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Custom Claim Scrubbing Rules

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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.

Creating custom scrubbing rules does not override the system’s standard claim scrubbing logic. Instead, custom rules function as an additional layer of validation that works alongside existing system rules. The standard scrubbing process will continue to run as designed, ensuring baseline compliance and error detection, while your custom rules provide enhanced, organization-specific checks to further improve claim accuracy and reduce submission errors.

Create claim scrubbing rules

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 descriptive name that clearly identifies the purpose of the rule. Using meaningful names, such as “Missing Referring Provider” or “Provider Claim Rule”, makes it easier to locate and manage rules as your list grows. 

You may configure up to three parameters, with the third parameter being optional. For each parameter, select a Condition and, when applicable, specify one or more Values. Together, these options determine the criteria used to identify claims that should be stopped for review. 

Available parameters include:

  • Payer - Stops claims associated with the selected payer(s). You can select one or more payer values to include in the rule criteria.
  • Diagnosis Code - Stops claims containing the selected diagnosis code(s) associated with the encounter or claim.
  • Place of Service - Stops claims with the selected place of service value, such as an office, hospital, or other service location.
  • Date of Service - Stops claims with a date of service that falls within the specified date range.
  • Rendering Provider - Stops claims where the selected rendering provider is associated with the service performed.
  • Referring Provider - Stops claims based on the selected referring provider. When this parameter is selected, a Conditions dropdown is displayed. Available conditions include:
    • Specific Values – 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. 
  • Attending Provider - Stops claims based on the selected attending provider. The available conditions depend on where the provider information is supported:
    • Specific Values – 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.
  • Purchasing Service Provider - Stops claims based on the selected purchasing service provider. Available conditions include:
    • Specific Values – Selected by default. Display a Values multi-select dropdown that allows you to select one or more provider names.
    • Blank for at Least One Line Item – Stops the claim when the selected provider parameter is blank on at least one line item. 
  • Operating Provider - Stops claims based on the selected operating provider. Available conditions include:
    • Specific Values - 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. 
  • Ordering Provider - Stops claims based on the selected ordering provider. Available conditions include:
    • Specific Values – Selected by default. Display a Values multi-select dropdown that allows you to select one or more provider names.
    • Blank for at Least One Line Item – Stops the claim when the selected provider parameter is blank on at least one line item.
  • Scheduling Provider - Stops claims based on the selected scheduling provider. Available conditions include:
    • Specific Values - 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.
  • Supervising Provider - Stops claims based on the selected supervising provider. Available conditions include:
    • Specific Values - 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. 
  • Billing Provider - Stops claims submitted under the selected billing provider.
  • Procedure Code - Stops claims containing the selected procedure code(s) associated with billed services.
  • Charge Amount - Stops claims with a charge amount that matches the specified value or criteria.
  • Patient Age - Stops claims when the patient's age matches the specified age criteria.
  • Patient Sex - Stops claims based on the patient's recorded sex.
  • Payer Priority - Stops claims based on the selected payer responsibility order, such as primary, secondary, or tertiary coverage.
  • 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.

In the Correction Reason field, enter clear instructions describing why the claim was stopped and what action is required to resolve the issue.

This message is for internal use only and is displayed within the encounter whenever the rule prevents a claim from being submitted, helping staff quickly identify and correct the problem before resubmission.

As you configure the rule, the Rule Preview updates automatically to display the logic that will be used when evaluating claims. Review the preview to confirm the rule is configured as intended before saving.  

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. 

Click Save Rule to activate the rule. 

Once saved, it appears in the Saved Rules list with an Active status, where it can be reviewed, edited, enabled, or disabled 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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