5010 Claim Hold Rules
With the 5010 Claim Hold Rules function, you can set up rules to
dictate when 5010 electronic claims should be held.
This function resembles and functions similarly to the other 'rule tree'
functions (for example, Billing Profile Rules). You can set up
rules to hold claims by Doctor, Form Type, Insurance
Carrier, Insurance Form, Plan Code, and Location.
When you access this function, the 5010 Claim Hold Rules screen
opens displaying the Claim Hold Rules 'tree' for the current database.
The tree is set up with the Default Rule at the top. The information
stored for the Default Rule controls all claims unless there is
another rule set up below it (or unless there is an overriding customization
in place).
When an encounter for a claim is saved or updated from the Procedure
Entry Function or from Edit an Encounter, the claim is checked
against the Claim Hold Rules criteria to see if it should be placed in
the Hold status automatically.
When a claim hold rule is added, edited, or deleted, after you click Save,
all claims are rechecked and moved to the correct claim status as indicated
in the rules, as follows:
- All claims in a status of In Process, Locked, Exceptions, or Hold
are checked and either moved to or remain in the Hold status.
- All claim files are checked, and any claim in a status of Ready
is removed from the claim file and changed to Hold status.
- All claim files are checked, and any claim in a claim file in a
status of Hold is changed to In Process, removed from the exception
report, and placed in the appropriate claim file.
Adding a New Rule
- Click Start on the rule tree, and then click Add New
Rule.
- In the When field, select the criteria the rule should match
against (Doctor, Form Type, Insurance Carrier,
Insurance Form, Plan Code, or Location).
- In the Equals field, type or select the value the criteria
must equal for the rule to apply.
- Set the Hold Claims value to Yes or No for
the rule.
- 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 history of changes that have been made
to Claim Hold Rules. Each version is listed with the date and the user
who made the change. The current version (what you saw on the 5010
Claim Hold Rules screen before clicking History) is indicated
by the word Visible. To view a different version of the rules in
effect, click the View link for that entry.
See Billing
Profile Rules for detailed
samples to set up additional rules.
Related Topics
- Billing Profile Rules
- 5010 Electronic Claim Loop and Segment Editor
- 5010 Submitter ID Rules
- 5010 Claim Exception Rules
