The Claim Rules by TOB tab on the Institutional Billing Maintenance window allows the Type of Bill (TOB) to control whether specific fields are populated on claims for the selected payers.
- From the Institutional Billing Maintenance window, select the Claim Rules by TOB tab.
- In the Claim Rules by Type of Bill section, do one of the following:
- To add a new claim rule by TOB, select open menu button and select New.
- To modify an existing claim rule by TOB, select the row for the rule in the list, select the open menu button and select Open.
The Claim Rules by Type of Bill Range window opens.
- In the Effective Date and Expiration Date fields, enter an effective date and an expiration date for the rule. These fields are required. Dates cannot overlap between rules for the same TOB range. If dates overlap, the following prompt displays when the OK button is selected: Effective/Expiration dates overlap with [Claim Rules by TOB Name].
- In the Description field, enter a descriptive name for the rule. This field is required.
- In the TOB From field, enter the three or four-digit starting TOB for the rule. For example, 731 or 0731. This field is required.
- In the TOB To field, enter the three or four-digit ending TOB for the rule. For example 734 or 0734. This field is required.
- In the Diagnosis Options section, select any of the following options:
- Populate Admitting Diagnosis: Select this check box to populate the admitting diagnosis on claims. Admitting Diagnosis pulls the code flagged as Admitting DX on the encounter Diagnosis Selection window, or if blank, the first code entered in Charge Posting.
Note: Admitting Diagnosis populates the 2300 HI segment, BJ qualifier (ICD-9) or ABJ qualifier (ICD-10), on electronic 837I claims, and FL 69 on paper UB04 claims.
- Populate Reason for Visit Diagnosis: Select this check box to populate the reason for visit diagnosis on claims. Reason for Visit Diagnosis pulls the principal diagnosis code.
Note: Reason for Visit Diagnosis populates the 2300 HI*APR segment on electronic 837I claims, and FL 70 on paper UB04 claims.
You can select one of the diagnosis options at a given time, and change the selection by clearing the selected diagnosis option.
A tooltip is added in the Diagnosis options section. When you hover over the tooltip icon, a message displays stating that the claim rules do not allow Admitting Diagnosis and Reason for Visit Diagnosis in the same claim. Therefore selecting both in this List of Options would result in a non-compliant claim. If both are needed based on differing lines of business then it recommended to add a new detail row for the other option.
- In the List of Options section, select check boxes as needed for the following options to populate specific fields on claims for the selected TOB range:
- Populate Present on Admission: Select this check box to populate the present on admission indicator for diagnosis codes on claims. The check box is selected by default. Present on Admission pulls the indicators entered on the encounter Diagnosis Selection window.
Note: The Present on Admission indicator follows the diagnosis code in the 2300 HI01-9 segment on electronic 837I claims, and FL 67 on paper UB04 claims.
- Populate Covered Days: Select this check box to populate covered days on claims. The check box is selected by default. Covered Days is determined by the DA (days) qualifier in the Revenue Codes master file. If the DA qualifier is selected for the revenue code, and a Value Code of 80 is assigned on the Encounter Maintenance window, UB tab > Value Codes sub-tab, then Covered Days is calculated as the number of charge lines with a Revenue Code and a DA qualifier.
Note: The Covered Days value code and amount populates the 2300 HI01-7 BE qualifier segment on electronic 837I claims, and FL 39a - 41d on paper UB04 claims.
- Populate Patient Discharge status from Encounter Maintenance: Select this check box to populate patient discharge status on claims. The check box is selected by default. Patient Discharge Status pulls from the Encounter Maintenance window > General tab > Discharge Status field. When the Discharge Status on an encounter is blank, a default status of 01 (Discharged to home/self care (routine charge)) is used on claims.
Note: Patient Discharge Status populates the 2300 CL103 segment on electronic 837I claims, and FL 17 on paper UB04 claims.
- Populate 837I Statement dates based on Bill Frequency: Select this check box to populate statement dates on claims. The check box is selected by default. Statement From and To Dates are populated as follows:
- If Bill Frequency = 2 (first in series), then Statement From = admission date, and Statement To = last service date on claim
- If Bill Frequency = 3 (interim in series), then Statement From = first service date on claim, and Statement To = last service date on claim
- If Bill Frequency = 4 (last in series), then Statement From = first service date on claim, and Statement To = discharge date from Encounter Maintenance
Note: Statement Dates populate the 2300 DTP*434 segment on electronic 837I claims.
- Populate Discharge Hour: Select this check box to populate discharge hour on claims. The check box is selected by default. Discharge Hour pulls from the Encounter Maintenance window > General tab > Discharge Time field. When the Discharge Time on an encounter is blank, a default time of 0800 is used on claims.
Note: Discharge Hour populates the 2300 DTP*096 segment on electronic 837I claims, and FL 16 on paper UB04 claims.
- Populate Admission Date: Select this check box to populate admission date on claims. The check box is selected by default. Admission Date pulls from the Encounter Maintenance window > General tab > Admit Date field. When the Admit Date on an encounter is blank, the encounter Billable Date is used on claims.
Note: Admission Date populates the 2300 DTP*435 segment on electronic 837I claims, and FL 12 on paper UB04 claims. D8 is populated in DTP02 when admission date is populated on the claim without an admission hour.
- Populate Admission Hour: Select this check box to populate admission hour on claims. The check box is selected by default. Admission Hour pulls from the Encounter Maintenance window > General tab > Admit Time field. When the Admit Time on an encounter is blank, a default time of 0800 is used on claims.
Note: Admission Hour populates the 2300 DTP*435 segment on electronic 837I claims, and FL 13 on paper UB04 claims. DT is populated in DTP02 when admission date and admission hour are populated on the claim.
- Populate charge line date of service: Select this check box to populate charge line date of service on claims.
Note: Date of Service populates the 2400 DTP segment on electronic 837I claims. The D8 qualifier is populated when the service line covers a single day (CCYYMMDD). The RD8 qualifier is populated when the service line covers a range of dates (CCYYMMDD-CCYYMMDD).
- To save changes and close the window, select OK.
