Rule sets are used during the visit verification process to link exceptions on visits that don't respect these rules, allowing a user to intervene before the visit is approved. Exceptions can require a reason and resolution in order to be verified, or simple acknowledgement. These rule sets are linked to the service code, payor or branch associated with the visit, in that order of priority.
Note that in multi-office environments, rule sets are created at the branch level, not at the HQ level. They are not shared across branches.
Managing rule sets
To set up or manage a rule set, go to accounting>accounting settings>verification rule sets. Existing rule sets will be displayed by name with their effective date (if multiple versions exist) and version details. By default, the list will be filtered to the latest versions of the rule sets.
Click the filter icon to search for a rule set by name, or by branch if it is multi-office. Turn off the show the latest sets toggle to display older versions. Previous versions will be identified by a version number.
Click view to review the rules included on each set.
Once a rule set has been used during the visit verification process, you will not be able to change attributes or add new rule types. To edit the set, create a new version of the rule set instead.
Creating a new rule set, or new version of the rule set
To create a new rule set or a new version of an existing set, select +create rule set.
A dialogue box will appear. Create a new set, or create a new version of an existing set.
If you are creating a new set, enter a unique name for your set.
If you are creating a new version, select the rule set you wish to create a new version of from the dropdown.
The name of the set selected will appear in the name field by default, but you can change the name if necessary. Note that the new name will apply to all versions of the set.
Select the effective date of the new version. Uncheck copy latest version if you do not wish to copy the rule types from previous versions. Click save to save all selections.
Add rule types to a rule set
To add rule types to a rule set click view.
Previously added rules will be listed on the next screen.
The following information will be displayed for each rule in the list:
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Rule type: for the complete list of rule types available, please see the rule types section.
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Required action (if applicable): reason(s) required or acknowledgement. If reasons are required, choose from the reasons listed to verify this exception. If reasons are not required, the user will simply need to acknowledge the exception to proceed to billing/claim generation and payroll.
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Threshold (if applicable): the threshold value that determines whether an exception will be raised.
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Unit (if applicable): the units in which the threshold for the rule type is measured.
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Comment required: yes or no. You can choose to require a comment for any rule type along with the required reason and resolution.
To add a new rule to the set, click +add rule.
In the dialogue, select which type of rule you wish to add to the set. The additional required fields will depend on the rule type you select.
You will be able to choose whether an acknowledgement or selecting specific reasons is required to verify an exception. If you select reason(s) required, you will also need to select which reasons are required to verify the exception. Note that only enabled reasons associated with one or more resolutions will be available to select.
For certain rule types, you also need to enter a threshold.
Once you have completed all fields, click save to add the rule type to the set.
Available rule types
For more information on available rule types, read this article. A description to the purpose of the rule type is now shown when users choose from the rule types available.
Link a branch to a rule set
To attach a branch to a rule set or detach a branch from a rule set, select Link to branches.
In the dialogue, you will see current branch, as well as other branches you have scope to for multi-office organizations.
You can filter this list of branches by name and rule sets they are linked to.
If the branch is not currently linked to any rule sets, not set will be displayed. Click the arrow to select a rule set to link it to.
To unlink a branch from a rule set, select not set. Once a branch has been unlinked from a set, not set will always be displayed.
When you are finished linking and unlinking branches, click close to exist the dialogue.
Rule sets can be linked to multiple branches. However, a branch can only be linked to one rule set.
Link a payor to a rule set
To link a payor to a rule set or unlink a payor from a rule set, select link to payors.
In the dialogue, you will see payors configured for your organization. For multi-office organizations, you can choose which branch you wish to view payors by. Note that the branch in the branch dropdown will default to the branch you are currently in.
You can filter this list of payors by payor code, status (enabled, disabled), and rule sets they are linked to.
If the payor is not currently linked to any rule sets, not set will be displayed. Click the arrow to select a rule set to link it to.
To unlink a payor from a rule set, select not set. Once a payor has been unlinked from a set, not set will always be displayed.
When you are finished linking and unlinking payors, click close to exist the dialogue.
Rule sets can be linked to multiple payors. However, a payor can only be linked to one rule set at the selected branch.
Link a service code to a rule set
To link or unlink a service code to/from a rule set, select link to service codes.
In the dialogue, you will see service codes configured for your organization.
You can filter this list of service codes by status (enabled, disabled), code name, departments, and rule sets they are linked to.
If the service code is not currently linked to any rule sets, not set will be displayed. Click the arrow to select a rule set to link the code.
To unlink a service code from a rule set, select not set. Once a service code has been unlinked from a set, not set will always be displayed.
When you are finished linking and unlinking service codes, click close to exist the dialogue.
Rule sets created at a branch can be linked to multiple service codes. However, a service code can only be linked to one rule set at the selected branch.