Take control of your claim validation process with custom-defined scrubbing rules tailored to your organization’s needs. Available only to users with the Billing Manager and Corporate Billing Manager roles, this feature helps reduce rejections and administrative overhead by identifying issues before claims are submitted.
Create claim scrubbing rules
Starting Thursday, August 6th, 2026, three new parameters have been added to Custom Claim Scrubbing to provide greater control over claim validation:
- Claim Created Date – Stops claims with a created date that falls within the specified date range.
- Line Item Unit – Stops claims containing one or more line items with the specified unit value.
- Admission Date – Stops professional or institutional claims with the specified admission date.
Custom rules are managed in Billing Utilities and can be enabled or disabled at any time. They provide flexible, parameter-based validation that improves visibility into claim quality and revenue cycle performance. Rules are evaluated across all fields within an encounter, and conditions can be satisfied by any encounter. For charge amount–based rules, calculations use the total combined charges from all line items. You can create an unlimited number of rules to meet your organization’s specific billing needs, enabling comprehensive and adaptable claim validation across a wide range of scenarios.
To begin, click the Utilities icon.
Navigate to Tools, then click Claim Scrubbing Rules.
Click Create New Rule to begin setting up a new rule.
In the Rule Name field, enter a name for your claim scrubbing rule. Use a clear and descriptive title that helps users quickly identify the purpose of the rule.
For example, a rule that validates missing provider information could be named “Provider Claim Rule” or “Missing Referring Provider.” A meaningful rule name makes it easier to locate, review, and manage rules as your list of custom claim scrubbing rules grows. the rule’s purpose.
Next, select your parameter(s). Such as:
- Payer
- Diagnosis code
- Place of service
- Date of service
- Rendering provider
- Referring provider
- Attending provider
- Purchasing service provider
- Operating provider
- Ordering provider
- Scheduling provider
- Supervising provider
- Billing provider
- Procedure code
- Charge amount
- Patient age
- Patient sex
- Payer priority
You may select up to three parameters, with the third being optional.
Most parameter condition options are multi-select, so you can include multiple values within a single parameter.
Provider parameter conditions
When a provider parameter is selected (Referring Provider, Operating Provider, Supervising Provider, Purchase Service Provider, Ordering Provider, Scheduling Provider, or Attending Provider), a Conditions dropdown is displayed.
The available conditions depend on where the selected provider parameter is supported.
- Specific Values (default) - Selected by default. Display a Values multi-select dropdown that allows you to select one or more provider names.
-
Blank for Encounter - Stops the claim when the selected provider parameter is blank at the encounter level.
- Blank for at Least One Line Item - Stops the claim when the selected provider parameter is blank on at least one line item.
- Blank for Encounter or at Least One Line Item - Stops the claim when the selected provider parameter is blank at the encounter level or on at both the encounter and line-item levels.
The available Conditions options vary based on where the provider parameter exists:
Provider parameters available at both the encounter and line-item levels:
- Specific Values
- Blank for Encounter
- Blank for at Least One Line Item
- Blank for Encounter or at Least One Line Item
Provider parameters available only at the encounter level:
- Specific Values
- Blank for Encounter
Provider parameters available only at the line-item level:
- Specific Values
- Blank for at Least One Line Item
For example, you could configure a rule using the following parameters:
- Referring Provider = Blank for encounter
- Place of Service = RXNT
- Payer = Carefirst Blue Cross Blue Shield MD and United Healthcare MD
Enter a clear and detailed explanation in the Correction Reason field to guide staff on how to resolve flagged claims. The message should specify what is missing or incorrect and what action is required to correct it.
An example of a correction reason could be: For claims submitted to CareFirst BlueCross BlueShield MD and UnitedHealthcare MD at RXNT, a Referring Provider is required. This claim was flagged because the Referring Provider is missing at the encounter level. Review and update the missing provider information before submitting the claim.
A Rule Preview will appear below, providing a real-time view of how the configured criteria will be applied. This preview allows you to verify that the selected parameters, conditions, and logic are set up correctly before saving the rule, helping ensure the rule behaves as intended when evaluating claims.
You can reset the rule at any time by clicking Clear, which removes all selected criteria and allows you to start over. If you prefer to exit without saving any changes, click Cancel.
After configuring your claim scrubbing rule, click Save Rule to apply and activate it.
After you save the rule, it appears in the Saved Rules list with an Active status. You can review or edit the rule at any time.
View claim scrubbing rules screen
On the Claim Scrubbing Rules screen, all saved rules are displayed for easy review and management. The Status column indicates whether a rule is Active or Inactive. The Name column displays the rule title, and the Rule column provides a summary of the rule's criteria and logic.
You can sort the columns by clicking a column header. You can also click the Filter icon to filter the column results. To restore the columns to their default order and view, click Reset Grid.
You can edit a claim scrubbing rule by selecting the pencil (edit) icon, which allows you to modify the rule’s parameters, conditions, or description as needed.
Click the three-dot menu to view options for deleting the rule or reviewing its history. The rule history displays each event, the event date, and the user who performed the action.
To include previously deleted rules in the export, select the Show Deleted checkbox. Deleted rules will then appear in the results and can be included in the exported data.
The Claim Scrubbing Rules screen can be exported for reporting or record-keeping purposes. You can download the data in either PDF or CSV format, making it easy to share, print, or analyze using external tools such as spreadsheets or reporting systems.
View corrections required
If any encounters in a submitted claim meets all criteria defined in a Claim Scrubbing Rule, the claim is automatically routed to the Correction Required queue. This helps ensure it is reviewed and corrected before being submitted for processing.
The Professional Encounter screen will display the applicable rule name along with a detailed explanation of why the claim was flagged. This information is also available when hovering over the correction tooltip. Additionally, it provides clear guidance on how to resolve the issue, based on the information entered in the Correction Reason field, helping users understand exactly what needs to be corrected before resubmission.
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