Claim Rule Overview and Ordering

A Claim Rule instructs the system to apply a certain behavior based on conditions set forth by the user. In essence, conditions are prerequisites a claim must meet before the behavior will be applied. 

User Permission

Managing Organization Admins can create and edit Claim Rules. Managing Organization Users can also manage Claim Rules if the appropriate permissions have been set within their User Profile. For additional information on user profiles, click here. 

How Do Claim Rules Work?

When creating new claims in Work Center, the system will use the information in the Practice Admin, the Attendance Calendar, and the U/R Plan (when applicable). During that process, the system will scan the EDI file of the new claim to filter any applicable claims that meet the conditions set forth within the rule. 

Creating Claim Rules

When creating a claim rule, you should focus on three areas: the rule name, the order, and the conditions for when it should be applied. 

Naming Convention for Rules

A good naming convention can make it easy to determine what a rule does without considering its details.

For example, Payer Name - Service - What field changes (Different Claim Form, Billing Profile Changing) to what?

Rule Ordering

The order of the claim rules determines which rule will be applied first (based on the conditions set). When a new rule is created, its default order will be set to 1; this means it will always be the first rule that applies. Since claim rules are applied last in the claim creation process, ensuring that the desired final behavior sets the order of the claim rules is important.

For example, if 2 Service Grouping Rules are in place and the claim meets both sets of conditions for each rule, the system will always apply the rule in the second position last.

Conditions

Conditions are prerequisites set by the user to instruct the system on what to look for when identifying claims the rule should apply to. When selecting multiple conditions, the rule will only apply when all the conditions are met. For more information about claim rule conditions, click here. 

Claim Rule Types

The system can apply three types of Claim Rules to a claim: Service Grouping Rules, Line-Item Rules, and Claim Form Rules. Let's review them together! 

• Service Grouping Rules are created using the service rendered as the primary condition of the rule. These rules can be particularly useful for standalone services since the billing profile cannot be manually selected.

  Set indicators that ensure services with the same Claim Type, Claim Method, Bill-Type Prefix (Institutional), and 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.

  • Set Service Billing Profile
  • Set Claim Type To
  • Change Claim Delivery Method
  • Update Bill-Type Prefix
  • Update Place of Service
  • Allow for Multiple Services
  • Allow for Multiple Dates Per Claim
  • Add Patient Condition Codes

• Use a Claim Line-Item Rule when specific information, such as modifiers, secondary IDs, and rendering provider changes, needs to be altered at the line-item level. 

  • Add Modifiers
  • Add Rendering Provider Modifiers
  • Use Rendering Provider as Rendering Provider Name and NPI
  • Use Practice Billing Entity as Rendering Provider Name and NPI
  • Set Secondary Provider ID
• The Claim Form Rule is the simplest and most common type of claim rule. It provides various behaviors, such as adding, altering, or omitting specific information in a claim. 
  • Update Bill-Type Prefix
  • Update Bill-Type Suffix
  • Use Facility or Practice Address as Billing Provider Address
  • Use Facility or Practice NPI as Billing Provider NPI
  • Use Facility Name or Practice Name as Billing Provider Name
  • Manage Billing Provider Tax ID
  • Add or Remove Billing Provider Taxonomy Code
  • Add or Remove Condition Codes
  • Add or Remove Claim Form Service Names
  • Add or Remove Claim ID Decimal
  • Add Diagnosis Related Group (DRG) Code
  • Manage Diagnosis Present on Admission Flag
  • Use Custom Facility Name
  • Add or Remove Other Diagnoses
  • Add or Remove Service Line Note
  • Add or Remove Occurrence Codes
  • Add Claim Form Procedure Description
  • Add or Remove Patient Reason for Visit Code
  • Add or Remove the Blue Shield Provider Number
  • Add or Remove CLIA Number
  • Add Institutional Secondary Provider ID
  • Add PCS Codes
  • Add or Remove Patient Admit Date
  • Add or Remove Patient Admit Hour
  • Add or Remove the Patient Admit Type
  • Add or Remove Patient Admit Diagnosis
  • Add or Remove Patient Discharge Date
  • Add or Remove Patient Discharge Hour
  • Add or Remove Patient Discharge Status
  • Add or Remove Payer Claim Mailing Address 
  • Add or Remove Facility Taxonomy 
  • Add or Remove Facility Location Number
  • Add or Remove Facility DOH License Number