Billing Rules per Payer

Billing Rules per Payer

Billing Rules are found under each Payer profile to customize specific billing requirements for that payer. To find the billing rules, navigate to the Payer List > select the Payer > and select “Billing Rules” at the top. 

 

  

 

Concurrent Billing 

Please refer to this article for detailed instructions  https://support.alohaaba.com/portal/en/kb/articles/concurrent-billing-how-does-it-work  


Claims Settings  

"Separate Claim By" allows users to separate the way claims are grouped together at the time of processing billing by the following options. By default, the system will group charge lines together on one form for the same client/rendering provider/service facility  

  • CPT Code – creates separate claim forms per client by same CPT code  

  • Date of Service – creates separate claim forms per client by same DOS  

  • Place of Service – creates separate claim forms per client by same POS  

Box 19 – Additional Information 

  • This is used specifically for payer “CTDS Arizona” when a school site code needs to be included on the claim, and the claim has a POS of 03 (School) 

  • The value here populates from the Client profile > Custom Field > CTDS Arizona 

Box 33B – ID Type: allows users to add custom values in Box 33b of the claim form for specific payer requirements (e.g. Medicaid) 

  1. Examples of ID types added here include 0B, 1D, 1G, G2, LU, or ZZ  

Box 33B – Billing Provider Secondary ID: an additional field that can be customized for specific payers

Claim File Options: allows users to generate 837p files as a single claim or per billing provider (this second option only applies to specific clearinghouses such as Network 180 or Philadelphia Medicaid). 

The default setting for this is "One File per Claim" (used for Office Ally or Availity clearinghouses). You would typically not change this unless you are working with a clearinghouse that requires you to generate the 837P file per Billing Provider. 

 

 

The default for all payers added to Aloha will appear as above.  

Note: Taxonomy codes for rendering and billing providers are pulled from Billing > Provider Identifier 

  • Include Rendering Provider Taxonomy Code on Claim: select if your payer requires you to include rendering provider taxonomy codes when billing

  • Include Billing Provider Taxonomy Code on Claim: select if your payer requires you to include the billing provider taxonomy code when billing

  • Merge same day appointments into one charge line: selected by default for all payers, except for Tricare

  • Appointments scheduled in the same day (e.g. morning and afternoon session) completed with the same client/CPT code/rendering provider/POS/service facility will get merged into ONE charge line on the CMS1500 form.  

  • As an example, this setting turned ON will prevent payers from denying you for a duplicate claim if you bill for two direct service sessions in the same day.  

Qualification Modifiers 

By default, Aloha recognizes the following modifiers by these educational equivalents. If your payer uses a different qualification with a modifier, these can be edited for each payer specific requirement.  

 

 These modifiers can be dragged and dropped and should placed with the highest qualification at the top. For example, if using an AH modifier for a BCBA, it should be dragged and placed between HP (Doctoral Degree) and HO (Master's degree). 

These qualification modifiers must also be added in the Payer services/fees in the Payer set-up. 

Place of Service Modifiers

Allows user to customize default modifiers based on the place of service in appointment.  
  1. e.g. POS 10 can be defaulted to modifier 95.  Whenever POS 10 is selected, the 95 modifier will be added to the appointment.  

 

These POS modifiers must also be added within the services/fees section in the Payer set-up.

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