Payment Processing Rules - Overview

Version 21.2
Path: Billing tab > More button (Customize group) > Payment Processing Rules


The Payment Processing Rules module allows you to build out rules based on the payer, claim type, national payer ID, payer reason, or CPT code that will be applied when an ERA file is processed in OP. Building these rules will streamline ERA processing by:

  • Auto setting a match status for transactions in the Adjudication window 
  • Create a follow-up task
  • Set the patient actions to create statements 

User Permission: To access the module, users must have the Billing_Payment_Processing_Rules security permission.

Navigate the Payment Processing Rules Window

  • Created rules will show in the left side of the Payment Processing Rules window in a grid:
  • At the top of the Payment Processing Rules window, you can:
    • Add: Click the Add button to start adding a new rule.
    • Edit: Click the Edit button after selecting a rule from the grid.
    • Save: Click the Save button when finished adding or editing a rule.
    • Cancel: Click the Cancel button to clear the input.
    • Print: Click the Print button to print the rules listed in the grid to the left.
    • Show inactive: Select the checkbox to show inactive rules (Date Expired is before today's date).
  • The Payment Processing Rule must have a Name and a Start Date (End Date is optional).
  • The window is displayed in two sections: Triggers and Actions. See the table below for more information.

Triggers and Actions

Both sections of the window must be completed to successfully build and apply the rule.

Part I: Triggers (the "When")
Part II: Actions
This section tells the story of when to trigger the rule. The criteria set here tells OP what to look for on an ERA when applying the rule when the ERA File is processed in OP. Click here to learn how to define Triggers. After defining the Triggers, you must complete the Action.This section tells OP what to  do with the ERA files for which the triggers have been met. There are three actions that can be selected as a part of the rule, and those actions will be applied to all ERAs that meet the rule. Click here to learn how to select the Action.

To learn how to create a new rule, continue to the Payment Processing Rule - Triggers section >>