Advanced Billing Rule Definition - PM

Rule

1. In the Add Or Edit Advanced Billing Rule field, select Add to add an advanced billing rule, or select Edit to edit an existing advanced billing rule.

2. If adding a rule, in the Advanced Billing Rule Description field, enter the description.
   Note: Advanced billing rules must be named differently for each system code when working with Autosync Maintenance functionality.

3. If editing a rule, in the Advanced Billing Rule field, select the advanced billing rule.
4. Select Print Advanced Billing Rules to generate the Advanced Billing Rule report that displays information entered in this form.
5. In the Active field:

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

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

7. 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.

8. 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.

9. In the Allow Charge Closure field:

• Select Yes to allow charges for services that have not met the advanced billing rule to be closed.
• Select No to prevent charges for services that have met the advanced billing rule from being closed. The service will display on the Client Ledger, but will have no associated charge.

10. In the Frequency field, enter the value that must meet the advanced billing rule:

• 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.

11. In the Frequency Times field, enter how often the service must be rendered to meet the advanced billing rule.
    Note: Selecting a frequency disables Diagnosis fields.

12. In the Effective Date and Expiration Date fields, enter the advanced billing rule start date and advanced billing rule end date.

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

• Compliance - compliance rules do not impact whether services are able to be claimed. Compliance rules identify when services meet all criteria of the advanced billing rule.
• Non-compliance - Non-compliance rules identify when services meet all the criteria of the advanced billing rule. Services that meet criteria in the rule will show up in the Advanced Billing Failed Compliance Report. Non-compliance rules do not impact whether services are able to be claimed.

Note: The remaining fields in the Rules subsection describe a list of conditions. When these conditions are met for compliance rules, the advanced billing rule is triggered. When these conditions are met for non-compliance rules, liability is not distributed.

14. 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 to filter the display of the Advanced Billing Rule Failed Compliance report.

15. 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.

16. In the Update Liabilities field:

• Select Yes to allow liability for the service to be updated; select No when the service liability should not be updated.
  Note: When Yes is selected and the form is submitted, a message displays indicating that the liability update process can run for up to 20 minutes. Select Ok to dismiss the message and update service liability in myAvatar PM.
• Updating liability does not affect services that have been closed or have been rendered in closed billing periods.

Diagnosis

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

18. In the Diagnosis Inclusive Or Exclusive field:

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

19. 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.
• In order to include a medical diagnosis in the advanced billing rule:
  • A medical diagnosis must be defined as the primary medical diagnosis (Medical Diagnosis form).
  • A medical diagnosis must be defined as the principal diagnosis (with an associated ICD-10 code) in the Diagnosis form. The ICD-10 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).

20. 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).

Age and Gender

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

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

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

24. 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.

25. In the Age field, enter the client’s age.

Comments

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

27. In the Combination of services that cannot be reimbursed on the same day field, select the mutually exclusive services.

28. In the Select Services That Must Also Be Rendered For Distribution field, specify which services must also be billed prior to billing the service code to which the advanced billing rule applies.

29. In the Selected Services Must Be Rendered By A Practitioner With One Of The Following Practitioner Categories For Coverage field, specify if a selected service must be rendered by a certain type of practitioner. If left blank, all categories for coverage in the system will be valid.

30. In the Selected Services Must Be Rendered Within How Many Days Prior To The Service For Incident To Services field, indicate how many days prior to the service the system should check that the selected services are rendered. The default setting is '0', indicating same day services.

31. In the Selected Services And Practitioner Categories For Coverage Applies For field, select whether coverage applies For Non-Incident To Services or Incident To Services. If a selection is needed for both types of services, two Advanced Billing Rules may be defined.

32. In the Diagnosis (ICD-10) field, select the ICD-10 codes to include in the rule definition.

33. The Diagnosis Group (ICD-10) field limits the diagnoses displaying for ICD-10 codes to only those that fall within the group selected.

34. Select File Advanced Billing Rule.

► Additional Sections

• Event Rules

► Registry Settings

• Enable ICD-10
• Enable Same Day Service Exclusion

► See Also

• Pre-populate ICD-10 Codes in Advanced Billing Rules Definition

► SQL Tables

• SYSTEM.table_medical_necessity_rule
• SYSTEM.billing_tx_failed_compliance