Service Grouping Rule - Changing Claim Form Type

  • Updated

Some payers may require a different claim type than what you normally send. For example, Beacon Health might want to see Drug Screening services on professional forms, while BCBS wants to see them on institutional forms. Set up the service billing profile to the default claim type that you'll send to most payers, then set up a service grouping rule to send the other claim form type to the other payers.

Creating a rule to change claim form type

  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.
  5. Check Current Sequence Behavioral Payer and select the correct payer from the drop-down menu.
  6. Select the correct service under Service.
  7. Select option to Set Values.
  8. Check Set Claim Type to, choose Professional or Institutional.
  9. (Optional) Check Set Place of Service to, choose one if it needs to be different from the service billing profile.
  10. Ensure that Is Active is set to Yes.
  11. Click Create.

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Correcting the claims that were previously submitted

If there are existing claims that need to be corrected to the new form, you have two options:

  1. Go to the patient profile > Insurance Billing> Review Corrections. Check for Corrections and Resolve the claims to change the claim form type.

    OR
  2. Wait for the correction generator to run overnight and check back to the Work Center > Insurance Claims > Create Corrected Claim tab for all patients that were affected by the new claim rule.

FAQ

My rule isn't working. What do I need to check?

  1. Check the order of your rule compared to other rules. Are there any conflicting conditions and behaviors in rules after your rule?
  2. Check the service billing profile for the institutional and professional claim form required fields. 
    • Institutional forms require a revenue code and bill type prefix.
    • Professional forms require a professional place of service and professional service line.
  3. Check that both the institutional and professional rates are added in Practice Admin > Facilities > Facility Services.

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