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System Maintenance - Advanced Billing Rule Definition - Cal-PM

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Define an advanced billing rule, a set of specific conditions for billing coverage. When these conditions are met, liability is distributed.

Notes:

Prerequisites:

Go to: Avatar PM > System Maintenance > System Definition > Advanced Billing Rule Definition and complete the sections on the form:

Rule Basics

  1. In the Add Or Edit Advanced Billing Rule field:

  • Select Add to add a new billing rule.
    OR
  • Select Edit to edit an existing billing rule.

  1. In the Active field:

  • Select Active for advanced billing rules that will affect liability distribution.
    ​​​​​​OR
  • Select Inactive for advanced billing rules that are not available.

  1. In the Advanced Billing Rule Description field, enter the description.
    Note: When working with Autosync Maintenance functionality, advanced billing rules must be named differently for each system code.

  2. In the Advanced Billing Rule field, select the advanced billing rule.

  3. In the Rule Category field, select the rule category.
    Note: Advanced billing rule categories can be used as a filter when viewing the Advanced Billing Rule Failed Compliance report.

  1. In the Covered Charge Category field, select the covered charge category.

  • The values selected in this field populate the Service Code field.
  • If no changes are made to the service codes, all current and future service codes associated with the ICC are covered by the Advanced Billing Rule.
  • If any fields are deselected from the Service Code field, each selected ICC will no longer be associated to the Advanced Billing Rule.

  1. In the Service Code field, select the service codes.
    Note: Selecting '(00000) All Service Codes' associates the advanced billing rule with all myAvatar service codes.

  2. In the Guarantor field, select the guarantors to associate with the advanced billing rule.
    Note: Selecting '(00000) All Guarantors' associates the advanced billing rule with all myAvatar guarantors.

  3. In the Frequency field, enter the value that must meet the advanced billing rule:
    Note: Selecting a frequency disables 'Diagnosis' fields.

  • Select Daily to define the number of days a service must be rendered.
  • Select Episodic to define the number of times the service must be rendered per episode.
  • Select Monthly to define the number of times the service must be rendered per month.
  • Select Calendar Year to use the number of times the service must be rendered per year.

  1. In the Frequency Times field, enter how often the service must be rendered to meet the advanced billing rule.

  2. In the Effective Date field, enter the advanced billing rule start date.

  3. In the Expiration Date field, enter the advanced billing rule end date.

Advanced Settings

  1. In the Diagnosis field, select the diagnosis to associate with the service.
    Note: Selecting '00000 - All Diagnosis Codes' associates the advanced billing rule with all myAvatar diagnosis codes.

  2. In the Diagnosis Inclusive Or Exclusive field:

  • Select Inclusive to associate all select diagnosis codes with the advanced billing rule.
    OR
  • Select Exclusive to associate diagnosis codes that were not selected (Diagnosis field) with the advanced billing rule.

  1. In the Rule Applies To field, select the type of service diagnosis code that will be verified if it is associated with the rendered service.

  • Select All Diagnoses Found For Service to apply the selected diagnosis codes to the advanced billing rule.
  • Select Primary Diagnosis Of Service to apply the primary service diagnosis to the advanced billing rule. Primary diagnoses are checked in the following order:
    • The primary service diagnosis is checked first.
    • The primary medical diagnosis is checked next.
    • The primary diagnosis is checked last.
  • To include a medical diagnosis in the advanced billing rule:
    • A medical diagnosis must be defined as the principal diagnosis (with an associated ICD-9 code) in the Diagnosis form. The ICD-9 value associated with the medical diagnosis is used. The diagnosis must be associated with a service rendered in an open client episode (no discharge date).

  1. In the Diagnosis Source field, select the type of diagnoses to associate with the advanced billing rule:

  • Select Primary Service Diagnosis to use the first service diagnosis. (Progress Note or Client Charge Input with Diagnosis Entry form)
  • Select Secondary Service Diagnosis to use the second service diagnosis. (Progress Note or Client Charge Input with Diagnosis Entry form)
  • Select Tertiary Service Diagnosis to use the third service diagnosis. (Progress Note or Client Charge Input with Diagnosis Entry form)
  • Select Quaternary Service Diagnosis to use the fourth service diagnosis. (Progress Note or Client Charge Input with Diagnosis Entry form)
  • Select Medical Diagnosis Input to use diagnoses associated with the client (Medical Diagnosis form).
  • Select Diagnosis Input to use the primary diagnosis associated with the client (Diagnosis form).

  1. In the Associated To Gender field, select Yes to associate the advanced billing rule with the client’s gender.

  2. In the Gender field, select the client's gender.

  3. In the Associated To Age field, select Yes to associate the advanced billing rule with the client’s age.

  4. In the Age Comparison field:

  • Choose Less Than to include clients who are younger than the age entered in the Age field.
  • Choose More Than to include clients who are older than the age entered in the Age field.

  1. In the Age field, enter the age.

  2. In the Rule Defines Conditions For field, select the conditions the advanced billing rule applies to:

  • Select Compliance to allow the bill to be processed. Compliance rules identify when services meet all criteria of the advanced billing rule.
  • Select Non-compliance to stop a bill from being processed. Non-compliance rules identify when services do not meet all the criteria of the advanced billing rule.
    Select Non-Compliance if the advanced billing rule is run unless a service meets all criteria of the advanced billing rule.

Compliance Conditions

The remaining fields describe a list of conditions:

  • For compliance rules, when these conditions are met the advanced billing rule is triggered.
  • For non-compliance rules, when these conditions are met liability is prevented from being distributed.

  1. In the Reason For Failed Compliance field, select the reason the service did not meet the advanced billing rule.
    Note: Reasons for failed compliance can be used as a filter when viewing the Advanced Billing Rule Failed Compliance report.

  2. In the Rule Comments field, enter comments associated with the advanced billing rule.

  3. In the Rule Results In field, select the action that occurs when a service meets the conditions of an advanced billing rule.

  • Select Message Only to display the service in the Advanced Billing Rule Failed Compliance report.
  • Select Liability Inhibit And Message to display the service in the Advanced Billing Rule Failed Compliance report, and inhibit liability for the service.

  1. In the Allow Charge Closure field:

  • Select Yes to allow closing charges for services that have not met the advanced billing rule.
    OR
  • Select No to prevent closing charges for services that have met the advanced billing rule. The service displays on the Client Ledger but does not have an associated charge.

  1. In the Update Liabilities field:

  • Select Yes to allow liability for the service to be updated. When 'Yes' is selected and the form is submitted, a message displays that the liability update process can run for several minutes. Select OK to dismiss the message and update service liability in myAvatar Cal-PM.
    OR
  • Select No when the service liability should not be updated.

Note: Updating liability does not affect services that have been closed or have been rendered in closed billing periods.

  1. In the Combination of services that cannot be reimbursed on the same day field, select the services that liability should not distribute to on the same day.

  2. Select File Advanced Billing Rule.

  3. Select Print Advanced Billing Rules to generate the Advanced Billing Rule report that displays information entered in this form.

► Additional Section
► Registry Setting
► SQL Tables
  • SYSTEM.table_medical_necessity_rule
  • SYSTEM.billing_tx_failed_compliance