Service Grouping Rule - Set Service Billing Profile for Current Sequence Payer

  • Updated

When submitting secondary claims, some payers may require a different revenue code or HCPCS/CPT code than what was billed to the primary payer. For example, Tricare might want to see a different CPT code than BCBS.

Set up a service billing profile with the coding needed for either payer, then use a Service Grouping rule to set the billing profile for when the claim is submitted to the primary or the secondary.

When using the Current Sequence Payer condition, the service billing profile selected will send to the payer based on the patient's profile coordination of benefits (COB). For example, if the rule is created to select a service billing profile for Tricare, the codes will send to the primary, secondary, or tertiary depending on the patient's profile.

Creating a rule to change the service billing profile

Before completing the steps below, make sure that the service billing profiles are created and referenced to the facility. To find more information on these steps, read more about how to Create a Service and Set Facility Rates.

  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 intended payer from the dropdown menu.
  6. Select the correct service under Service.
  7. Select option to Set Service Billing Profile.
  8. Check to Set Service Billing Profile, choose the Billing Profile that should be used.
  9. Ensure that Is Active is set to Yes.
  10. 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

I need to send different codes to the primary and the secondary payers, how do I accomplish this?

Set up a separate service grouping rule for each payer with the condition Current Sequence Behavioral Payer and the behavior to select the appropriate service billing profile. When closing and submitting to secondary, the claim should generate with the service billing profile that was selected in the claim rule, and the rate will copy from the primary claim.

 

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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