Payment Processing Rules - Triggers
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Last Modified on 05/16/2023 12:22 pm EDT
Version 21.2
Path: Billing tab > More button (Customize group) > Payment Processing Rules
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| Disclaimer: - Part I of creating a new Payment Processing Rule is covered in this article (Payment Processing Rules - Triggers).
- Part II of creating a new Payment Processing Rule is covered in the Payment Processing Rules - Actions article.
To create a new rule, you must complete the steps in this article AND continue to complete the steps in the Actions article. |
About
Below you'll learn how to start creating a new rule, and about the Payment Processing Rules 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 an ERA. 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.
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| User Permission: To access the module, users must have the Billing_Payment_Processing_Rules security permission. |
Create a New Rule and Define Triggers (or the "When")
- Navigate to the Payment Processing Rules by following the path above.
- Click the Add button. The criteria fields will become enabled.
- Enter a unique name for the rule in the Rule Name field. This is required to save the rule. The limit is 255 characters.
- Confirm/enter the Start and End Date in the respective fields. The rule will be applied to claims with a claim date that falls between the start and end date of a rule.
- The Start Date defaults to the current date when clicking the Add button. This is a required field, and can be changed if necessary.
- An End Date should only be entered if appropriate. If the rule will never expire, leave this field blank. Type an End Date if you want a date for the rule to stop being applied.
- Use the table below to complete the left-hand side of the window. Please note: These fields are optional. However, if no Payment Transaction Contains fields are selected when creating a rule, upon clicking Save, the system will default the Insurance Code field to [*], meaning the rule will apply to all payers.
| 1 | The When Payment Transaction contains section allows you to select the criteria with which to identify the transactions these completed rules will be applied to. This section gives the practice the ability to align the rule for the appropriate payer(s) and Claim Filing Type: - You can choose one of the three options, or,
- You can choose to populate both the National Payer ID and Claim Filing Type fields.
- This is enabled 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 no Payment Transaction contains is selected when creating a rule, upon clicking Save the system will default the Insurance Code field to [*], and the rule will apply to all payers. |
| 1a | National Payer ID: The drop down will provide a list of all available National Payer IDs in your system, populated directly from your practice's Payer List.- Selecting a National Payer ID will apply the rule to all payers with that payer ID.
- You will see the Insurance Code field gets defaulted with [*] upon saving your rule, indicating it’s all payers with that National Payer ID.
- When editing a rule with a National Payer ID, the Insurance Code field becomes non-editable until the Payer ID is cleared.
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| 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. |
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| Note: If you go back to edit a rule with a National Payer ID selected, you will see that the Insurance Code field defaulted to [*] when you last saved the rule, and the Insurance Code field became non-editable. To change the Insurance Code type: - Clear the National Payer ID field.
- Then select a different Insurance Code from the drop-down.
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| 1b | Insurance Code: The drop down will provide a list of all available payers in your system, populated directly from your practice's Payer List. - Selecting an individual payer will apply the rule to only transactions/claims linked to that payer.
- To apply the rule to all payers, select [*] (All Payers).
- If no Payment Transaction contains is selected when creating a rule, upon clicking Save the system will default the Insurance Code field to [*].
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| 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. |
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| 1c | Claim Filing Type: The drop-down will provide a list of all available claim filing types in your system. This is the Claim Filing Type set in the Payer Details.- Selecting a Claim Filing Type will apply the rule to all payers with that filing type.
- You will see the Insurance Code field gets defaulted with [*] upon saving your rule, indicating it’s all payers with that Claim Filing Type.
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| 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. |
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| Note: If you go back to edit a rule with a Claim Filing Type, you will see that the Insurance Code field defaulted to [*] when you last saved the rule, and the Claim Filing Type field became non-editable. To change the Claim Filing type: - Clear the Insurance Code field.
- Then select a different Claim Filing Type from the drop-down.
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2 | Once you have selected the rules to apply to the appropriate payer(s), you can now select additional details on the ERA to narrow down your rule in the The Payment Transaction also contains section. |
2a | Payer Reason Code: The drop-down will contain all possible claim adjustment codes in your system. Selecting a payer reason code will apply the rule when that payer reason code is listed on ERA for specific transactions.
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| Note: If there is no National Payer ID, Insurance Code, or Claim Filing Type selected in addition to the Payer Reason Code, upon saving the rule the system will default [*] into the Insurance Code field and the rule will be applied to all insurances. |
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2b | CPT Code, With the Modifier:- The CPT Code field allows you to select a specific CPT Code that would trigger the rule to be applied when the ERA is processed. Select the CPT Code using one of the following ways:
- Type the CPT Code in the field, OR
- Click the ellipsis button to the right of the field. This opens the CPT-4 Search Window where you can search for and select the CPT Code.
- The With the Modifier drop-down allows you to specify that the rule should be applied when the CPT Code appears with the selected Modifier to apply the rule. The drop-down contains all possible modifiers.
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2c | When It Occurs: This drop-down allows you to specify that the rule should be applied when the CPT code (or CPT code with modifier) appears in a specific position on the claim.
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| Note: This drop-down defaults to Anytime, even if you did not select a CPT Code in the previous field. |
The drop-down options include: Anytime: Anytime the CPT Code (or CPT code with modifier) appears on the claim the rule is applied. First: Only when the CPT code (or CPT code with modifier) appears first on the claim the rule is applied. Second: Only when the CPT code (or CPT code with modifier) appears second on the claim the rule is applied. Third: Only when the CPT code (or CPT code with modifier) appears third on the claim the rule is applied. Fourth: Only when the CPT code (or CPT code with modifier) appears fourth on the claim the rule is applied. Fifth: Only when the CPT code (or CPT code with modifier) appears fifth on the claim the rule is applied. Anytime after the first: anytime the CPT code (or CPT code with modifier) appears after the first position on the claim the rule is applied.
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2d | Concurrent CPT Code: This field allows you to select a specific CPT code that would appear in addition to the first CPT Code selected to trigger the rule to be applied when the ERA is processed. Select the CPT Code using one of the following ways:- Type the CPT Code in the field, OR
- Click the ellipsis button to the right of the field. This opens the CPT-4 Search Window where you can search for and select the CPT Code.
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You have completed the triggers section of the Payment Processing Module (or the "when").
To complete the building of the rule, continue to the Payment Processing Rule - Actions section >>
