On the Add/Modify Program Information window, the Threshold Rules sub-tab under the Practice tab enables you to configure payer-specific threshold rules for the program. For example, in a Behavioral Health practice, a payer may require that patients in a specific program have a minimum number of addiction counseling hours per week, or a minimum number of therapy units per month before billing the payer for those services.
- Access File Maintenance.
- Select System Master Files, then PM, and then Programs.
The Program List window opens.
- From the list, select a program and then do one of the following:
- Select Open Menu
and then select Open.
- Right-click and then select Open.
- Double-click to open the program.
The Modify Program Information window opens.
- Select the Practice tab, and then Threshold Rules on the left.
Existing rules are listed in descending order by effective date with the following information:
- Effective Date
- Expiration Date
- Threshold Description
- Do one of the following:
- To create a threshold rule, select Open Menu and then select New.
- To modify a threshold rule, select the rule from the list, then select Open Menu and then select Open.
The
Program Threshold Rules Maintenance window opens.
- In the Effective Date field, enter the date the rule goes into effect. This field is required.
- In the Expiration Date field, enter the date the rule expires. This field is required.
- In the Description field, enter a description for the rule. This field is required.
- In the Valid Payers section, select the payers the rule applies to. This field is required and at least one payer must be selected.
- In the Program SIM section, select the SIM codes the rule applies to.
The codes available for selection are from the Limit Service Items section on the System tab.
If the rule applies to all SIM codes in the Limit Service Items list, leave this section blank.
If the rule applies only to specific SIM codes in the
Limit Service Items list, do the following:
- In the Threshold Details section, do the following:
- In the Minimum field, enter a value between 1 and 999. This field is required, and the value must be less than the maximum.
- In the Maximum field, enter a value between 1 and 999. The value must be equal to or greater than the minimum.
- In the Service Unit field, select one of the following:
- Minutes
- Hours (default)
- Units
- Encounters
Note: This option is not available when Encounters is selected in the Service Duration field.
- In the Service Duration field, select one of the following:
- Encounters
Note: This option is not available when Encounters is selected in the Service Unit field.
- Week (default)
Note: A week is defined as Monday through Sunday.
- Months
Note: A month is defined as the first calendar day through the last calendar day.
- Do one of the following:
- To save changes and close the window, select OK.
- To save changes and add another rule, select Next.
Note: The Next button appears on the Program Threshold Rule Maintenance window when adding a new rule, but not when modifying an existing rule.
The rule displays in the Threshold Rules list.
