CMS-1500 Electronic Claim Generation Rules

The following rules are used to determine whether to generate a claim and which services will be included. A claim and claim service will be generated unless eliminated by any one of these rules.

Claims will be split so that they are in groups by provider, diagnosis record, authorization number, and case record.

Patient Selection

Skip if the patient is not active.

Skip if selecting by the patient's principal provider and patient has a different provider.

Skip if patient has no insurance selected for the billing.

Patient Insurance Selection

Skip if carrier is not set to be included in electronic claims.

Skip if carrier is not set to submit to this receiver.

Skip if selecting by provider and selected provider is set to not bill to carrier.

Skip if the patient insurance option is set not to bill in batch claims.

Skip if there is no insurance eligibility within the date range.

Skip if primary insurance and not set to bill primary insurance.

Skip is secondary insurance and not set to bill secondary insurance.

Service Selection

Skip if service is not in the date range.

Skip if service is not within insurance eligibility dates.

Skip is selecting by service provider and service has a different provider.

Skip is service has a zero balance and not billing zero balance services.

Skip if this is a cancellation and carrier doesn't accept cancellations.

Skip if this is a no-show and carrier doesn't accept no-shows.

Skip if the service provider is set to not bill to this carrier.

Skip if carrier has paid on this service and not set to rebill when already paid.

Skip if carrier has sent an EOB denial and not set to rebill services with a carrier EOB.

Skip if billing is secondary and no primary payment/EOB if the secondary carrier requires a primary EOB.

Skip if already billed to the carrier and not rebilling all services.