====== Claim Rules Engine ======

The Claim Rules Engine lets you automatically modify claims during processing — without touching raw EDI. Instead of learning loop IDs and segment positions, you create simple rules like "for this payer, use this billing provider" or "add modifier 25 to E/M codes."

Rules are configured per account and apply automatically to every claim that matches the rule's conditions. No module assignment needed — just create a rule and it takes effect on the next claim processed.

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===== How It Works =====

Rules run during the **Validation Check** stage of claim processing, after payer/provider matching but before the claim is sent. Each rule module:

  - Queries rules you've configured for the account
  - Checks conditions (payer, date range, CPT codes, etc.)
  - Modifies the claim's EDI data automatically
  - Logs what it changed in the claim's notes and applied modules list

All rule modules share a common structure:
  * **Date Range** — When the rule is active (start date required, end date optional for no expiration)
  * **Payer Number** — Optional filter to apply only for a specific payer
  * **Notes** — Free text for your reference (why this rule exists, who requested it, etc.)

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===== Available Rule Modules =====

==== Provider Rules ====

  * **[[guides:claim-rules:rendering-provider-swap|Rendering Provider Swap]]** — Replace a rendering provider's NPI and name on claims. Use when a provider leaves, for locum tenens, or NPI corrections.
  * **[[guides:claim-rules:billing-provider-override|Billing Provider Override]]** — Override the billing provider for specific payers. Supports filtering by subscriber state, rendering NPI, CPT codes, POS, and claim type. Can also override pay-to provider.
  * **[[guides:claim-rules:referring-provider-auto-add|Referring Provider Auto-Add]]** — Automatically add a referring provider when one isn't present. Filter by CPT codes for Medicare/Medicaid referral requirements.
  * **[[guides:claim-rules:taxonomy-code-override|Taxonomy Code Override]]** — Override the taxonomy code on billing and/or rendering provider. For multi-specialty providers who need different taxonomies per payer.

==== Claim Data Rules ====

  * **[[guides:claim-rules:subscriber-id-override|Subscriber ID Override]]** — Modify subscriber/member IDs. Strip dashes or spaces, add prefixes or suffixes, or replace entirely. For payer-specific ID formatting requirements.
  * **[[guides:claim-rules:place-of-service-override|Place of Service Override]]** — Change the place of service code. Filter by CPT codes and original POS value. Common for telehealth POS corrections.
  * **[[guides:claim-rules:filing-indicator-override|Filing Indicator Override]]** — Override the claim filing indicator code (SBR09). Fix rejections from wrong filing indicator values.
  * **[[guides:claim-rules:modifier-rules|Modifier Rules]]** — Add, remove, or replace modifiers on service lines. Filter by payer and CPT codes. Replaces hardcoded telehealth modifier logic.

==== Facility & Notes ====

  * **[[guides:claim-rules:service-facility-override|Service Facility Override]]** — Override or add the service facility on claims. For payers that require a specific facility on file.
  * **[[guides:claim-rules:claim-note-auto-add|Claim Note Auto-Add]]** — Automatically add NTE note segments to claims. For payer special instructions or authorization references.

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===== Claim Type Support =====

Not all rules apply to all claim types. Here's what runs where:

^ Module ^ Professional (837P) ^ Institutional (837I) ^ Dental (837D) ^
| Rendering Provider Swap | Yes | — | Yes |
| Billing Provider Override | Yes | Yes | Yes |
| Subscriber ID Override | Yes | Yes | Yes |
| Service Facility Override | Yes | — | Yes |
| Referring Provider Auto-Add | Yes | Yes | Yes |
| Place of Service Override | Yes | — | Yes |
| Claim Note Auto-Add | Yes | Yes | Yes |
| Taxonomy Code Override | Yes | Yes | Yes |
| Filing Indicator Override | Yes | Yes | Yes |
| Modifier Rules | Yes | Yes | Yes |

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===== Getting Started =====

  - Navigate to **Rules** in the main menu
  - Click any rule module in the left sidebar under "Rules Engine"
  - Fill in the form at the top of the page
  - Click **Save**
  - The rule takes effect on the next claim processed for that account

Rules are tracked — you can see which rules were applied to a claim in the claim's **Applied Validation Modules** list and **Notes**.

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===== Permissions =====

Each rule module has three permission levels:
  * **Read** — View existing rules
  * **Add/Update** — Create new rules or modify existing ones
  * **Remove** — Delete rules

Contact your administrator to get the appropriate permissions assigned to your role.

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//Need help? Contact ClaimRev support at [[mailto:help@claimrev.com|help@claimrev.com]] or call 918-842-9564.//