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Advanced Workflow Rules Engine (OP AWARE) Actions

Version 20.5
Path: Billing tab > More button (Customize group) > Advanced Workflow Rules

<< Return to the OP AWARE Triggers

Overview

After completing all of the applicable Triggers for the OP AWARE rule, the Actions section located on the right-side of the window must be completed in order to tell OP what to do with superbills that fit the criteria outlined for the rule. If you have not yet entered the rule Triggers, click here to return to the Triggers section of the workflow. There are seven different Actions, and each of them offer a unique set of fields for completing the rule. 

Edit

The Edit Action allows users to edit any CPT Code found in the specified CPT Group (when Group is selected as the Trigger) or replace the CPT Code (when Code is selected as the Trigger) with a specified code. The Edit action further allows the user to choose to add additional information to the CPT line. 

Example: All of your Insurance Payers require a 59 modifier on CPT Code 94664 when it is billed on the same claim as CPT Code 94640.

Detailed steps for creating an Edit rule can be shown/hidden by clicking:

Add

The Add action allows users to add an additional CPT Code to a claim. Additional information can also be selected to be added to that CPT Code. 

Example: All of your Insurance Payers require two 87804 CPT lines when an Influenza A/B test is performed. 

Detailed steps for creating an Add rule can be shown/hidden by clicking:

Remove

The Remove Action simply removes the CPT Code specified in the Triggers. This action does not apply to rules that have CPT Group set as the Trigger.

Example: One of your Insurance Payers has a front-end edit that rejects claims containing CPT Code 99000. You need to create a rule to remove 99000 when it is present on superbills for the Payer.

Detailed steps for creating a Remove rule can be shown/hidden by clicking:

Split

The Spilt Action splits the specified CPT Code or codes from the specified CPT Group and creates a separate superbill. The separate superbill can be routed to the same insurance or to a different one, selected in the Actions section. 

Example: Your practice performs Ear Piercing at Well Visits, but since it is not billable to Insurance, it must be split apart from the billable claim lines.

Aside from splitting billable services from non-billable services, Split rules are especially useful when specific CPT Codes that exist on the same superbill have to be sent to different Insurance Payers.   

Detailed steps for creating a Split rule can be shown/hidden by clicking:

Combine

The Combine Action takes two occurrences of a CPT code on a superbill and combines them into one CPT Code line. Detailed steps for creating a Combine rule can be shown/hidden by clicking:

Attach PCP

The Attach PCP Action allows a practice to attach the patient's PCP as the Rendering Provider on the claim when the Triggers have been met. This Action should be applied when the circumstance for adding the PCP is more specific than setting it at the Provider, Location, or Insurance Payer level. Detailed steps for creating an Attach PCP rule can be shown/hidden by clicking:

Override POS

The Override POS Actions allows a practice to override the Place of Service on a superbill when the Triggers have been met. A Place of Service must be selected in order to save this rule. Detailed steps for creating an Override POS rule can be shown/hidden by clicking:

After you have completed the Actions section of the rule building, click the Save button to save your rule.