Advanced Workflow Rules Engine (OP AWARE) Actions
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Last Modified on 08/12/2022 2:25 pm EDT
Version 20.10
Path: Billing tab > More button (Customize group) > Advanced Workflow Rules
<< Return to the OP AWARE Triggers
About
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.
| Note: The Audit Trail of Changes to records located in the Audit Logs window will contain log messages when a billing rule is created or modified. |
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:
Use the table below to complete the Edit Actions for the rule.
a | Select Edit from the Action drop-down menu. |
b | When Group is selected as the Trigger, the specified Group name is displayed in bold (ex: Billing Group 1 as pictured above). There is no selection to be made here. | When Code is selected as the Trigger, that Code is displayed in bold.- In the Replace CPT above with field, enter (or search for and select) the CPT code that will replace the code listed.
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c | This section gives the practice the ability to include modifiers (up to 4) for the CPT Group or Code.- Select the appropriate Modifier(s) 1-4 from the drop-down menus.
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d | This section gives the practice the ability to place the Modifiers selected in above section in a specific order.- Select the appropriate radio button to:
- Add the Modifier(s) selected to the end after pre-existing modifiers on the claim.
- Insert the Modifier(s) selected before pre-existing modifiers on the claim.
- Replace any pre-existing modifiers with the modifier(s) selected above.
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e | This section gives the practice the ability to add the following information, when needed:- Select the EPSDT indicator Y or N from the drop-down menu.
- Select the EPSDT 2 Code from the drop-down menu.
- Select the Units to be added to the specified CPT Code or Group.
- Select the Diagnosis Code to be added to the specified CPT Code or Group.
- Select the Diagnosis Group to be added to the specified CPT Code or Group.
- Enter the NDCID to be added to the specified CPT Code or Group.
- Enter a Claim Note to be added to the Reference Info section of the claim, such as if the payer requires a note that says "under mother's insurance" for newborn claims.
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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:
Use the table below to complete the Add Action for the rule.
a | Select Add from the Action drop-down menu. |
b | This section gives the practice the ability to choose the CPT Code that will be added to the claim. - Enter the CPT Code that should be added, or click the ellipsis button to search for and select the CPT Code.
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c | This section gives the practice the ability to include modifiers (up to 4) for the CPT Code selected in the above section.- Select the appropriate Modifier(s) 1-4 from the drop-down menus.
|
d | This section gives the practice the ability to place the Modifiers selected in above section in a specific order.- Select the appropriate radio button to:
- Add the Modifier(s) selected to the end after pre-existing modifiers on the claim.
- Insert the Modifier(s) selected before pre-existing modifiers on the claim.
- Replace any pre-existing modifiers with the modifier(s) selected above.
|
e | This section gives the practice the ability to add the following information, when needed, to the added CPT line:- Select the EPSDT indicator Y or N from the drop-down menu.
- Select the EPSDT 2 Code from the drop-down menu.
- Select the Units to be added to the specified CPT Code or Group.
- Select the Diagnosis Code to be added to the specified CPT Code or Group.
- Select the Diagnosis Group to be added to the specified CPT Code or Group.
- Enter the NDCID to be added to the specified CPT Code or Group.
- Enter a Claim Note to be added to the Reference Info section of the claim, such as if the payer requires a note that says "under's mother's insurance" for newborn claims.
|
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:
Use the table below to complete the Remove Action for the rule.
a | Select Remove from the Action drop-down menu. The CPT Code selected in the Triggers section is displayed in bold. |
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:
Use the table below to complete the Split Action for the rule.
a | Select Split from the Action drop-down menu. The CPT Code or Group selected in the Triggers section is displayed in bold. |
b | This section gives the practice the ability to choose the Insurance Payer that will be attached to the separate superbill. - Select the Insurance Payer that should replace the Insurance Payer on the original superbill.
|
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:
Use the table below to complete the Combine Action for the rule.
a | Select Combine from the Action drop-down menu. The CPT Code selected in the Triggers section is displayed in bold. |
b | This section gives the practice the ability to include modifiers (up to 4) for the combined CPT Code selected in the above section.- Select the appropriate Modifier(s) 1-4 from the drop-down menus.
|
c | This section gives the practice the ability to place the Modifiers selected in above section in a specific order.- Select the appropriate radio button to:
- Add the Modifier(s) selected to the end after pre-existing modifiers on the claim.
- Insert the Modifier(s) selected before pre-existing modifiers on the claim.
- Replace any pre-existing modifiers with the modifier(s) selected above.
|
d | This section gives the practice the ability to add the following information, when needed, to the added CPT line:- Select the EPSDT indicator Y or N from the drop-down menu.
- Select the EPSDT 2 Code from the drop-down menu.
- Select the Units to be added to the specified CPT Code or Group.
- Select the Diagnosis Code to be added to the specified CPT Code or Group.
- Select the Diagnosis Group to be added to the specified CPT Code or Group.
- Enter the NDCID to be added to the specified CPT Code or Group.
- Enter a Claim Note to be added to the Reference Info section of the claim, such as if the payer requires a note that says "under's mother's insurance" for newborn claims.
|
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:
Use the table below to complete the Attach PCP Action for the rule.
a | Select Attach PCP from the Action drop-down menu. |
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:
Use the table below to complete the Override POS Action for the rule.
a | Select Override POS from the Action drop-down menu. |
b | This section gives the practice the ability to choose the Place of Service that will be override the Place of Service on the superbill. - Select the Place of Service that should replace the Place of Service on the superbill.
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After you have completed the Actions section of the rule building, click the Save button to save your rule.
Version 20.8
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:
Use the table below to complete the Edit Actions for the rule.
a | Select Edit from the Action drop-down menu. |
b | When Group is selected as the Trigger, the specified Group name is displayed in bold (ex: Billing Group 1 as pictured above). There is no selection to be made here. | When Code is selected as the Trigger, that Code is displayed in bold.- In the Replace CPT above with field, enter (or search for and select) the CPT code that will replace the code listed.
|
c | This section gives the practice the ability to include modifiers (up to 4) for the CPT Group or Code.- Select the appropriate Modifier(s) 1-4 from the drop-down menus.
|
d | This section gives the practice the ability to place the Modifiers selected in above section in a specific order.- Select the appropriate radio button to:
- Add the Modifier(s) selected to the end after pre-existing modifiers on the claim.
- Insert the Modifier(s) selected before pre-existing modifiers on the claim.
- Replace any pre-existing modifiers with the modifier(s) selected above.
|
e | This section gives the practice the ability to add the following information, when needed:- Select the EPSDT indicator Y or N from the drop-down menu.
- Select the EPSDT 2 Code from the drop-down menu.
- Select the Units to be added to the specified CPT Code or Group.
- Select the Diagnosis Code to be added to the specified CPT Code or Group.
- Select the Diagnosis Group to be added to the specified CPT Code or Group.
- Enter the NDCID to be added to the specified CPT Code or Group.
- Enter a Claim Note to be added to the Reference Info section of the claim, such as if the payer requires a note that says "under mother's insurance" for newborn claims.
|
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:
Use the table below to complete the Add Action for the rule.
a | Select Add from the Action drop-down menu. |
b | This section gives the practice the ability to choose the CPT Code that will be added to the claim. - Enter the CPT Code that should be added, or click the ellipsis button to search for and select the CPT Code.
|
c | This section gives the practice the ability to include modifiers (up to 4) for the CPT Code selected in the above section.- Select the appropriate Modifier(s) 1-4 from the drop-down menus.
|
d | This section gives the practice the ability to place the Modifiers selected in above section in a specific order.- Select the appropriate radio button to:
- Add the Modifier(s) selected to the end after pre-existing modifiers on the claim.
- Insert the Modifier(s) selected before pre-existing modifiers on the claim.
- Replace any pre-existing modifiers with the modifier(s) selected above.
|
e | This section gives the practice the ability to add the following information, when needed, to the added CPT line:- Select the EPSDT indicator Y or N from the drop-down menu.
- Select the EPSDT 2 Code from the drop-down menu.
- Select the Units to be added to the specified CPT Code or Group.
- Select the Diagnosis Code to be added to the specified CPT Code or Group.
- Select the Diagnosis Group to be added to the specified CPT Code or Group.
- Enter the NDCID to be added to the specified CPT Code or Group.
- Enter a Claim Note to be added to the Reference Info section of the claim, such as if the payer requires a note that says "under's mother's insurance" for newborn claims.
|
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:
Use the table below to complete the Remove Action for the rule.
a | Select Remove from the Action drop-down menu. The CPT Code selected in the Triggers section is displayed in bold. |
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:
Use the table below to complete the Split Action for the rule.
a | Select Split from the Action drop-down menu. The CPT Code or Group selected in the Triggers section is displayed in bold. |
b | This section gives the practice the ability to choose the Insurance Payer that will be attached to the separate superbill. - Select the Insurance Payer that should replace the Insurance Payer on the original superbill.
|
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:
Use the table below to complete the Combine Action for the rule.
a | Select Combine from the Action drop-down menu. The CPT Code selected in the Triggers section is displayed in bold. |
b | This section gives the practice the ability to include modifiers (up to 4) for the combined CPT Code selected in the above section.- Select the appropriate Modifier(s) 1-4 from the drop-down menus.
|
c | This section gives the practice the ability to place the Modifiers selected in above section in a specific order.- Select the appropriate radio button to:
- Add the Modifier(s) selected to the end after pre-existing modifiers on the claim.
- Insert the Modifier(s) selected before pre-existing modifiers on the claim.
- Replace any pre-existing modifiers with the modifier(s) selected above.
|
d | This section gives the practice the ability to add the following information, when needed, to the added CPT line:- Select the EPSDT indicator Y or N from the drop-down menu.
- Select the EPSDT 2 Code from the drop-down menu.
- Select the Units to be added to the specified CPT Code or Group.
- Select the Diagnosis Code to be added to the specified CPT Code or Group.
- Select the Diagnosis Group to be added to the specified CPT Code or Group.
- Enter the NDCID to be added to the specified CPT Code or Group.
- Enter a Claim Note to be added to the Reference Info section of the claim, such as if the payer requires a note that says "under's mother's insurance" for newborn claims.
|
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:
Use the table below to complete the Attach PCP Action for the rule.
a | Select Attach PCP from the Action drop-down menu. |
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:
Use the table below to complete the Override POS Action for the rule.
a | Select Override POS from the Action drop-down menu. |
b | This section gives the practice the ability to choose the Place of Service that will be override the Place of Service on the superbill. - Select the Place of Service that should replace the Place of Service on the superbill.
|
After you have completed the Actions section of the rule building, click the Save button to save your rule.