Charge Management Action Examples

Charge Management Action Examples

Charge Management Action Examples 4.8


Add a Legacy ID in HCFA Box 33b for a Secondary Payer

Scenario: BCBSTX is Primary and MagnaCare is Secondary.

  • MagnaCare wants a Legacy ID in Box 33b on the HCFA (Paper Claim), but the Primary, BCBSTX, does not require this.

Criteria

  • Select Policy-Insurance (2) - ID > EQUALS > 109 (MagniCare ID)
  • Encounter - Is Reversed > DOES NOT EQUAL > Yes

Actions

  • Claim Insurance: Select the Insurance you want to change
  • In this case, 109 (MagniCare)
  • Select HCFA Legacy ID - 33B from the Field dropdown.
  • Action: Select Replace on Claim.
  • Value: Enter the Legacy ID that you want on the Secondary Paper Claim.

Test Validation Rule

  • Before saving, Test the Rule to verify that the Action is working the way you intended.
  • Select the Test All Encounters button.
  • In the Will Trigger Validation panel, select one of the Encounter links to verify the action is working.

  • Select Save [F2].


Validation Panel on the Encounter Dashboard

The Charge Management Action displays in the Validation Panel on the Encounter Dashboard.


Include Rendering in Loop 2420A

Scenario: If AETNAMCR is Primary or Secondary, the Rendering needs to be in Loop 2420A.

Criteria

  • Policy-Insurance ID (1) > EQUALS > AETNAMCR
  • Select the or link.
  • Policy-Insurance ID (2) - EQUALS > AETNAMCR

Conditions

  • Encounter - Is Reversed > DOES NOT EQUAL > Yes

Actions

  • Claim Insurance: Select BCBSTX
  • Select Include Rendering - ANSI 2420A from the Field dropdown.
  • Action: Select Replace on Claim.

Test Validation Rule

  • Before saving, Test the Rule to verify that the Action is working the way you intended.
  • Select Save [F2].

Loop 2420A

e


Include Taxonomy in Loop 2000A

Scenario: If BCBSTX is Primary or Secondary, the Rendering should be in Loop 2000A.

  • Charge Entry Validation: Select None or Warning
  • Warning will display a Validation Warning when the Encounter is saved.
  • Batch Validation: Uncheck
  • Validation Message: Enter the Message that the User will see.


Criteria

  • Policy-Insurance ID (1) > EQUALS > BCBSTX
  • Select or.
  • Policy-Insurance ID (2) - EQUALS > BCBSTX

Conditions

  • Procedure - DOS: > GREATER THAN OR EQUALS TO > 09/01/2024

Actions

  • Claim Insurance: Select BCBSTX
  • Select Taxonomy - ANSI 2000A from the Field dropdown.
  • Action: Select Replace on Claim.



Test Validation Rule

  • Before saving, Test the Rule to verify that the Action is working the way you intended.

  • Select Save [F2].


Change a Procedure Code

Scenario: Medicare requires a different Procedure Code on the Claim than other Payers.

Details Panel

  1. Description: Enter a Description to identify the Charge Action.
  2. Charge Entry Validation:
  • Warning: Displays a Validation Pop-Up each time the CPT is being changed, and allows the User to Save the Charge with the change.
  1. Batch Validation: Uncheck
  2. Validate When Conditions Are: Met
  3. Enter a Validation Message that will appear in the Pop-Up when the Save button on the Charge is selected.


Criteria Panel

  1. Select the Add Criteria Parameter link.
  • The Procedure Code must be entered in the Criteria panel not the Conditions panel.
  • Select Procedure > Procedure - CPT ID
  • EQUALS
  • Enter the Procedure Code to be changed.
  1. Validate by Line: Yes must be chosen.


Conditions Panel

To include Primary and Secondary:

  1. Select the Add Condition Parameter link.
  • Select Policy > Policy - Insurance (1) - ID.
  • Select CONTAINS.
  • Select or enter the Insurance ID.
  1. Select the OR link.
  • Select Policy > Policy - Insurance (2) - ID.
  • Select CONTAINS.
  • Select or enter the Insurance ID.


Actions Panel

  1. Field: Select Procedure Code.
  2. Action: Select one of the following.
  • Replace on Claim: This only changes the Procedure Code on the Claim itself. It will not be seen on the Encounter.
  • Use Case: When you have Primary and Secondary Insurances, you may want to see the original Procedure Codes on the Encounter.
  • Replace on Encounter & Claim: This changes the Claim and the Encounter.
  • Use Case: When there is a Primary Insurance only.
  1. Value: Enter or lookup the Procedure Code you want to change to.


Test Validation Rule

  1. Use the Test options to ensure that you are getting the intended results.
  2. After testing, select Save [F2].


Add a Value Code and Value Amount

Scenario: Include Value Code and Value Amount on the UB04 Box 39a and ANSI Institutional Loop 2300 for a specific Insurance or Insurance Group.

  • This will override any pre-existing Value Codes and Amounts.


Details Panel

  1. Description: Enter a Description to identify the Charge Action.
  2. Charge Entry Validation:
  • Warning: Displays a Validation Pop-Up each time the Value Code is being changed or added, and allows the User to Save the Charge with the modification.
  1. Batch Validation: Uncheck
  2. Validate When Conditions Are: Met
  3. Enter a Validation Message that will appear in the Pop-Up when the Save button on the Charge is selected.


Criteria Panel

  1. Select the Add Criteria Parameter link.
  • The Insurance or Insurance Group must be entered in the Criteria panel, not the Conditions panel.
  • Select Policy - Insurance (1) - ID
  • EQUALS
  • Look up or enter the Insurance to be changed.


Conditions Panel

Use only if there are other Conditions that need to be considered when adding the Value Code/Amount.


Actions Panel

  1. Claim Insurances: Add the Insurances on the Claims that should be considered.
  2. Field: Select Value Code - ANSI.
  3. Action: Select one of the following:
  • Replace on Claim: This only changes the Value Code on the Claim itself. It will not be seen on the Encounter.
  • Replace on Encounter & Claim: This changes the Claim and the Encounter.
  1. Value: Enter the Value Code and Amount separated by a forward slash.
  • Example: 85/44216

Use the Plus icon to add a second line for the UB04.

  1. Field: Select Value Code - UB04
  2. Action: Same as above.
  3. Value: Enter the Value to go in Box 39a on the UB04 with the same format as above.


Test Validation Rule

  1. Use the Test options to ensure that you are getting the intended results.
  2. After testing, select Save [F2].


Value Code Charge Management Action Results

UB04 Box 39a

ANSI Loop 2300


Learn More

Charge Management Actions

Charge Management Tag and Worklist Assignment

Charge Management Rules

Charge Management Rule Examples

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