Use this rule when you need the taxonomy code of the rendering provider to populate in Box 24J for a specific payer. This rule will suppress the rendering provider's NPI from Box 24J each time you send a claim for this payer. This rule will also make the corresponding change for electronic claims.

This rule can also be filtered by Service Facility Locations if you wish to suppress this information at only one of your locations. Once the rule has been selected, click the green + under the Location/Custom Value column. In the box on the left, select the location that you want the rule to be applied to and click the arrow at the top to move it into the Selected List on the right. Then, click Select to save.

Use this rule when you need the service facility location NPI to display in Box 32a even if its the same as the Billing Provider NPI.

Use this rule to send the family planning indicator only on the EDI in the SV1 segment.

Use this rule to send EPSDT information on the HCFA claim form EDI.

Use this rule to send the EPSDT selection in box 24H shaded area of the claim form and EDI.

Use this rule to display the rendering provider’s commercial number on box 17A.

Use this rule when you need the rendering provider’s taxonomy code to populate in Box 17A. This rule will also make the corresponding change for both PDF and electronic claims.

Use this rule when you need to hide the rendering provider signature on file in Box 12 of the claim form.

Use this rule when you need to hide the rendering provider signature on file in Box 13 of the claim form.

Use this rule to display the billing provider’s taxonomy code in Box 33B of the claim form and to send the billing provider’s taxonomy code in the PRV section of the EDI.

Use this rule to display the patient's last seen date on Box 19 along with the attending provider's NPI. This rule will only take effect if an attending provider is selected for a claim.

Use this rule to display rendering provider’s commercial number in 24J shaded area of the claim form. This rule can also be filtered by Service Facility Locations. For instance, if you wish to display the provider's commercial number in the 24J shaded area at only one of your locations, you should set up a filter for that specific location. Once the rule has been selected, click the green + under the Location/Custom Value column. Select the desired location and click the arrow at the top to move it into the Selected List section, then click Select on the bottom right side.

Use this rule to group line items and create multiple claims for an encounter.

Use this rule to send CLIA on Box 19 of the claim form and in the EDI. In order for this rule to apply, you must check the CLIA Lab Procedure checkbox on the Procedure Code screen.

In addition, ensure that the CLIA is included in the Service Facility Location.

Once those settings are in place, your encounter must include a payer that has the claim-specific rule you set up, the service facility location with the CLIA, and the CLIA Lab Procedure option must be selected on the procedure code. This will update the populated information on box 19.

Use this rule when you need to supress the Service Facility Location information in Box 32 in the HCFA claim form and EDI if it is the same as the Billing Provider in Box 33.

Use this rule to suppress the paid amount in the EDI when rebilling a payer that had previously paid for the same claim. This rule is mainly used while resending claims after corrections.

When using this rule for condition codes to show on Box 10D of the HCFA claim form and in the EDI, you must set the Show Condition Codes in Professional Encounters in your encounter preferences to "Y". Once the encounter preference has been set, select the Condition Code from the drop-down menu within the encounter screen.

Use this rule to swap values between 1A (Insured's ID Number) and 9A (Other Insured's policy or group number) in the HCFA claim form.

Use this rule to send a common claim note for every claim associated with the payer. This note will only be sent if there is no claim specific note added in the Manage Claims section.

Use this rule to copy information from Box 2 (Patient's Name) to Box 4 (Insured's Name) and Box 5 (Patient's Address) to Box 7 (Insured's address) if the subscriber is Self in the HCFA claim form.

Use this rule to always display the encounter balance in Box 30 of the HCFA claim form. This balance excludes the miscellaneous charges.

Use this rule to send Non Covered Charge Amount on EDI.

Use this rule to send the Delay Reason Code in the EDI. Once this rule is set, select the reason code from the drop-down in the Manage Claims screen.

Use this rule to send the Initial Treatment Date in the claim form and EDI. Ensure that the Initial Treatment Date is selected under the Case Dates. In the HCFA claim form, Box 14 will indicate the date with the qualifier as 454 and the same information is sent in the EDI.

Use this rule to send the Initial Treatment Date without a qualifier in the HCFA claim form and EDI. Ensure that the Initial Treatment Date is selected under the Case Dates. In the HCFA claim form, Box 14 will indicate the date without any qualifier, and the same information is sent in the EDI.

Use this rule to display "Continuation" in Box 28 if there are more than 6 line items in the HCFA claim form.

Use this rule to send Provider Suffix in the claim form and EDI. Once this rule is set, select the provider suffix from the Provider Type drop-down on the Rendering Provider screen.

Use this rule to display the state license number of the rendering provider in Box 24J shaded and also to send this information in the EDI.

Use this rule to send the Attached Report Type Code and Identification Code (ACN) in the HCFA claim form and EDI. Once this rule is set, the Attached Report Type Code and ACN are available for selection on the encounter screen.

Use this rule to remove the G2 qualifier from Box 24I and 33B on the HCFA claim form and the EDI.

Use this rule to suppress the payment information in Box 29 of the HCFA claim form.

Use this rule to send “99” in Box 19 of the HCFA claim form in the EDI.

Use this rule to send the rendering provider's SSN in Box 25 of the HCFA claim form and in the EDI.

Use this rule to send the Service Facility Location NPI in the REF segment of the EDI.

Use this rule to send “None” in Box 11 of the HCFA claim form and in the EDI.

Use this rule to send the patient DOB in Box 3 and gender in Box 11A of the HCFA claim form and in the EDI.

Use this rule to send the service facility location CLIA in the EDI Loop 2400 Segment Ref.

In addition, ensure that the CLIA Lab Procedure is selected under the procedure code and that the CLIA is entered under all Service Facility Locations.

In the encounter, the referring provider should be included and the service facility locations should be selected. The first location will be used at the encounter level, and the second location will be used at the line item level. 

Use this rule if you don't want PR segments containing "0" sent in the claim EDI.

Use this rule to send the anesthesia start and end times associated with each CPT code in the shaded area of the claim right above the CPT code. 

Use this rule to send the third-party liability code of the previous payer in the electronic and print claims. This rule does not apply to primary claims. 

In addition, ensure that the appropriate carrier code has been added under the Third Party Liability section of that payer's screen.

When this rule Is enabled, the rendering provider NPI is sent in box 19 as follows;

• In Box 19 of the print claim
  • XXNPIProviderName (last, first 20 characters).
  • If there are multiple unique rendering providers, then their NPIs are sent in Box 19 as follows - XXNPIProviderName 3 blanks XXNPIProviderName (last, first 20 characters).
• In the EDI
  • The information is sent in Loop 2300, segments NTE 01 snd NTE 02.
• Box 19 on the CMS 1500 print claim has a character limit. So only the allowed number of characters will be present on the print claim, however the entire data will be sent in the EDI.
• The hierarchy for printing and sending information on Box 19 is as follows;

1. If “Display CLIA on Box 19” rule is enabled for the payer and the CLIA checkbox for the procedure code is checked and CLIA has value on service facility location then CLIA value will be sent in box 19.
2. Or if “Display Last Seen Date on Box 19” rule is enabled and “Last Seen Date” in encounter dates is added then it will be sent in Box 19.
3. Or if “Charge Transaction Code (CPT)” has value in “Narrative” field then we will be sending that in box 19.
4. Or Send Rendering Provider NPI in Box 19 is enabled, then this information will be sent in the claim form, and EDI
5. Or If we have added “Claim Note” while creating new claim then it will be passed in box 19.

Use this rule to send the clinical trial number on electronic and print claims.

On the payer screen, select Send clinical trial number on electronic and print claims.

Navigate to the Professional Encounter screen, and enter the clinical trail number in the Claims Notes section within Manage Clams. 

Click Create Claim. 

Enter the Clinical Trail Number. 

Click Send Claim or Save Claim to transmit the clinical trial number to Box 19 of the claim form and the Loop 2300 REF segment of the EDI.