Payer Rules: Case Management

The Case Management payer rule is intended to reduce the manual work needed to bundle case management so that billers don't need to manually calculate services rendered on a rolling 30-day period.

Required Permissions
You must be a Super Admin to add and edit payer and billing rules.

Creating a Billing Rule

Before you begin, you must create a payer rule. For detailed instructions, click here.

1. Once you've created a payer rule, click Add Billing Rule.
2. Select Case Management from the Billing Rule Type drop-down.
3. Add the codes that will trigger the payer rule in the Trigger Codes field. You can either type them in or use the drop-down list. The code(s) chosen here will dictate which codes appear in the Bundle Code field. (If you choose a CCode, the Bundle Code list will pull all CCodes listed in Settings > Billing Audit Tool > Codes > Professional, etc.)
4. The billing period is set to Rolling 30 Days but can be changed to Monthly, if needed.
5. Next, choose the desired bundle code from the Bundle Code drop-down list.
6. Type in the minimum required services or use the up and down arrows in the Min Required Services field. The bundle code will not apply until the bundle meets the required minimum set here.
7. Type in the minimum direct services or use the up and down arrows in the Min Direct Services field. The bundle code will not apply until the bundle meets the required minimum set here. Direct services can be marked using the case_management_type in evaluation templates. For more information on field types like direct services, click here.

8. Select the desired date of service from the Date of Service drop-down.

   

   1. First Day of Service: Choosing this option will set the bundle's date of service to the date of the first performed service in the bundle.
   2. Last Day of Service: Choosing this option will set the bundle's date of service to the date of the last performed service in the bundle.
   3. First Day of Month: Choosing this option will cause the bundled row's date of service to be the first day of the month that matches the latest date in the bundle.
   4. Last Day of Month: Choosing this option will cause the bundled row's date of service to be the last day of the month that matches the latest date in the bundle. The rule defaults to this option.

9. Finally, select the bundle's through date. The selection here will dictate which of the following will be used as the end date for the bundle. 

   

   1. First Day of Service: Choosing this option will set the bundle's through date to the date of the first performed service in the bundle.
   2. Last Day of Service: Choosing this option will set the bundle's through date to the date of the last performed service in the bundle.
   3. First Day of Month: Choosing this option will cause the bundled row's through date to be the first day of the month that matches the latest date in the bundle.
   4. Last Day of Month: Choosing this option will cause the bundled row's through date to be the last day of the month that matches the latest date in the bundle. The rule defaults to this option.
10. Click Update to save your rule.