NextGen Knowledge Center

Setup the Payer Exception Claim Rules Tab

The Payer Exception Claim Rules tab on the Institutional Billing Maintenance window allows the Revenue Code to control specific claim override options for the selected payers.

  1. From the Institutional Billing Maintenance window, select the Payer Exception Claim Rules tab.
  2. In the Payer Exception Claim Rules section, do one of the following:
    • To add a new payer exception claim rule, select open menu button and select New.
    • To modify an existing payer exception claim rule, select the row for the rule in the list, select the open menu button and select Open.
    The Payer Exception Claim Rules window opens.

  3. 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 payer revenue code or category. If dates overlap, the following prompt displays when OK is selected: Effective/Expiration dates overlap with [Payer Exception Claim Rules Name].
  4. In the Description field, enter a descriptive name for the rule. This field is required.
  5. In the Define Payer Exception Claim Rules by Rev Code or Rev Code Category section, select one of the following:
    • Revenue Code
    • Revenue Code Category(s)
  6. In the Select Options section, select one or both of the following:
    • Override Rev Code Qualifier: Select either UN (units) or DA (days) to override the qualifier for the selected revenue code(s) on claims.
    • Create Summary Claim: Select this check box to create a summary claim where all service lines with the selected revenue code(s) rollup to a single service line on the claim. The quantity on the single service line is the sum of the quantities on all service lines. To create a detail claim where each service line with the selected revenue code is listed separately on the claim, do not select this check box.
  7. To save changes and close the window, select OK.