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 the 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 the CLIA number in Box 19 of the claim form and in the EDI. To enable this rule, make sure the CLIA Lab Procedure checkbox is selected for the procedure code in the Charge Transaction Code screen. To do this, navigate to Procedure Codes, select the appropriate code, check the CLIA Lab Procedure box in the Charge Transaction Code screen, and click Save.

In addition, verify that the CLIA number has been entered in the Service Facility Location to ensure proper billing. To do this, navigate to Service Facility Locations and select the appropriate location. In the Service Facility Location screen, enter the CLIA number in the CLIA field and click Save.

Ensure your encounter includes a payer that has this claim-specific rule configured, a Service Facility Location with the CLIA number, and that the CLIA Lab Procedure option is checked for the procedure code. This setup will generate the CLIA information in Box 19 of the claim form.

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 a Delay Reason Code in the EDI. After setting the rule, you can select the appropriate reason code from the dropdown menu in the Manage Claims screen. For example, if a claim is delayed because the payer requires prior authorization for a procedure, you would set the rule and select the code labeled “Authorization Delays.” To access the available reason codes, navigate to the Professional Encounter screen and click Manage Claims. 

In the Manage Claims screen, select the appropriate code from the Delay Reason Code dropdown menu. Then, click Send to submit the claim immediately, or click Save to store the claim and submit it at a later time.

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 the 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 include the Attached Report Type Code, Attached Transmission Code, and Identification Code (ACN) in the EDI file. Once the rule is configured:

• The Attached Report Type Code is sent in Loop 2300, segment PWK01.
• The Attached Transmission Code is sent in Loop 2300, segment PWK02.
• The Identification Code Qualifier “AC” is sent in Loop 2300, segment PWK05.
• The Identification Code (ACN) is sent in Loop 2300, segment PWK06.

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. To do this, navigate to Procedure Codes, select the appropriate code, check the CLIA Lab Procedure box in the Charge Transaction Code screen, and click Save.

In addition, verify that the CLIA number has been entered in the Service Facility Location to ensure proper billing. To do this, navigate to Service Facility Locations and select the appropriate location. In the Service Facility Location screen, enter the CLIA number in the CLIA field and click Save.

Next, navigate to the Professional Encounter screen. Choose the provider from the Referring Provider dropdown menu and select the location from the Place of Service dropdown menu. The first location will be used at the encounter level

To select a second location for a line item, click the Edit folder associated with that line item. Choose the desired location from the Place of Service dropdown menu and click Save. This will ensure the line item is billed with the correct service location.

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 a value on the service facility location, then the 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 a value in the Narrative field then we will be sending that in Box 19.
4. Or if 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 a Claim Note while creating a 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 trial number in the Claims Notes section within Manage Claims. 

Click Create Claim. 

Enter CT, and then you will 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.

Use this rule to remove the billing provider taxonomy code in box 33 of the HCFA claim form and EDI.

Use this rule to send "Homebound" in Box 19 of the claim form and Loop 2300 of the EDI.

Use this rule to display the accident/injury date in Box 14 of the claim form instead of Box 15.

Use this rule to send ABA session times on the printed claims and EDI. After enabling this claim-specific rule for a payer, mark the CPT code as an ABA service on the procedure code screen. When submitting an encounter with a payer who has this rule enabled and an ABA CPT code, the user must enter a start and end time within the line item folder. By following these steps, the ABA session times will be included in both the printed claim and EDI submission.   

Use this rule to send the Rendering Provider NPI in Box 24J shaded area on the claim form and in Loop 2420 of the EDI.

Use this rule to include the third-party liability code from the previous payer in Loop 2330B of electronic claims and Box 9D of paper claims. This rule does not apply to primary claims. Additionally, confirm that the correct carrier code has been entered in the Third Party Liability field on that payer’s screen.

Use this rule to include the third-party liability code from the previous payer in Loops 2320 and 2430 of electronic claims and Box 9D of paper claims. This rule does not apply to primary claims. Additionally, confirm that the correct carrier code has been entered in the Third Party Liability fields on that payer’s screen.

Use this rule to send the Claim Reference Number, entered on the Manage Claims screen, in the REF*F8 segment of loop 2330B. 

• When the rule is enabled, the Claim Reference Number must be sent in Loop 2330B for all resubmission codes.
• If the resubmission code is 7 or any other code where the system already sends the claim reference number in Loop 2300, that existing behavior will remain unchanged.
• In these cases, the Claim Reference Number will be sent in both Loop 2300 and Loop 2330B.

After selecting the rule, navigate to the patient’s encounter. From the Professional Encounter screen, click on Manage Claims.

On the Manage Claim screen, locate the Original Ref No field and enter the Claim Reference Number to ensure it is properly associated with the claim.

Next, click Save Claim to save the claim, or click Send Claim to submit the claim to the payer. 

If a previous claim has already been created for the selected payer, the options to Send Claim or Save Claim will not be available. In this case, you will need to click Create Claim to generate a new claim, allowing you to enter or update the necessary information for submission.

The Claim Reference Number will automatically appear in the Original Ref No field. You can update this number manually if any changes are required before submitting the claim. Then, click Save Claim to save the claim, or click Send Claim to submit the claim to the payer. 

Use this rule to suppress the Rendering Provider NPI on claim forms and EDI for encounter-level rendering providers only.

• When the rule is enabled, the NPI of the Rendering Provider selected at the encounter-level will be excluded from both the claim form and the EDI. This suppression applies only to encounter-level rendering providers and does not affect other provider NPIs on the claim.