Change Rendering Provider Type

Some clients may experience rejections when the Billing Provider and the Rendering Provider are the same entity. Use this claim rule to update the type of rendering provider on a professional claim form.

Workflow

Let's review how to update the rendering provider type on a professional claim form.

1. Navigate to Management Center > Claim Rules.
   
2. Click Create Claim Form  Rule.
3. Select the Practice.
   
4. Next, give the rule a name.
5. Update the Claim Type drop-down to Professional and change the order of the rule when applicable.
6. Then select Conditions to create criteria a claim should meet before the rule will apply.
7. Next, click on the Behaviors drop-down, select Rendering Provider Type, then click Add.
8. Update the drop-down to one of the following choices:
   1. Individual to create the claim as normal, with the rendering provider's first and last name displayed on two separate lines.
   2. Organization to create the claim with the rendering provider's first and last name displayed on a single, individual line.
      
9. To create multiple behaviors, repeat steps 7 and 8.
10. Click Save to complete the process.
    

Box Number(s)

• UB-04: N/A
• CMS-1500: Box 31- Signature of Physician or Supplier Including Degrees and Credentials

Frequently Asked Questions and Helpful Hints

Let's review some helpful hints and some more commonly asked questions!

Frequently Asked Questions

• The best way to determine if a scheduled change set is appropriate is to gauge how many claims will be affected. For example, if you want the rule to apply to previously billed claims as well as new claims going forward, create the rule without a scheduled change set. 
  
  However, if you want the rule to apply only to newly created claims, use a scheduled change set to instruct the system to look only for claims with dates of service on or after the set date. For more information on scheduled change sets, click here.
• If you are creating the rule to apply to previously billed claims, navigate to the Patient > Treatment Episode > Claims > Review Corrections section and click Check For Corrections. If corrections are generated, follow the process outlined here to complete the process. If no claims are flagged for rejection, click here to troubleshoot the rule why the rule may not be applying.

Helpful Hints

If one of your conditions is payer-based, select any applicable Current Sequence options instead of the Primary Behavioral Payer. This will ensure the rule applies to secondary and tertiary claims when needed. To read more about how to set claim rule conditions and order, see the Claim Rule: Setting Claim Rule Conditions article.