/
How to: Manage Services and Service Rules

How to: Manage Services and Service Rules

Manage Services How to Guide

In this guide we will review how to maintain and create new billable services. Pre-requisite is that Procedure Codes must be completed.


Go to Master Data > Manage Services:

Click on the New Services option in the upper right-hand corner:

You will start with the service information:

  • Service Name: Add in the name that will appear on the Census (not what appears on the claim form, this will also appear on your Authorizations drop down list)

  • Bill Under Legal Entity / Billing Facility: (Box 2 on a UB04 or Box 33 on a 1500).

  • Admission Type: This is specific to your UB04 (it is a required field) example 2 means Urgent and appears in Box 14

  • Description: The actual description on the claim form so be sure to be clear and concise on what you say ex. "Residential Treatment" not RTC.

  • Bill Under Service Facility / Service Facility: (Box 1 on UB04 or 32 on 1500). If you have multiple locations you can state to the pull the service location from the patients chart at the time the service was render (use patient's at time of service), or you can select the location that the service will always default to on the claim form regardless of where the client was at the time of the service. Example Group is always billed through Test Service Facility 1 and will be on the claim form even though the client is listed at Service Facility 2.

  • Charges are added to the Census when: can be one of 3 selections

  • User Manually Selected: meaning the user will manually select the item on the census to be generated by selecting the N/A option and choosing from the list of services

  • Inpatient Service, when patient is active with Auth: this means if the service has an authorization and the client has finished a full day on the census, the service will be placed automatically on the census for claim generation

  • Outpatient, when form linked to this service is completed: when this is selected a field called billable forms will appear and is required to be completed:

     

  • You will need to add what forms link to this service by typing in the name of the form and then adding it to the list. The Billable on option states this service can automatically generate on the Blue Highlighted days in this example if any of the 3 forms listed are completed on Mon Wed or Friday signed and meeting time requirements individually or combined (further down in the rule) It will automatically place the service on the census for claims generation.

Below the service information there are 2 checkboxes:

  • If the checkbox is selected Requires Authorization means that this service will always require an authorization to bill out the claim. If the authorization is missing this claim will be placed in a hold status

  • Don't Consolidate for Professional Only (meaning 1500's) - this service will be on its own claim if there are like services on that day/week that will go on a 1500 together it will split this onto its own.

If ever in doubt hover over the question mark and it will give a clear description as well.

Below you have the Global and in network rates:

To add a Global rate simply click on the "+" button

You will then be prompted to select the beginning date of the effectiveness of that price and the amount once completed click save:

You can track all price changes should you have a new price starting on 1/1/23, based on the date of service not date of submission it will pull the correct pricing.
To add a contracted rate, choose the insurance company from the list and click on the "+" button, keep in mind this is based on the Home Plan not submit to:

Once you do it will add the insurance to the list to add the effective date and rate to the list as well, the rate type will default to Contracted Rate meaning you have a contract for this price, you can change it to Estimated Rate, meaning this is the estimated rate you expect to be paid:

Click on the "+" button to add in the dates and amounts and save. Once done you can choose to bill with the contracted rate by checking the checkbox above the rate stating to Use contracted rate for billing:

Below we set the Default Rule:

Choose the claim type either 1500 or UB04. For Both UB and 1500 the following apply:

Select the Procedure Code (CPT) this is connected to the Procedure Code bank we created prior

  • NPI to Use (Facility or Physician)

  • The physician you are billing under

  • Diagnosis Codes you want to pull onto the claim (Mental health/SA/Medical etc.) this will be based on how the facility separates these out

  • Diagnosis Type – All means it will include all Dx Codes included in the Diagnosis Codes selection. If you choose Primary/Secondary/Tertiary only, if there are 4 Dx Codes listed and 3 are deemed Primary and one Secondary it will only pull the Primary onto the claim form if you selected to have Primary only

  • Only Generate claims if the patient – if listed "at any level of care" this means claims can be generated at any time, if you select "Is Not In…."Detox/Res/PHP etc. it will wait to generate the claim until the patient has changed Levels of Care or Discharged. There is also a selection for "Or the service has been rendered in the prior month" this means it will hold the claims until the next month, example I have selected services through out May only when it is June 1 it will create the claims.

  • Always use the medical insurance - When selected will apply the medical policy to the claims in the event there is a behavioral health carve out on file.

UB04's

  • Revenue Code – this is required to be filled out

  • Mins Required – only required to be filled out when Outpatient auto claim generation is being used

  • Value Codes Box 39 (Value 80 Code) either custom or standard, when standard it will count the lines on the claim form and add it as well as the 80. If custom it will open the Value box for you to customize

  • Inpatient is used when service relates to inpatient services (tied to LOC)

  • Use Alternative Service Facility Name - Allows Service Facility Alias for naming.

  • Use the last claim type of bill when the last service date is the day – the is saying what is the last billable day upon discharge, you can choose day before discharge, usually use for inpatient or Of Discharge, usually used for outpatient

  • Include present on admission indicator can be based on the insurance provider. When setting up the insurance provider there is an option on each individual provider to either include the present on admission indicator (the Y next to the Dx Codes) or not. This default will look at each insurance individually. If you select Yes or No in the dropdown it will apply the Y or not each time regardless of the insurance provider.

  • Type of Bill can be custom for First Middle and Last claim which will over ride the insurance or can be based on the individual insurance provider and the set up with the bill types for both Inpatient vs Outpatient

  • STAT Box 17 discharge Type (only when discharged) will pull from the clients chart, when discharged there is a code linked to each discharge type and it will be placed on the claim form. In the event the facility would like for that discharge code to be overridden with a different code in the event you want to always us ex. "01" always

  • Inpatient Checkbox – when selected or deselected this will look at the bill type (when defaulted to insurance provider) to pull the inpatient or outpatient bill types

  • Include admission information checkbox – when selected box 12 and 13 will be included, when deselected it will not and it is recommended to choose the checkbox stating "If Admission Date is not included move box 69 to box 70" this is moving the admission Dx (box 69) to the Reason Dx (box 70)

  • Box 15 – Source of Admission we currently default to 9 but is a customized field

  • Box 81 is open for both Qualifier and Taxonomy code

  • Box 57 pulls automatically with BCBS provider ID when billing with BCBS only. The field is open and can be customized and will override the BCBS provider ID if filled out

  • Box 74 can be customized with the principal procedure code and base it on Admission Date or Service Date choose that the service is inpatient or outpatient and whether or not you want to include the pay to address, Only Generate Claims if the patient (this is a selection of generating claims based on where a client is at the time the service is rendered such as Anytime, or when a client has dropped to a different level of care or if you only want claims to generate when the service was provided in the prior month), Box 80 is the remarks open for text, Diagnosis Type is the ability to choose all or a specific type ex. Primary, Secondary etc.,

1500's

  • Place of service (POS) - is customized this is the place of service placed on to the claim form based on where the service was rendered

  • Box 23 – this will default to the Authorization information but can be changed to show the CLIA number information

  • Including the provider taxonomy code on box 24j, when this is checked off it will look at the rendering physician and include their Taxonomy, box 24i will open up for you to add in the qualifier

  • Box 32b and 33b have the same choice dropdown, it will default to Tax ID but you can choose to have no value or the taxonomy code

  • Inpatient checkbox – when selected will include the Admission date in Box 18


Once you have completed your default rule make sure to click save in the bottom right-hand corner and you are ready to add on rules.

To add a Rule, meaning the Default rule is how you bill most often, but there is an exception based on an insurance requirement you can add a rule by selecting the Add Rule option to the upper right-hand corner above the default:

You will be prompted to select whether the rule will be based on the Insurance Provider or Financial Class (if set up in the realm). Financial Class is primarily utilized for Medicaid, this allows the facility to make a bulk rule that will apply to the insurance companies all listed within the Financial class housed in the Insurance Provider settings:

When you Add Rule (for insurance provider) the following screen will be identical to the Default Rule with the exception of the header:

  • Insurance Type – Home or Submit, this is stating that your rule is based off of the Home Plan provider or the Submit to Location

  • Insurance Provider – this will be your list of insurance providers to base your rule on

  • Member ID – if the rule is specific to a Member ID you can place it in this location be sure to choose insurance as well

  • License Credentials – primarily used in conjunction with the Financial Class. You can assign each of your provider a License Credential like LMHC and then create a rule stating if you bill with an LMHC follow this rule with this insurance or group of insurances (Financial Class).

If using the Financial Class:

  • Financial Class – Apply the class that the rule is for

  • Member ID – if the rule is specific to a Member ID you can place it in this location be sure to choose insurance as well

  • License Credentials – primarily used in conjunction with the Financial Class. You can assign each of your provider a License Credential like LMHC and then create a rule stating if you bill with an LMHC follow this rule with this insurance or group of insurances (Financial Class).

All fields within the Rule are the same as the Default, make your selections based off of how the claim is created for that provider or group of providers.
When rules are created there are 4 options to the right of the rule:

  • Overlapping papers – means you can copy the rule and change the Insurance or any information to cut down time on rule creation

  • The "X" – is a way to delete the rule if it no longer applies

  • The arrows up and down – allows you to move the rule up on down the purpose of this is in a situation where you have a rule for Home plan is ex. BCBS Ohio and the Submit to location is BCBS FL, if I have a rule for Home Plan and Submit To both listed in the rules section, whichever Rule is first it will follow the rule.

There is a Rule Rate- this works in the same fashion as the contracted rates but is applied to the rule so if you have a rate that applies to the rule that is the Submit to insurance it will pull the appropriate rate.