5010 Claim Exception Rules

With the 5010 Claim Exception Rules function, you can set up your own 5010 electronic claim exceptions and enter custom exception text that displays for charges matching the parameters of the rule. This function resembles and functions similarly to the other 'rule tree' functions (for example, Billing Profile Rules).

You can set up rules based on Electronic Form Number, Insurance Carrier, Insurance Doctor, Insurance Form Type, Location, Performing Doctor, or Plan Code.

5010 Claim Exception Rules Screen

When you access this function, the 5010 Claim Exception Rules screen opens displaying the Claim Exception Rules 'tree' for the current database. The tree is set up with the default Exception Text directly under the Start drop-down menu. The default Exception Text applies to all 5010 claims unless overridden by a rule set up below it.



Each rule in the tree displays the criteria (for example, Location: ER (23)) followed by a child Exception Text entry. The Exception Text can be set explicitly for that rule, or it can be set to Inherited, in which case the rule uses the Exception Text from its parent rule (or the default Exception Text at the top of the tree if there is no parent rule).

Adding a New Rule
  1. Click Start on the rule tree, and then click New Rule Below.
  2. In the When field, select the criteria the rule should match against (Electronic Form Number, Insurance Carrier, Insurance Doctor, Insurance Form Type, Location, Performing Doctor, or Plan Code).
  3. In the Equals field, type or select the value the criteria must equal for the rule to apply.
  4. Type the custom Exception Text that should display for charges matching this rule, or leave it set to Inherited to use the parent rule's Exception Text.
  5. Click Insert to add the rule to the tree, and then click Save to save the changes.



Action Column Functions

History – Click to view a complete history of changes that have been made to Claim Exception Rules. The Rule History window opens, listing each version with the Version Date and the user who saved it in the Saved By column. The current version is labeled Visible. To view an earlier version, click the View link for that entry.



See Billing Profile Rules for detailed samples to set up additional rules.
 
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