Custom Rule: Medicare 3-Day Payment Window

On the Main Menu, click Settings >Billing. In the left menu, under Practice Links — Client-Configurable Rules, click Medicare 3-Day Payment Window

To access this page, the Wholly owned or operated by hospital field on the Medical Groups page must be set to Yes for the medical group. To access custom rules, you must have the Billing Admin: Custom Rules permission or Manager/Superuser access.

1. Display the Medicare 3-Day Payment Window page: On the Main Menu, click Settings >Billing. In the left menu, under Practice Links — Client-Configurable Rules, click Medicare 3-Day Payment Window.
2. Name — Enter a name for this rule.
3. Description — Enter a description of this rule.
4. Start date — Enter or select a start date for this rule.
5. End date — Enter or select an end date for this rule.
6. Allow override — This option is selected by default.

Select filters to define groups of claims to hold for review under the Medicare 3-Day Rule

7. Department Filter — Filter claims by service department or place of service type.
• All — Do not filter on service department or place of service type.
• Service Department — Click Selected or All Except. Then select one or more service departments.
• Place of Service Type — Click Selected or All Except. Then select one or more place of service types.
8. Supervising Provider Filter — Filter claims by supervising provider or supervising specialty.
• All — Do not filter on supervising provider or specialty.
• Supervising Provider — Click Selected or All Except. Then select one or more supervising providers.
• Supervising Specialty — Click Selected or All Except. Then select one or more supervising specialties.
9. Procedure Code Group Filter — Filter claims by procedure code group.
• All — Do not filter on procedure code group.
• Selected — Click Selected and then select one or more procedure code groups to include claims with these procedure groups.
• All Except — Click All Except and then select one or more procedure code groups to exclude claims with these procedure groups.
10. ICD-9 Diagnosis Code Group Filter — Filter claims by ICD-9 diagnosis code groups.
• All — Do not filter on ICD-9 diagnosis code groups.
  Note: The All option is selected by default for existing custom rules that have All selected for ICD-9 diagnosis code groups.
• Selected — Click Selected and then select one or more ICD-9 diagnosis code groups to include claims with these diagnosis groups.
• All Except — Click All Except and then select one or more ICD-9 diagnosis code groups to exclude claims with these diagnosis code groups.
• None — Click None to prevent this custom rule from firing on an applicable ICD-9 diagnosis code group.
  Note: The None option is selected by default for existing custom rules that contain specific ICD-9 diagnosis code groups.
11. ICD-10 Diagnosis Code Group Filter — Filter claims by ICD-10 diagnosis code groups.
    • All — Do not filter on ICD-10 diagnosis code groups.
      
    • Selected — Click Selected and then select one or more ICD-10 diagnosis code groups to include claims with these diagnosis groups.
    • All Except — Click All Except and then select one or more ICD-10 diagnosis code groups to exclude claims with these diagnosis code groups.
    • None — Click None to prevent this custom rule from firing on an applicable ICD-10 diagnosis code group.
      
12. Click Save.

Note: Please review and update any custom rules with specific ICD-9 diagnosis codes or diagnosis code groups so that the custom rules will continue to work after the ICD-10 transition.

Effective July 1, 2012, CMS expanded the scope of the Medicare 3-Day Rule to include entities wholly owned or operated by a hospital that provide Medicare Part B outpatient services.

According to Medicare, an entity is wholly owned or operated by a hospital if the hospital is the sole owner of the entity, and/or if the hospital has exclusive responsibility for conducting and overseeing the entity's routine operations, regardless of whether the hospital also has policy-making authority over the entity.

When your practice enrolled with Medicare, you indicated on your Medicare Enrollment Application (form CMS-855B) whether your practice is wholly owned or operated by a hospital. Please review CMS guidelines for additional information regarding the 3-Day Rule and wholly owned or operated by hospital designations.