Service Grouping Claim Rules

The service grouping rule allows users to make changes for individual services and set the conditions for when to make the change.

This type of claim rule is especially useful for standalone services because standalone services do not have the option to manually select a billing profile in the claim creation process. Instead, they require claim rules to select non-default billing profiles.

Regardless of service type, claim rules are appropriate if there are fixed conditions that should trigger changes.

This article covers the following topics:

• Creating a rule to change a service grouping
• Example 1 - Using Set Service Billing Profile to select a specific billing profile
• Example 2 - Using Set Values Behavior to change Place of Service
• Example 3 - Using Set Values Behavior to Disallow Multiple Dates Per Claim

Creating a rule to change a service grouping

There are two options for a service grouping rule:

• Setting the service billing profile
• Setting a specific service grouping value

First, changes needed to update the rate, HCPCS, or Revenue Code will require another billing profile. For help creating billing profiles please see, How to Create a Service and Set Rates. After the service billing profile is created, use the Set Service Billing Profile behavior to change the billing profile when certain conditions are met. See Example 1 below for an example of how this works.

Second, specific grouping changes to Claim Type, Claim Method, Bill Type Prefix, Place of Service, Allow Multiple Dates Per Claim, and Allow Multiple Services Per Claim can be made without having a separate billing profile. See Example 2 and Example 3 for how this can work.

Example 1 - Using Set Service Billing Profile to select a specific billing profile

Detox claims submitted to Aetna keep denying for incorrect CPT codes. An Aetna-specific billing profile has been built out, but the UR manager does not always remember to select this profile for Aetna patients. Every claim billed out with the incorrect CPT codes need to be corrected.

1. Navigate to Management Center click into Claim Rules.
2. Select the Organization and Practice from the drop-down menus.
3. Click Create Service Grouping Rule.
4. Name the rule.

TIP: Use the naming convention "Condition Service – Behavior". This ensures that the rule’s impact and scope are easily distinguishable from other claim rules. The rule for this example might be named, "Aetna DTX - use Aetna Billing Profile".

5. Checkmark Primary Behavioral Payers and select Aetna from the drop-down menu. Leave other fields under condition unchecked.
6. Select DTX under Service.
7. Select option to Set Service Billing Profile.
8. Next to Set Service Billing Profile, choose the Billing Profile that should be used when sending DTX claims to Aetna.
9. Ensure that Is Active is set to Yes.
10. Click Create.
    
    Since this rule is active at the baseline, corrections will generate overnight for all claims that meet the conditions but were submitted with different information than what the behavior specifies. In this example, DTX claims submitted to Aetna that went out with the incorrect CPT codes will have corrections generated to change that CPT code to the one specified in the DTX Aetna Billing Profile.

 

Example 2 - Using Set Values Behavior to change Place of Service

Lab Test services for this treatment center are usually billed as institutional from the Inpatient Psychiatric Facility. However, when Lab Tests are billed to Humana as the medical payer, the claims must go out as Professional and have place of service code 81 for an Independent Lab. Claims started to deny for this in the spring and corrections are needed for claims rendered in and after April. You also found out that these changes will be needed for Value Options starting in August.

1. Navigate to Management Center click into Claim Rules.
2. Select the Organization and Practice from the drop-down menus.
3. Click Create Service Grouping Rule.
4. Name the rule.

TIP: Use the formula "Condition Service – Behavior". This ensures that the rule’s impact and scope are easily distinguishable from other rules. The rule for this example might be named, "Humana Lab test - Prof POS 81".

5. Check Current Sequence Medical Payer and select Humana from the drop-down menu.
6. Select Lab Test under Service.
7. Select option to Set Values.
8. Check Set Claim Type to, choose Professional.
9. Check Set Place of Service to, choose 81 – Independent Laboratory.
10. Ensure that Is Active is set to No.
11. Click Create.
12. Click into the rule.
13. Click Create Scheduled Change Set.
14. Set the date of the scheduled change and Create.
15. Click the pencil next to the schedule change date.
16. Switch Is Active to Yes and Save.
    Scheduled Change Sets impact claims by date of service. In this example, the scheduled change set would be added for 4/1/18. This means that claims for dates of service 4/1/18 and onward would be impacted by this rule. The rule was inactive before 4/1/18 so it would not impact or prompt corrections for claims with dates of service before that date.
17. To add Value Options to this rule as of 8/1, click Create Scheduled Change Set.
18. Set the date of the scheduled change and Create.
19. Edit the name of the rule to add the other payer. The name of this rule would be "Humana, Value Options Lab test - Prof POS 81".
20. Click Add Payer under Current Sequence Medical payers.
21. Select Value Options from the drop-down menu.
22. Click Save.

Example 3 - Using Set Values Behavior to Disallow Multiple Dates Per Claim

Going forward, Aetna claims for Equestrian Therapy cannot be billed with other services and must only have one date per claim.

1. Navigate to Management Center click into Claim Rules.
2. Select the Organization and Practice from the drop-down menus.
3. Click Create Service Grouping Rule.
4. Name the rule.

TIP: Use the formula "Condition Service – Behavior." This ensures that the rule’s impact and scope are easily distinguishable from other rules. The rule for this example might be named, Equestrian Therapy - One Unit per Claim.

5. Check Current Sequence Behavioral Payers and select Aetna from the drop-down menu.
6. Select Equestrian Therapy under Service.
7. Select option to Set Values.
8. Check Set Allow Multiple Dates Per Claim and ensure it is toggled to No.
9. Check Set Allow Multiple Services Per Claim and ensure it is toggled to No.
10. Ensure that Is Active is set to No.
11. Click Create.
12. Click into the rule.
13. Click Create Scheduled Change Set.
14. Set the date of the scheduled change and Create.
15. Click the pencil next to the schedule change date.
16. Switch Is Active to Yes and Save.
    Scheduled change sets impact by date of service. In this example, the scheduled change set would be added for the current date. This means that no corrections would be prompted for claims that have already been billed. Instead, the rule would only impact claims going forward.