Billing Rules per Payer

Billing Rules per Payer

Idea
Aloha gives you the flexibility to customize billing rules to fit your organization’s workflows and preferences. However, it’s important to remember that each payer has its own specific billing and documentation requirements. We recommend reviewing your payer’s guidelines regularly to ensure that your custom settings align with their rules and avoid potential claim rejections or delays.
To find the billing rules, navigate to the Payer List > Select Payer > Billing Rules

 
 

Info

The 2.17.4 Release in October 2025 led to changes in Billing Rules.  Please make sure to view the release notes for changes.  All changes are up to date in this article and include:

  1. Additional fields in claim settings
  2. Customized format from Payer Profile moved to Claim Settings
  3. Addition of MUEs

Concurrent Billing 

Aloha has a Concurrent Billing Rule feature that allows scheduling two overlapping services while only billing one. When this billing rule is created, it will only bill one service in the overlapped time of the appointments. 


Some payers do not allow certain services to be billed at the same time.  For example, Tricare typically does not allow 97153 (Direct) and 97155 (Protocol Modification) to be billed at the same time.  Aloha can be customized so both appointments will appear on the schedule, but one will have the billing minutes zero'd out or "scrubbed" upon completion of the appointments.
 

Setting Up Concurrent Billing Rules

  1. Go to your Payer Profile 

  1. Click on the tab Billing Rules

  2. Change the default from Concurrent Billed "Allowed" to "Not Allowed"

  1. Click to begin entering rules for all services that cannot be billed concurrently.


  1. Select two overlapping services.

  2. Select which service is the one to be billed

  3. Click Save

Implementation of Concurrent Billing Rules

Prior to the concurrent billing rules being applied, this is an example of what it will look like on the Schedule. 


On the schedule, these rules will apply after the two overlapped appointments are both “completed.” It does not matter which of the two appointments are completed first, as long as both are marked "complete".  The system will proceed by splitting up the overlapped time into a non-billable and billable portions so that it can be billed appropriately. 



Claims Settings  

"Separate Claim By" allows users to separate chargelines 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.  However, using this option, claims can be separated by the following.

  • CPT Code 

  • Date of Service 

  • Place of Service

Box 19 – Additional Information 

  • There is an option to add text to Box 19 of the CMS 1500 on all new claims.

  • 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 populates from the Client profile > Custom Field > CTDS Arizona 

Box 32- Service Facility

  1. Service Facility can be set to match the Billing Provider or be left blank.
Box 33B – ID Type
  1. Allows users to add custom values in Box 33b of the claim form for specific payer requirements (e.g. Medicaid).  Examples of ID types added here include 0B, 1D, 1G, G2, LU, or ZZ  

Box 33B – Billing Provider Secondary ID

  1. An additional field that can be customized for specific payers

Claim File Options

  1. 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). Do not change unless the clearinghouse requires the 837P file be generated per Billing Provider. 

 Include Appointment Time on Claims

  1. Allows the option to include the appointment time on claims in either AM/PM (12-hour) or Military Time (24 Hour). 

  2. This is no longer located in the customized format section of the payer profile.  This is defaulted to "Do not include".

Use Service Provider as Rendering Provider

  1. Check this box if the Payer requires all service providers (e.g., RBT) to have their own NPI or Medicaid ID.  This is common for Medicaid payers and Tricare.  If everything is billed under the BCBA, do not check this box.
Include Rendering Provider Taxonomy Code on Claim
  1. Select if the payer requires rendering provider (Box 24J) taxonomy codes on claims
Include Billing Provider Taxonomy Code on Claim
  1. Select if the payer requires billing provider (Box 33) taxonomy codes when billing
InfoNPIs, Medicaid IDs and Taxonomy codes for rendering and billing providers are pulled from Billing > Provider Identifier Merge same day appointments into one charge line 
  1. Selected by default for all payers, except for Tricare to prevent duplicate claim rejections and denials

  2. 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.  

Appointment Settings

To require a client/caregiver signature to complete an appointment, toggle this setting on.  This will prevent appointments from being billed or set to payroll until a client/caregiver signature is acquired.

Qualification Modifiers 

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



Notes 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). 

Alert
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 as the location of the appointment (located in Appointment Info), the 95 modifier will be added in the appointment's Billing Tab.



 

Alert
These POS modifiers must also be added within the services/fees section in the Payer set-up.
Warning
Don't forget!  
  1. The location should be recorded as where the patient is, not the provider.
There are two Telehealth POS: 
  1. 02- Telehealth Provided Outside of the Patient's Home (e.g., daycare or community)
  2. 10- Telehealth Provided in the Patient's Home (e.g., the patient is receiving services in their own home).

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