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Rule Verification Table - PM

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The following table displays pre-billing rule verifications.

  • This information is required by the 837 process.
  • Any client record with open or unbilled services that does not meet a rule will display on the Pre-Billing Edit Report.

 

Data

Data Source

Subscriber Policy Number

Financial Eligibility form

Diagnosis

Diagnosis form

If medical diagnosis is enabled (through registry setting), it will be used.

Service Code Diagnosis Requirement registry setting can override this requirement for 837P file

Client’s relationship to subscriber

Extended dictionary (Client’s Relationship To Subscriber, Financial Eligibility form)

Place of service

Extended dictionary Place Of Service (837 Professional) for each service, off of Location.

Service facility address

Program Maintenance form.

Claim filing indicator code

Guarantor/Payors form (837 section)

Bill as primary guarantor

Guarantor/Payors form (837 section)

Subscriber name/address

Financial Eligibility form

UB-04 revenue code

Service Fee/Cross Reference Maintenance form

CPT-4 / HCPCS code

Service Fee/Cross Reference Maintenance form

The following data is pulled from the Guarantor/Program Billing Defaults form:

Submitter name
Submitter primary identification number
Receiver name
Receiver primary identification number
Billing provider name
Billing provider identification code qualifier
Billing provider primary identification number
Billing provider Demographics
Payer identification code qualifier
Payer identification number
Authorization information qualifier
Authorization information
Security information qualifier
Security information
Interchange sender ID qualifier
Interchange sender ID
Interchange receiver ID qualifier
Interchange receiver ID
Acknowledgement requested
Usage indicator
Application sender's code
Application receiver’s code

 

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