Charge Management Rule Examples

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 Provider Credentialing.


Error - At Least One Procedure has a $0.00 Fee

This is a System-delivered Charge Management Rule. The rule can be changed to be a warning, or it can be expired or deleted.

  • There is also an System Setting to allow or not allow $0.00 Procedure Line Fees.


Alert for Providers who are Credentialing with a specific Insurance

  • Go to the Insurance Library and select the Credentialing Required checkbox.

  • Create a Charge Management Rule.
  • Add Criteria
  • Insurance - Requires Credentialing equals Yes.
  • Billing Provider - ID equals (enter Provider ID)
  • Use Includes instead of equals if you want to include more than one Billing Provider. Separate by commas and no spaces.

Charge Management Rule for Self-Pay

To flag Patients that do not have Insurance attached, you can create a rule with the following criteria. When the Charge screen is saved, a warning will display.

  • For Charge Entry Validation, select Warning.
  • The word, PATIENT, must be entered in the Insurance (1) field. The lookup cannot be used.


Charge Management Rule for DME

Charge Management Rule for Medical Necessity Diagnosis Codes

For Procedure Codes that require specific Diagnosis Codes for medical necessity, you can create a rule to look for missing Diagnosis Codes for a designated Procedure Code and Payer.

  • Criteria: 
  • Policy - Insurance(1) - ID - EQUALS: the Insurance Policy that requires the Diagnosis Code(s).
  • Procedure - CPT - ID - EQUALS: The Procedure Code that requires Diagnosis Codes for medical necessity.
  • Validate by Line: Yes
  • Conditions:
  • Diagnosis - Diagnosis - All - DOES NOT INCLUDE: A comma separated list of Diagnosis Codes.
  • There should not be a space after the comma.

Charge Management Rule for Workers Compensation Claim Attachments

Some Worker's Compensation Claims require an attachment, but the attachment may not be available during Charge Entry. To flag the Worker's Comp Charges that do not have an attachment during the batching process, set up a Charge Management Rule with the following criteria and conditions.

  • Charge Entry Validation: None
  • Check the Batch Validation checkbox.
  • Criteria:
  • Policy - Insurance(1) - Reporting Group - EQUALS: WCOMP (Workers Comp)
  • OR;
  • Policy - Insurance(1) - CFI - EQUALS: WC (Workers Comp)
  • Conditions:
  • Encounter - Has Claim Attachment - EQUALS: N

Charge Management Rule for Workers Compensation Accident

If Worker's Comp Encounters require an Accident, create a Charge Management Rule with the following criteria. 

  • Select a Charge Entry Validation or Batch Validation
  • Criteria:
  • Policy - Insurance(1) - CFI - EQUALS: WCOMP (Workers Comp)
  • Encounter - Accident- EQUALS

Learn More



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