Create and Manage Service Billing Profiles

A billing profile guides the system in generating each claim by including details like the procedure code, revenue code, and place of service. Each service in the RCM must have at least one primary billing profile linked to it, not only to provide a blueprint for the claim but also to assign a facility rate (charge) associated with the service.
 

User Permissions

Only users with admin-level profiles can create and manage service billing profiles. For more information on user profiles and permissions, click here. 

Billing Profile Types and Settings

Service Billing Profiles are configured for institutional and professional services. In contrast, non-medical services do not require a billing profile, as they are always created as private-pay (patient-billable) claims. Every service created will have a default billing profile assigned, but how and when the system uses that profile will depend on the service type. 

• Standalone Services: The system will automatically use the default billing profile set within the service. However, this can be changed by editing the service in the Attendance Calendar or by using a Service Grouping Rule.
• U/R-required Services: The system will use the billing profile referenced within the patient's U/R plan. However, this can be changed by using a Service Grouping Rule.

Profile Type	Claim Form Service Name	Revenue Code	Procedure Code	Bill-Type Prefix	Place of Service	Unit Measurement
Institutional	Required	Required	Optional	Required	N/A	Days
Professional	Required	N/A	Required	N/A	Required	Units

Billing Profile Settings and Definitions

HCPCS Unit Measurement: This setting instructs the system whether to measure the amount of services rendered in days or units. Allow Partial Units: This is used for Medication Assisted Treatment (MAT) Billing. Allow Zero Units: This setting is for MAT Billing. Allow Multiple Services Per Claim: When enabled, claims can be created using two or more different services. Allow Multiple Units Per Claim: When enabled, an individual claim may contain multiple units recorded for the same service. Allow Multiple Dates Per Claim: When enabled, an individual claim may span multiple dates of service. Allow Multiple Months Per Claim: When enabled, an individual claim may span multiple months. Itemize 837I Claims: This setting will create itemized EDI files for institutional claims. Itemize 837P Claims:This setting will create itemized EDI files for professional claims. Write Present on Admission Indicator: When enabled, the present-on-admission indicator will appear on the claim with the primary diagnosis code. Can Inherit Referring Rendering Provider: When enabled, services without a referring rendering provider may be combined with services that have a referring rendering provider on a claim. Prevent Multiple Same Service Entries on the Same Day: When enabled, a claim cannot be created when two entries for the same service fall on the same day. NDC Code: When enabled, this setting allows organizations to complete MAT billing. For more information on NDC codes, click here. Rate Code: This field is used in conjunction with value code 24. For more information on Value Codes, click here. Sequence Priority: The sequence number indicates the priority of service display on a claim with multiple recorded services. A lower number means the service will appear higher in the list.

Create Service Billing Profiles

Let's review how to create Service Billing Profiles! 

1. In the Practice Admin section, click Service.
   
    
2. Next, click on the desired service.
   
3. In the Service window, click the Billing Profiles tab.
    
4. Next, click Create Service Billing Profile.
    

5. Enter the Profile Name and Claim Form Service Name.

   Note: A rule must be in place before the Claim Form Service Name will be added to the claim. 

   

6. Update the Default Claim Payer when appropriate.
   

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  7. Update the Preferred Claim Type drop-down to Institutional. Toggle on the Require Preferred Claim Type to limit the claim form creation to only the institutional claims.
     
  8. Next, enter the necessary information in the Institutional Revenue Code and Bill-Type Prefix fields.
     

  9. When applicable, include the HCPCS/CPT code and institutional modifier.

     Note: A Claim Form Rule must be in place before service modifiers will be added to the claim. 

     

  10.  Update the HCPCS Unit Measurement Basis field from Days to Units when appropriate.
       
  11. Then toggle on/off any of the following settings for additional configuration.
      
  12. Finally, click Create to complete the process.
       
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  7. Update the Preferred Claim Type drop-down to Professional. Toggle on the Require Preferred Claim Type to limit the claim form creation to only the professional claims.
     
  8. Next, update the professional place of service.
     
  9. Then change the HCPCS unit measurement basis from Days to Units when appropriate.
      
  10. Toggle on/off any of the following settings for additional configuration.
      
  11. Then click Create.
      
  12. In the Billing Profiles screen, click on the profile name.
      
  13. Next, click Professional Service Lines.
      
  14. Click Create Service Line.
      
  15. Enter the HCPCS/CPT code.
      

  16. Add any modifiers when appropriate.

      Note: A Claim Form Rule must be in place before service modifiers will be added to the claim. 

      

  17. If more than one professional service line is referenced, update the Order field to indicate which HCPCS/CPT code the system should use first.
       
  18. Finally, click Create to complete the process.
       

Manage Service Billing Profiles

If you are making changes to previously billed profiles, the system will attempt to generate corrections. For more information on corrections, click here.

• Let's review how to manage an existing billing profile!
  1. From the Practice Admin, click the Services tab.
     
  2. Next, click on the Service Name.
     
  3. From the Service window, click the Billing Profiles tab.
     
  4. Click on the Profile Name.
     
  5. If you wish to alter the billing profile from its original configuration, click the edit icon next to  Baseline. This will generate corrections for all claims created using the billing profile.
     
  6. If you wish to alter the billing profile to affect only certain claims based on their service date, click Create Scheduled Change Set.
     
  7. Enter the effective date and click Save.
     
  8. Next, click the edit icon.
     
  9. Make the desired changes to any fields and/or settings and click Save to complete the process. 
     

Helpful Hints

Let's review some helpful hints for working with service billing profiles!

• No. Billing profiles used to bill claims cannot be deleted; they can only be deactivated. To do so, use this process, then at step 9, toggle off Is Active and click Save to complete the process.
• Claim rules are used to modify the content of a claim without changing the overall configuration of the billing profile or creating a new profile. Review the rules below to determine if any one of them is a good fit.
  Institutional Claims:
  Bill-Type Prefix - Claim Form Rule or Service Grouping Rule
  Bill-Type Suffix
  Add or Remove Value Codes (required to include value code 24 on the claim)
  
  Professional Claims:
  Update Place of Service
  
  Both Claim Types:
  Add or Remove Claim Form Service Name (required to include Claim Form Service Name on the claim)
  Add Modifiers (required to add modifiers from the billing profile on the claim)
  Set Service Billing Profile
  Set Claim Type To
  Allow for Multiple Services
  Allow for Multiple Dates Per Claim
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  • Naming Conventions: We recommend creating a single billing profile labeled All Payers and configuring it to include the most common information payers typically want to see on a claim. If one payer's requirements differ from the group's, determine whether a new billing profile is needed or a claim rule can be created to update the desired information.
  • Using Scheduled Change Sets: If a billing profile has been used in over 50 claims and only a few require modifications, we suggest using a Scheduled Change Set. These sets direct the system to apply changes exclusively to claims with a DOS on or after the date specified in the set. This approach helps prevent unnecessary corrections from being flagged for review.