Custom Rule: Procedures that Require Authorization/Referral

1. Display the Custom Rule: Procedures that Require Authorization/Referral page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — My Custom Rule Parameters, click Procedures that Require Authorization/Referral.

2. Name — Enter a name for the rule.
3. Description — Enter a description of the rationale or issue.
4. Instructions — Enter instructions to your staff about how to manage the rule.
5. Transfer type — Select primary claims, secondary claims, or all transfer types.
6. Start date — Enter an effective date for the rule. This date range applies to the claim date of service. If you leave the Start date blank, the rule applies to all claims past, present, and future.
7. End date — Enter an expiration date for the rule. This date range applies to the claim date of service. If you leave the End date blank, the rule applies to all claims past, present, and future.
8. Next claim status — Select the resulting claim status when a claim violates the rule.
9. Allow override — Select Yes if you want an override link to appear in the claim note if the rule fires.

Insurance Filter

10. You can specify conditions based on Insurance Reporting Category, Custom Insurance Group, or Insurance Package. The default selection is All, which does not create any conditions.
11. Insurance Reporting Category — Select specific IRCs. An Insurance Product Type filter appears so that you can refine the logic to include specific insurance products within the IRC.
12. Custom Insurance Group — Select specific insurance groupings used in your practice.
13. Insurance Package — Enter insurance package IDs in the fields provided to specify conditions for this rule.

Department Filter

14. You can specify conditions based on Service Department, Place of Service Type, or Patient Department. The default selection is All, which does not create any conditions.
15. Service Department — Select departments to limit the rule to service departments where the rule applies.
16. Place of Service Type — Select types to limit the rule to selected place of service types.
17. Patient Department — Select departments to limit the rule to the patient departments where the rule applies.

Created By User Filter

18. You can specify conditions based on the users who created the claims using the Selected or All Except options. The default selection is All, which does not create any conditions.
19. Username — Select usernames to limit the rule to specific users who created claims.

Supervising Provider Filter

20. You can specify conditions based on Supervising Provider, Supervising Provider Type, or Supervising Specialty. The default selection is All, which does not create any conditions.
21. Supervising Provider — Select the usernames of individual supervising providers.
22. Supervising Provider Type — Select individual supervising provider types.
23. Supervising Specialty — Select individual supervising provider specialties.

Rendering Provider Filter

24. You can specify conditions based on Rendering Provider, Rendering Provider Type, or Rendering Specialty. The default selection is All, which does not create any conditions.
• Rendering Provider — Select the usernames of individual rendering providers.
• Rendering Provider Type — Select individual rendering provider types.
• Rendering Specialty — Select individual rendering provider specialties.

Procedure Code Filter

25. You can specify conditions based on procedure codes using the Selected or All Except options. The default selection is All, which does not create any conditions.
26. Procedure Code — When you enter individual procedure codes, you can enter ranges of consecutive procedure codes in a single box (for example, 99210-99499), but you cannot include modifiers in a range of codes.
    No wildcards (*) are allowed.
    Note: You can specify fee-affecting modifiers, but not non-fee-affecting modifiers. You cannot include modifiers in a range of codes.
    Note: You can enter as many procedure codes as you require for a given rule. When you fill a row of boxes, a new row appears automatically.

Procedure Code Group Filter

27. You can specify conditions based on procedure code groups using the Selected or All Except options. The default selection is All, which does not create any conditions.
28. Procedure Code Group — If you click Selected, select procedure code groups to make the rule apply only to claims with the selected procedure code groups. If you click All Except, select procedure code groups to make the rule apply to all claims except those claims with the selected procedure code groups.

ICD-9 Diagnosis Code Filter

29. You can specify conditions based on ICD-9 diagnosis codes using the Selected or All Except options. The default selection is All, which does not create any conditions. Select None if you do not want the custom rule to fire on an applicable diagnosis code set.
    • The None option is selected by default for existing custom rules that contain specific ICD-9 diagnosis codes in the ICD-9 Diagnosis Code Filter.
    • The All option is selected by default for existing custom rules that have All selected in the ICD-9 Diagnosis Code Filter. The custom rules fire based on the diagnosis code set expected by the payer.

Note: Please review and update any custom rule with specific ICD-9 diagnosis codes to ensure that the custom rules continue to fire after the ICD-10 transition.

30. Diagnosis Code — When you enter individual ICD-9 diagnosis codes, you can enter ranges of consecutive codes in a single box. No wildcards (*) are allowed. Enter a period to open the Diagnosis Lookup tool.
    Note: You can enter as many ICD-9 diagnosis codes as you require for a given rule. When you fill a row of boxes, a new row appears automatically.

ICD-10 Diagnosis Code Filter

31. You can specify conditions based on ICD-10 diagnosis codes using the Selected or All Except options. The default selection is All, which does not create any conditions. Select None if you do not want the custom rule to fire on an applicable diagnosis code set.
32. Diagnosis Code — When you enter individual ICD-10 diagnosis codes, you can enter ranges of consecutive codes in a single box. No wildcards (*) are allowed. Enter a period to open the Diagnosis Lookup tool.
    Note: You can enter as many ICD-10 diagnosis codes as you require for a given rule. When you fill a row of boxes, a new row appears automatically.

1. Display the Custom Rule: Procedures that Require Authorization/Referral page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — My Custom Rule Parameters, click Procedures that Require Authorization/Referral.
2. Click the history link to the left of the custom rule. The audit history pop-up window appears for that rule.

 

You can override individual custom rules or every custom rule of the same category on the Claim Edit page. One claim note appears for each custom rule that is holding the claim.

• To override a single custom rule, click the override link in the Claim Status column of the claim note.
• To override all custom rules of the same type (for example, all custom rules created on the Custom Rule: Invalid Modifiers page), click the override all custom rules from same category link in the claim note.
  Note: This link appears only if overlapping custom rules fire on the same claim.