Overview

Claim specific rules are used when a payer requests certain information to be included in a particular section of the claim form. These rules need to be set up for each insurance company that you want to change what is displayed on the CMS 1500 claim form. When adding or editing a payer in the Insurance Companies section of Practice Setup, claim specific rules can be created at the bottom of the screen.  

Explanation of rules  

RXNT provides a list of claim specific rules that can be set up for each payer. 

Use Taxonomy Code in Box 24J shaded area in the HCFA claim form and EDI.

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.

Supress rendering provider NPI in 24J.

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.

Always display service facility NPI in the claim form.

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.

Send Family Planning Indicator on 2400 SV1 (Medicaid Claims).

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

Send EPSDT information on the claim form and EDI.

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

Send EPSDT reason code on EDI and display in 24H shaded area.

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

Display provider commercial number on box 17A.

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

Display taxonomy code 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.

Hide signature on Box 12.

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

Hide signature on Box 13.

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

Medicaid - Show taxonomy code on Box 33B.

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.

Display last seen date on Box 19.

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 Provider Commercial Number in box 24J shaded area.

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.

Create claim at line item level.

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

Display CLIA on Box 19.

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.

Surpress info in Box 32 if same as Box 33.

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.

Medicare of Massachusetts.

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.

Display Condition Code on Box 10D.

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.

Swap 1A and 9A columns for Policy Number on claim form.

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.

Custom claim notes and comments.

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.

When subscriber is self: Duplicate information from Boxes 2 and 5 into 4 and 7 respectively.

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.

Display balance due in Box 30 of CMS-1500 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.

Send Non Covered Charged Amount on EDI.

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

Display delay reason code in loop 2300.

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.

Move the date of intial treatment to Box 14 of print claims.

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.

Suppress the qualifier in Box 14 of print claims.

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.

Display “Continuation” in Box 28 of Medicaid paper claims.

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

Add provider suffix to professional claims.

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 state license number in Box 24J (shaded) on the claim form and the EDI.

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.

Send medical records for electronic claims.

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.

Remove G2 qualifier from Box 24I and Box 33B.

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

Suppress payment information in Box 29.

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

Send “99” in Box 19 for the procedure code G2172.

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

Use rendering provider SSN in Box 25 on the claim form and EDI.

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

Send Service Facility Location NPI in the REF segment of the EDI.

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

Send “None” in Box 11 of the claim form and EDI.

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

Display DOB in Box 3 and gender in Box 11A when the subscriber is self.

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.

Send referring and reference laboratory CLIA number on the electronic claim.

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. 

Remove PR segments that contain only $0 from the EDI.

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

Send Anesthesia time and duration on print and electronic claims.

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. 

Send Third Party Liability Code for claims billed after the primary claim.

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.

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