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.

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

1. Queries rules you've configured for the account
2. Checks conditions (payer, date range, CPT codes, etc.)
3. Modifies the claim's EDI data automatically
4. 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.)

• Rendering Provider Swap — Replace a rendering provider's NPI and name on claims. Use when a provider leaves, for locum tenens, or NPI corrections.
• 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.
• Referring Provider Auto-Add — Automatically add a referring provider when one isn't present. Filter by CPT codes for Medicare/Medicaid referral requirements.
• Taxonomy Code Override — Override the taxonomy code on billing and/or rendering provider. For multi-specialty providers who need different taxonomies per payer.

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

• Service Facility Override — Override or add the service facility on claims. For payers that require a specific facility on file.
• Claim Note Auto-Add — Automatically add NTE note segments to claims. For payer special instructions or authorization references.

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

1. Navigate to Rules in the main menu
2. Click any rule module in the left sidebar under “Rules Engine”
3. Fill in the form at the top of the page
4. Click Save
5. 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.

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.

Need help? Contact ClaimRev support at help@claimrev.com or call 918-842-9564.