837 Institutional/UB-04 Adjudication Rules

Define billing rules for 837 Health Care Claim institutional claims and services. These rules will be checked during batch adjudication.

1. Go to: Avatar MSO > System Maintenance > 837 Institutional/UB-04 Adjudication Rules
2. In the Facility Type Code field, select the facility type code.
3. In the Add New Or Edit Existing field:

• Select Add to create a new billing rule.
• Select Edit to change a billing rule.
  Choose Select Facility Type Rule Group To Edit. Choose the billing rule, select Ok.

3. In the Facility Type Rule Group ID field, enter the rule ID.
4. In the Facility Type Rule Group Description field, enter the description.
5. In the Inactive field, select Yes to make the billing rule inactive.
6. In the From Date field, enter the billing rule start date.
7. In the Through Date field, enter the end date.
8. In the Frequency Code field, select the frequency codes.

• Inclusive/Exclusive
  If Inclusive is selected, the rule will apply to all frequency codes selected.
  If Exclusive is selected, the rule will apply to any frequency codes that were not selected.
  If this field is left blank the default behavior will be Inclusive.

9. In the Type Of Admission field, select the admission type.

• Inclusive/Exclusive
  If Inclusive is selected, the rule will apply to all admission types selected.
  If Exclusive is selected, the rule will apply to any admission types that were not selected.
  If this field is left blank the default behavior will be Inclusive.

10. In the Revenue Code field, enter the revenue code, and select.

• Inclusive/Exclusive
  If Inclusive is selected, the rule will apply to all revenue codes selected.
  If Exclusive is selected, the rule will apply to any revenue codes that were not selected.
  If this field is left blank the default behavior will be Inclusive.

10. In the Procedure Code Group field, enter the code group, and select.
    Procedure codes are defined in the Procedure Code Group Definition form.

• Inclusive/Exclusive
  If Inclusive is selected, the rule will apply to all procedure codes selected.
  If Exclusive is selected, the rule will apply to any procedure codes that were not selected.
  If this field is left blank the default behavior will be Inclusive.

11. In the Provider field, enter the provider name, and select.

• Inclusive/Exclusive
  If Inclusive is selected, the rule will apply to all providers selected.
  If Exclusive is selected, the rule will apply to any providers that were not selected.
  If this field is left blank the default behavior will be Inclusive.

12. In the Funding Source field, enter the funding source, and select.

• Inclusive/Exclusive
  If Inclusive is selected, the rule will apply to all funding sources selected.
  If Exclusive is selected, the rule will apply to any funding sources that were not selected.
  If this field is left blank the default behavior will be Inclusive.

13. In the Rule Group Status field:
    Select the action to perform if a service matches the rule settings.

• Select Approve to approve the service.
• Select Deny to deny the service.
• Select Pend to assign the service pending status.

Note: If any of the following fields are blank, the existing logic for the service will be used, and will not be overriden by the billing rule defined in this form.

14. In the Approve, Deny, Pend fields, select the action to perform if the rule meets the criteria:

• Approve - the service is approved.
• Pend - the claim is not processed until the claim is approved or denied.
• Deny - the service is denied.

15. In the Condition Code(s) field, select the conditions associated with the billing rule.
16. In the Condition Code(s) - Status field, select the condition code status.
17. In the Value Code(s) field, select the value codes.
18. In the Value Code(s) - Status field, select the code status.
19. In the Diagnosis Range field, enter the diagnosis range for the adjudication rule in one of the following formats: 'start-end' or an individual diagnosis code. Separate multiple entries with a comma.
20. In the DRG Range field, enter the diagnosis reporting group range using the following format: start-end.
21. Select Submit.