Charge Management Action Examples

Charge Management Action Examples

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


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].

      
      


Learn More

Charge Management Actions

Charge Management Rules


    • Related Articles

    • Charge Management Actions

      Release 4.8 Some Payers require different information on a Claim that other Payers do not require. Some of those changes can be accomplished using the Charge Management Update panel on the Add/Modify Charge Management Rule screen. The change occurs ...

    • Charge Management Rule Examples

      Alert for Provider Credentialing There is a System delivered Charge Management Rule to display a Validation Warning for Providers who are not yet Credentialed with a Specific Insurance. Use this link for more detailed documentation: Hold Billing for ...

    • Charge Management Tag and Worklist Assignment

      Assign a Tag to a Charge Management Rule Access: Libraries > Charge Management Rules When a Tag is assigned to a Charge Management Rule, and the Charge meets the Rule's criteria, the Tag will be auto-assigned to the Encounter. On the Add/Modify ...

    • ERA Management Profiles, Rules, and CARC Crosswalk

      The System-delivered ERA Management Profile includes 22 Rules for ERA Payment posting. Additional ERA Profiles must be created to add new Rules based on the Insurance or Billing Group. Events override any Rules that are created. ERA Profiles Add a ...

    • Charge Management Rules

      Using the Charge Management Rules, create Validation Rules to catch common errors before Claims are sent to the Payer. These Rules are customizable to suit the specific needs of your practice. Using these rules can reduce the amount of rejected ...