NSF Claim Generation Rules

NSF claims list up to three insurance carriers for each patient. Each of these can be marked to be included for claim payment or for information only. The last four rules for patient insurance selection determine whether to include for claim payment or for information only.

Claims will be split so that they are in groups by provider, diagnosis record, authorization number, and case record. Claims can also be split by year of service according to a Generator option for NSF receivers.

The following rules are used by the program 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.

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 for selected billing.

Skip if patient has no services selected for billing.

Patient Insurance Selection

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

Skip if there is no insurance elegibility with the date range.

Use for information only (not for claim payment) if selecting by provider and selected provider is set to not bill to carrier.

Use for information only (not for claim payment) if primary insurance and not set to bill primary insurance.

Use for information only (not for claim payment) if secondary insurance and not set to bill secondary insurance.

Use for information only (not for claim payment) if the patient insurance option is set to not bill in batch claims.

Service Selection

Skip is service is not in the date range.

Skip if service is not within insurance eligibility dates.

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

Skip if 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 the carrier doesn't accept cancellations.

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

Skip if carrier has been paid on this service and net 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 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.

Skip is already billed to the carrier and not rebilling this service.