UR Required Services: Creating a New Billing Profile

Changes are needed for a subset of claims grouped under an existing billing profile. To resolve, create a new billing profile so the necessary changes only impact the subset group of claim, instead of all claims submitted with the current billing profile.

Example: A single billing profile is used for all out of network payers but the changes being made should only impact one of the out-of-network payer.

Do No Use: If a billing profile already exists for the group of claims. Example: Changes are needed for Aetna claims going forward and a billing profile already exists that is used exclusively for Aetna claims.

Create a New Billing Profile

Let's review the steps for creating a new billing profile to apply to a specific subset of claims and updating the UR plan for the impacted patients to use the new billing profile. 

1. Navigate to the patient’s Treatment Episode and open the Scheduling and Utilization tab.
2. From the UR tab, locate the UR plan used to submit the claim.
3. Tip: If it is not clear which UR plan will correct the claims, click edit to the right of the potential UR plan.
4. All associated claims are listed under the warning at the top.

5. Note the Service and Service Billing Profile selected on the UR plan.
6. Navigate to Practice Admin.
   Note: Only Admin users can access this tab. Contact one of your account admins to make the needed edits if this tab is not visible.
7. Open the Services tab and locate the service from the UR plan.
8. Click on the Service and open the Billing Profiles tab.
9. Click Create Service Billing Profile and set the Facility Rate for the new Service/Profile combination. See the Facility Rates section of this article.
10. Navigate to the patient's Treatment Episode > Scheduling and Utilization > UR tab.
11. Click Edit next to the UR plan used to submit the claim.
12. Under Service Billing Profile. Choose the newly created Billing Profile from the drop-down menu.
13. Save the Utilization Plan.
14. Navigate to the patient’s Insurance Billing tab and open the Review Corrections tab.
15. Click Check for Corrections and click Submit.
16. Once corrections populate, click Compare to view changes. Click here for more information on comparing claim versions.
17. Click Resolve to create a corrected claim.
18. Complete the Select Correction Action form as described in the Claim Corrections and Rejections article.
19. Once the corrected claim is created, send it to the payer from the Submit Claims tab in the Work Center > Insurance Claims.
20. If the desired corrections do not appear, refer to the Corrections Troubleshooting article.