Claim rules
Most claims should look exactly like your defaults. Some shouldn't: one payer wants the supervisor in Box 17 and another rejects it; one clinician is paneled with a payer under their own NPI; a Medicaid program wants a credential modifier on every line an intern bills. A claim rule says "when the claim is for this clinician and/or this payer, change these boxes," and every claim created after that follows it. No claim is edited by hand.
In this guide, we'll cover:
What a rule is
A rule has two halves.
If names which claims the rule is for. Pick any of clinicians, payers, locations (the session's office or video location) and service codes (CPT/HCPCS). Leaving a list empty means "any". You must fill in at least one, or the rule would apply to every claim.
Then names what changes on the claim. Add one or more fields:
| Field | Claim box | Choices |
|---|---|---|
| Supervising provider | Box 17 / 17b (loop 2310D) | Clinician only — the supervisor is left off. Clinician + supervisor in Box 17 — the supervisor's name and NPI are added when the clinician is under supervision. |
| Billing provider | Boxes 25 and 33 | Individual (a person: pick a team member or type a first and last name) or Organization (a practice name), then NPI, Tax ID and type, taxonomy, billing address, and the rare payer-assigned submitter ID. Opens pre-filled with your practice's own values. |
| Add modifiers | Box 24D | Up to four modifiers added to every matching service line, after the appointment's own. |
| Place of service | Box 24B | A place-of-service code for matching service lines, replacing the one the session's location would give. |
| Service facility | Box 32 | One of your locations, sent as the service facility even when its address matches your billing address. |
With no matching rule, a claim follows the Default row at the top of the Claim rules list: Boxes 25 and 33 use your practice defaults, place of service comes from the session's location, and modifiers come from the appointment, the location and the client's defaults. The Default row also holds one setting you can change: for supervised clinicians, whether the supervisor is added in Box 17 for every payer (the usual Medicaid expectation) or not added unless a rule adds it for a particular payer. Rules are exceptions to that default.
Adding a rule
- Go to Settings → Insurance & Superbills and scroll to Claim rules.
- Click Add rule and give it a name. The name is for you; it never appears on a claim.
- Under If, choose the clinicians and/or payers.
- Under Then, click Add field and fill in each panel. The minus button removes a panel.
- Click Save rule.
Rules can be edited later: click the row. Each row also has Duplicate, an On switch, and Delete. Turning a rule off keeps it for later; deleting removes it.
Where rules show up
The same rules appear wherever a biller would look for them:
- Settings → Insurance & Superbills → Claim rules: the full list.
- A payer's row under Settings → Payers: a Claim rules chip lists the rules that name that payer, and the gear icon on the row opens the rule that sets the payer's billing provider (or starts one).
- A team member's page: the Claim rules card lists the rules that affect them. For a supervised clinician it also answers the question in one line: Supervisor on claims — All payers, All payers except Premera, Only CHPW, or Never. Edit Role shows the same line under the supervisor picker, with a link to change it by payer.
- A claim: a Rules applied badge in the header names each rule that fired when the claim was created and which boxes it set. Rules are resolved when the claim is created; editing a rule later does not change a claim you already prepared.
When two rules could apply
The most specific rule wins: a rule that names more of clinician, payer, location and service code beats one that names fewer. A rule that names both a clinician and a payer beats a rule that names only one of them. So "Dana: clinician only" (clinician) can be the default, and "Dana at Optum: clinician + supervisor" (clinician and payer) the exception.
Two rules of equal specificity that set the same field and could both match the same clinician and payer are not allowed. Saving the second one is refused with the name of the rule it overlaps; narrow one of them or turn one off. Modifiers are the exception: when several rules add modifiers, they are all added, up to four per line.
A supervising provider saved on a client's own billing settings (the DN/DQ referring-provider fields) still wins over any rule for that client, and the claim's warnings say so.
Examples
| Need | If | Then |
|---|---|---|
| Medicaid wants the supervisor, a commercial payer rejects it | Payer: Premera | Supervising provider: Clinician only |
| Optum/UHC supervised sessions (supervisor in Box 17 plus modifier U5) | Clinicians: the interns · Payer: Optum | Supervising provider: Clinician + supervisor · Add modifiers: U5 |
| Credential modifier on everything an intern bills | Clinician: the intern | Add modifiers: HO |
| One clinician paneled with one payer under her own NPI | Clinician: Dr. Shah · Payer: CHPW | Billing provider: her NPI and tax ID |
| Medicare knows you as an individual with an SSN | Payer: Medicare Part B | Billing provider: individual NPI, Tax ID type SSN |
| One payer wants telehealth coded 02 instead of 10 | Payer: Anthem · Location: Video Office | Place of service: 02 |
| Credential modifier on one Medicaid code only | Service code: H0004 | Add modifiers: HO |
| A payer wants your office listed as the facility | Payer: CHPW | Service facility: Main Office |
FAQs
What happened to billing profiles? They became claim rules named "Billing profile: payer", with the same values, under Claim rules. Nothing about those claims changed.
Does a rule change claims I've already created? No. Rules are applied when a claim is created and recorded on it (the Rules applied badge). To apply a new rule to a claim you already prepared, delete the claim and create it again, or edit the claim form.
Modifiers and place of service on a claim with several sessions. Each service line is judged on its own location and code, so a batch that mixes office and video sessions gets the right answer per line. Box 17, the billing provider and Box 32 follow the first line.
Can a rule make the supervisor the rendering provider (bill as supervisor)? Not yet. Rules can add or leave off the supervisor in Box 17; the clinician who held the session stays in Box 24J.
Who can add rules? Practice owners, practice managers and billers — the same people who manage payers and billing settings.