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.

• LIMITSAVES: DO NOT ALLOW SAVING OF PROCEDURE LINES WITH ZERO DOLLAR TOTALS

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.

• Criteria: Insurance (1) - ID EQUALS PATIENT

• 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

Criteria and Condition Fields: Includes vs Contains and Multi-Select Fields

Multiple Entries in a Field using Includes

Example 1

• Multiple consecutive CPT Codes: Validate Encounters that have one of these Office Visit Codes: 99212, 99213, 99214, and 99215.

• For CPT - ID select Includes and enter: 99212-99215 (use dash with no space)
• If an Encounter contains one of these CPT codes, the Validation Warning or Error will be triggered.

• Multiple non-consecutive CPT Codes: 77422 and 77424

• For CPT - ID select Includes and enter: 77422,77424,77427 (comma separation with no space)
• If an Encounter contains either one of these CPT codes, the Validation Warning or Error will be triggered.

Example 2

• Multiple Providers: Validate Encounters with Providers, AK and SW

• For Billing Provider - ID, select Includes and enter AK,SW (comma separation with no space)
• If the Billing Provider is either AK or SW, the Validation Warning or Error will be triggered.

Example 3

• Validate Encounters that have specific combinations of CPT Codes, such as 99214 and 77424.

• Criteria: Procedure - CPT - ID select Includes and enter 99214
• Conditions: Procedure - CPT - ID: select Includes and enter 77424.
• If an Encounter contains both of the CPT Codes, the Validation Warning or Error will be triggered.

Example 4

• Validate Encounters that have a range of specific combinations of CPT Codes, such as 99212-99215 and 77422-77427.

• Criteria: Procedure - CPT - ID select Includes and enter 99212-99215
• Conditions: Procedure - CPT - ID select Includes and enter 77422-77427
• If an Encounter contains an Office Visit Procedure Code (99212-99215) in combination with at least one of the Procedure Codes, 77422-77427, the Validation Warning or Error will be triggered.

Combination of Criteria and Conditions using Contains

Example 1

• Validate Encounters that have specific combinations of CPT Codes, such as Office Visit (99212-99215) and Radiation Treatment (77422-77427).

• Criteria: Procedure - CPT - ID select Contains and enter 9921 (leave off the last digit)
• Conditions: Procedure - CPT - ID: select Contains and enter 7742 (leave off the last digit)
• If an Encounter contains any Procedure Code beginning with 9921 and Procedure Code beginning with 7742, the Validation Warning or Error will be triggered.

Example 2

• Validate Patients that have Type 2 Diabetes as Diagnosis 1 and Hypertension as Diagnosis 2.

• Criteria: Diagnosis - Diagnosis 1: select Contains and enter E11
• Conditions: Diagnosis - Diagnosis 2: select Contains and enter I10
• If an Encounter has Dx 1 as Type 2 diabetes and Dx 2 as Hypertension, the Validation Warning or Error will be triggered.

Learn More

• Charge Management Rules

• Charge Management Tag and Worklist Assignment