Take control of your claim validation process with custom-defined scrubbing rules tailored to your organization’s needs. This feature helps reduce rejections and administrative overhead by identifying issues before claims are submitted.
For instance, you can create a rule that flags claims missing required diagnosis codes or prevents submission if a specific payer requires additional information. If a claim does not meet the defined criteria, it will be flagged for review, allowing your team to correct the issue before it reaches the clearinghouse.
Create claim scrubbing rules
Custom rules are managed within Billing Utilities and can be enabled or disabled at any time. These rules support flexible parameter-based validation, giving you greater visibility and control over claim quality and revenue cycle performance. Rules are validated across all line items within a claim, and conditions may be met by any single line item. However, charge amount–based rules are calculated using the combined total of all line item charges. You can create as many rules as needed to support your organization’s specific billing requirements, allowing for flexible and comprehensive claim validation across different 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. For example, you might use a descriptive title such as “Missing Diagnosis Code” to clearly identify 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.
For example, you could set a rule using Payer = Aetna, Diagnosis Code = E11.22 & N18.30, and Place of Service = RXNT Office. This rule would identify any claims where Aetna is the payer, at least one of the specified diagnosis codes is included, and the place of service is set to RXNT Office, ensuring those claims are flagged and reviewed for proper validation before submission.
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: Claim is missing required diagnosis codes E11.22 and/or N18.30 for Aetna office visits. Please review the encounter and update the diagnosis coding to both diagnosis codes to accurately reflect the services provided prior to resubmission.
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. Once saved, the rule will appear in the list of saved rules with an Active status. From there, it can be reviewed, edited, or deleted at any time as needed.
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 currently Active or Inactive, depending on whether it has been enabled or deactivated. The Name column shows the rule’s title, while the Rule column provides a brief description of the rule’s criteria and logic.
This screen can be exported for reporting or record-keeping purposes. You have the option to download the data in either PDF or CSV format, allowing for easy sharing, printing, or further analysis in external tools such as spreadsheets or reporting systems. To include previously deleted rules, select the Show Deleted checkbox. This will display any deleted rules in the results so they can be included.
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.
To view the rule history, click the three-dot menu and select History. This opens a log of all rule activity, including the rule event (such as created or edited), the date the change occurred, and the name of the user who created or edited the rule.
View corrections required
If any line item 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.