Advanced Workflow Rules Engine (OP AWARE) Triggers
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Last Modified on 08/12/2022 3:03 pm EDT

Version 20.10
Path: Billing tab > More button (Customize group) > Advanced Workflow Rules

About

Below you'll learn about the OP AWARE fields available for creating the Triggers for which the rule will be applied. The Trigger (or the "when") tells OP what data to look for on a superbill. When the specified elements are found, the defined Action will be applied. At the bottom of this page, click to continue to the Action section once you have entered the Triggers for the rule. OP AWARE Rules can only be triggered for Insurance Payers that are marked as Active for all in the Basic Information tab of the payer's setup.

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.

Create a New Rule and Define Triggers (or the "When")

  1. Navigate to OP AWARE by following the path above.
  2. Click the Add button.
  3. Enter a unique name for the rule in the Rule Name field. This is required to save the rule.
  4. Confirm/enter the Start and End Date in the respective fields. The Start Date defaults to the current date. An End Date should only be entered if appropriate. If the rule will never expire, leave this field blank. 

Note: After a rule has been saved, the End Date cannot be removed or extended if any of the associate Billing Groups have an Inactive status.

  1. Use the table below to complete the left-hand side of the window. Please note: All fields are optional, unless noted as required below.

a

This section gives the practice the ability to decide what CPT Code or Group will drive the rule that is being created. This is the first element OP will look for when applying the rule.

  1. Required Select Code or Group from the CPT drop-down, depending on the basis for the rule.
  • If selecting Code: Enter the CPT Code in the field or use the ellipsis button to search for and select the code.
  • If selecting Group: Use the drop-down to select the Billing Group that includes each CPT code for which this rule should be applied.
  1. Select the Modifier(s) from the Modifier drop-down menu(s) that accompany the selected CPT Code or Group on superbills.
  2. Select where on the superbill the selected CPT Code or Group and Modifier combination occurs. If left blank, the default of Anytime will be applied.
b

This section gives the practice the ability to further specify the CPT Code or Groups on a superbill. When a selection is made in both sections a and b, OP will look for a combination of two (or even three) CPT Codes or Groups.

  1. Select the additional Code or Group from the CPT drop-down that appears on the claim with the CPT Code or Group selected in the section above.
  2. Select the additional Modifier(s) from the Modifier drop-down menu(s) that accompany the additional CPT Code or Group on claims.
c
This section gives the practice the ability to align the rule for the appropriate payer(s). You can choose one of the three options or a combination, as follows: OP allows you to populate both the National Payer ID and Claim Filing Type fields to accommodate situations where a private payer manages Medicaid plans. That National Payer ID may have different rules for commercial claims than it does for Medicaid claims. If these fields are left blank, the rule will apply to all payers.
  1. Select the National Payer ID for the patient's primary insurance from the drop-down. The list available is populated directly from the practice's Payer List.

Example: If a practice has several entries in their Payer List for Aetna plans, but all entries have the same National Payer ID, selecting that National payer ID here will apply this rule to all of the Aetna payers.


  1. Select the Insurance Code for the patient's primary insurance from the drop-down. The list available is populated directly from the practice's Payer List. To apply the rule to all payers, select [*] All Payers.

Example: If a practice has several entries in their Payer List for Aetna but this rule only applies to one of them, selecting that Insurance Code will only apply the rule to that payer.


  1. Select the Claim Filing Type for the patient's primary insurance from the drop-down. This is the Claim Filing Type set in the Payer Details.

Example: If a practice has several Medicaid / MCO payers in their payer list, all set with the Claim Filing Type of Medicaid, selecting that Claim Filing Type here applies the rule to all of those payers.

d
This section gives the practice the ability to take into consideration additional superbill details that should be looked at when OP applies this rule.
  1. Select the superbill Location to which the rule will be applied.
  2. Select the Rendering Provider ID whose superbills will have this rule applied.
  3. Select the Diagnosis Code or Group for which the rule will be applied.
e
This section gives the practice the ability to enter the patient's age in days (d), weeks (w), months (m), or years (y) as it pertains to the application of the rule.
  1. Click in the date range field, and enter the appropriate date range. If assistance is needed with the proper format, click the info bubble for an example.
f
This section gives the practice the ability to narrow down the rule application to superbills that include a specified Place of Service.
  1. Click in the POS drop-down, and select the Place of Service.

You have completed the triggers section of OP AWARE (or the "when").

To complete the building of the rule, continue to the OP AWARE Actions section >>

Version 20.8
Path: Billing tab > More button (Customize group) > Advanced Workflow Rules

Overview

This section introduces a user to the OP AWARE fields available for creating the Triggers (or the "when") circumstances for which the rule will be applied. The Trigger (or the "when") tells OP what data to look for on a superbill. When the specified elements are found, the defined Action will be applied. At the bottom of this page, click to continue to the Action section once you have entered the Triggers for the rule.

Create a New Rule and Define Triggers (or the "When")

  1. Navigate to OP AWARE by following the path above.
  2. Click the Add button.
  3. Enter a unique name for the rule in the Rule Name field. This is required to save the rule.
  4. Confirm/enter the Start and End Date in the respective fields. The Start Date defaults to the current date. An End Date should only be entered if appropriate. If the rule will never expire, leave this field blank. 

Note: After a rule has been saved, the End Date cannot be removed or extended if any of the associate Billing Groups have an Inactive status.

  1. Use the table below to complete the left-hand side of the window. Please note: All fields are optional, unless noted as required below.

a

This section gives the practice the ability to decide what CPT Code or Group will drive the rule that is being created. This is the first element OP will look for when applying the rule.

  1. Required Select Code or Group from the CPT drop-down, depending on the basis for the rule.
  • If selecting Code: Enter the CPT Code in the field or use the ellipsis button to search for and select the code.
  • If selecting Group: Use the drop-down to select the Billing Group that includes each CPT code for which this rule should be applied.
  1. Select the Modifier(s) from the Modifier drop-down menu(s) that accompany the selected CPT Code or Group on superbills.
  2. Select where on the superbill the selected CPT Code or Group and Modifier combination occurs. If left blank, the default of Anytime will be applied.
b

This section gives the practice the ability to further specify the CPT Code or Groups on a superbill. When a selection is made in both sections a and b, OP will look for a combination of two (or even three) CPT Codes or Groups.

  1. Select the additional Code or Group from the CPT drop-down that appears on the claim with the CPT Code or Group selected in the section above.
  2. Select the additional Modifier(s) from the Modifier drop-down menu(s) that accompany the additional CPT Code or Group on claims.
c
This section gives the practice the ability to align the rule for the appropriate payer(s). You can choose one of the three options or a combination, as follows: OP allows you to populate both the National Payer ID and Claim Filing Type fields to accommodate situations where a private payer manages Medicaid plans. That National Payer ID may have different rules for commercial claims than it does for Medicaid claims. If these fields are left blank, the rule will apply to all payers.
  1. Select the National Payer ID for the patient's primary insurance from the drop-down. The list available is populated directly from the practice's Payer List.

Example: If a practice has several entries in their Payer List for Aetna plans, but all entries have the same National Payer ID, selecting that National payer ID here will apply this rule to all of the Aetna payers.


  1. Select the Insurance Code for the patient's primary insurance from the drop-down. The list available is populated directly from the practice's Payer List. To apply the rule to all payers, select [*] All Payers.

Example: If a practice has several entries in their Payer List for Aetna but this rule only applies to one of them, selecting that Insurance Code will only apply the rule to that payer.


  1. Select the Claim Filing Type for the patient's primary insurance from the drop-down. This is the Claim Filing Type set in the Payer Details.

Example: If a practice has several Medicaid / MCO payers in their payer list, all set with the Claim Filing Type of Medicaid, selecting that Claim Filing Type here applies the rule to all of those payers.

d
This section gives the practice the ability to take into consideration additional superbill details that should be looked at when OP applies this rule.
  1. Select the superbill Location to which the rule will be applied.
  2. Select the Rendering Provider ID whose superbills will have this rule applied.
  3. Select the Diagnosis Code or Group for which the rule will be applied.
e
This section gives the practice the ability to enter the patient's age in days (d), weeks (w), months (m), or years (y) as it pertains to the application of the rule.
  1. Click in the date range field, and enter the appropriate date range. If assistance is needed with the proper format, click the info bubble for an example.
f
This section gives the practice the ability to narrow down the rule application to superbills that include a specified Place of Service.
  1. Click in the POS drop-down, and select the Place of Service.

You have completed the triggers section of OP AWARE (or the "when").

To complete the building of the rule, continue to the OP AWARE Actions section >>

Tags: OP AWARE

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