to Institutional
8. Select available behavior “Billing Provider – Address”
9. Set Billing Provider Address to Facility Address
10. Click Create

Note: You can add more than one behavior per claim rule if the conditions are the same. See image below.

Example

UB04/Box 24J - Set Rendering Provider as Practice Billing Entity (For when the provider is not associated with rendering services).

1. Select Claim Line Item Rule
2. Select your practice
3. Title your rule: “All Payers – Set Rendering Provider to Practice Billing Entity”
4. Set Claim Line Number to Greater Than or Equal to 1
5. Set Is Active to Yes
6. Set Order to 1
7. Set Claim Type to Professional
8. Checkmark “Set Rendering Provider Name & NPI to:”
9. Set Rendering Provider Name and NPI to Practice Billing Entity
10. Click Create.

Example

All Forms/Magellan – Select Current Sequence Payer in this example because the address is required even if Magellan is not the primary payer. Select Require and Write to Claim so that AveaOffice will not allow claim submission until the address is included.

1. Select Create Claim Form Rule
2. Select your practice
3. Title your rule “Magellan – Add Claim Mailing Address”
4. Select Current Sequence Payer as Magellan
5. Set Is Active to Yes
6. Set Order to 1
7. Set Claim Type to Institutional
8. Select available behaviors “Payer – Claim Mailing Address”
9. Set to “Require and Write to Claim”
10. Click Create.

NOTE: This can be done for both Institutional and Professional claims