Billing Profile Rules

With the Billing Profile Rules function you can control the information that goes on your electronic and paper claims with a high degree of specificity.


Billing Profile Rules Overview
This function allows you to set up various rules to dictate the data on claims in multiple situations. You may need to include different information on claims depending on the provider, the location, the insurance carrier, the insurance form type or the insurance plan. For example, if you need to send a specific taxonomy code when a certain doctor provides services at a certain location, but not the other locations, you can do that. Or, if you need to send a specific provider number to one insurance carrier but not the rest, you can set up a billing profile rule to do that, too.

When you access this function, the Billing Profile Rules screen opens displaying the profile rules 'tree' for the current database. The tree is set up with your Default Profile at the top. The information stored in the Default Profile is what goes on all claims unless there is another rule and profile set up below that (or unless there is an overriding customization in place), so it is very important to ensure that the details in the Default Profile are correct.

NOTE: When this function was introduced with the release of CGM webPRACTICE version 7.4.0, a Default Profile was set up with your most commonly used billing scenario, focusing primarily on the billing/pay to data that goes into Box 33 on the HCFA (and its electronic equivalent). You can make any necessary changes to the Default Profile at any time. You can also create a New Profile to be used under a rule at any time, but there is always, only one Default Profile.


Default Profile
Click Default Profile to view or edit the data. The Edit Profile screen opens and the Profile Name is unavailable, indicating that you cannot change the default profile name. The Override column of check boxes is also unavailable, indicating that this is the Default Profile. Any time you change any of the information in CGM webPRACTICE that the Default Profile pulls from, the Default Profile automatically updates with the changed information.

NOTE: You can reach the full Doctor Code Table and Location Code Table from the Claim Management menu so you do not have to exit the System Menu entirely to access information that you might need to set up the provider and location information for your rules and profiles.

The Edit Profile window has been divided into three separate images that reflect what you see as you scroll down.

Profile Name Effective Date Entity Type Entity Name Billing Provider Name Billing Address

Pay To Address Billing Provider Contact Name: Contact Information: Tax ID Number

NPI Number Social Security Number Group Taxonomy Number Mammography Number CLIA Number
Building the Profile Rules Tree
The Billing Profile Rules tree is built using rules and profiles. A good way to think about it is, a rule is the 'if' and the profile is the 'then'; the rule is the condition and the profile is the result. For example, IF charges are for Ins Dr = Dr. Baker (the rule), THEN this different Pay to Address should be used (the profile).

As mentioned above, all of your claims are generated off of what is stored in the Default Profile. If you have billing situations that require information that is different from the Default Profile, you must create a rule. To create a new rule, click Start at the top of the tree and select New Rule Below. This will create a new rule directly below the Default Profile.

The Insert Rule window opens so you can select the new rule and its associated profile.

NOTE: There is no way to delete a profile after it has been saved. The profile must be saved as history so you can always refer to exactly what was billed on claims based on that profile.

To continue the example, select New Profile in the Use Profile field to create a new profile for the 'When Provider (Ins Dr on the charges) Equals Andrew Baker (2)' rule.

The Edit Profile window opens so you can create the profile information you want to store. Enter a Profile Name and select an Effective Date. For example, if you want to have a Pay To Address, Billing Provider Contact Name, Contact Information and Tax ID Number that is different from what is on the Default Profile for when Andrew Baker, M.D. is the Ins Dr on the charges, then you must select the check boxes in the Override column next to those fields. The fields become active and you can enter the different information.

Click Save and the Insert Rule window shows the newly named new profile (Andrew Baker, MD).

Click Insert and the tree reflects the newly added rule and profile. You must click Save for this newly added information to be saved to the tree. When you click Andrew Baker, MD the Edit Profile screen containing just the overridden information displays. So now, when a claim is sent for Andrew Baker, MD, it will contain everything in the Default Profile with the exceptions of what is different in this separate rule/profile.

Now you can continue to add rules and profiles in this manner under the Default Profile, or you might need to add an additional rule for the Andrew Baker, MD profile (for example). To do this, click the rule that you want to perform an action on (Provider: ANDREW BAKER, MD (2)) and the rule selection list appears.

Click New Rule Before to insert a new rule and profile before the ANDREW BAKER, MD rule on the tree. This does not mean that it takes any precedence to the rule you are inserting it before. The rules and profiles in this case are on the same hierarchy. In this example, you may just want to keep the profiles organized in alphabetical order by the provider's last name. Rule Provider: DIANNA ARMSTRONG (DAR) and profile DIANNA ARMSTRONG were added before the ANDREW BAKER, MD rule. This just means that as claims are creating, they will create with information from the Default Profile until it runs across a claim for Ins Dr = DAR, then it pulls in the overridden portions of that profile. Then when it runs across a claim for Ins Dr = 2, it pulls in the overridden portions of that profile, and so on.

You might have a situation where you need to further specify a rule. For example, if the ANDREW BAKER, MD profile is always in effect except when he is seeing patients at a specific location, then a rule can be set up for that. Click the Provider: ANDREW BAKER, MD rule and select New Rule Below.

Now, when Dr. Baker is the insurance doctor on the claim and the claim is for Location=2, the claim pulls the Default Profile information and pulls in the overridden information from the ANDREW BAKER, MD and LOC TWO CLIA profiles.

You can also select any of the existing rules and choose to select a New Rule After. Again, this does not indicate any hierarchy in the rules. It just inserts a rule on the same branch of the tree as the rule that you are choosing for the new rule to go after. So, rather than an additional rule underneath an existing rule - like the location rule that was inserted under the Provider: ANDREW BAKER, MD - this creates a new rule on the same level.

Now, the new rule and profile for provider Jay Staub has been inserted after the rule and profile for Andrew Baker, MD. Therefore, it is its own rule and profile under the Default Profile and has nothing to do with the rules and profiles set up for Dianna Armstrong or Andrew Baker, MD.

You can change the profile that exists under a rule by clicking the rule you want to change the profile on and selecting Change Profile.

The Change Profile window opens. Select another existing profile from the Profile drop-down list.

Now the LOC TWO CLIA profile is under the Jay Staub rule.

To delete a rule, click the rule you want to delete and click Delete Rule.

The rule is deleted and any profiles that existed under that rule are removed. The profiles are not deleted. They still remain in the profile list as accessible profiles. Again, after a profile is created and saved, it cannot be deleted. The Jay Staub rule and the LOC TWO CLIA profile are now gone.

A rule can also inherit the profile directly above it. You can select Inherit Profile when you create a new rule or change a profile under an existing rule. In this example, the ANDREW BAKER, MD rule, no longer needs the ANDREW BAKER, MD profile. Now, when Andrew Baker, MD is the insurance doctor on the claim, we want it to send the claims based on what is stored in the DIANNA ARMSTRONG profile. Click, ANDREW BAKER, MD and select Change Profile and select Inherit Profile.

The ANDREW BAKER, MD profile has been removed from beneath the Provider: ANDREW BAKER, MD rule.

But, if you click the ANDREW BAKER, MD rule and select Change Profile, the Inherit Profile is selected, which indicates that when Andrew Baker, MD is the insurance doctor on the claim, that it inherits the profile directly above it (in this example, the DIANNA ARMSTRONG profile.

If you select a profile that cannot be used because of how the tree is set up before it, that rule displays in red font, indicating that this is a 'dead-end' rule selection and there is no way for the rule or information in the profile below to pull into the claim. In this example, the rule is when BILL BATES is the insurance doctor on the claim, the PAYSON profile should be used. But, it is inserted under the rule of when Andrew Baker is the insurance doctor on the claim. There cannot be more than one insurance doctor on the claim, so there is no way that the claim creation would ever get to this rule. There are many rule and profile scenarios that could result in a 'dead end' rule.

Action Column Functions
Click History in the Action Column to view a historical list of the profile tree. The Rule History window opens displaying the Date and time that the tree was saved and the user code it was Saved By. The list is in chronological order. The last entry on the list is the most currently saved profile and the one listed as currently Visible. Click the View link next to any entry that you want to review. This is helpful when you need to see exactly what was billed on a claim for a particular moment in time.

The Billing Profile Rules screen for the selected view displays as it existed on the date and time it was saved. Note the warning message at the top of the screen. If you click Save while viewing any tree in the history, that tree will be saved as the current tree.

To return to your current tree, click Cancel or click History in the Action Column to return to the Rule History screen where you can select to view the most current tree.

Click New Profile in the Action Column to create a new profile. The standard Edit Profile screen opens and you can create a profile, as instructed at the beginning of this help section. The profiles created here are not immediately visible anywhere on the tree. They are added to the profile lists to select from when you are creating a rule and want to add or change a profile.