Creating Billing Rules to Split Style Items

You can create billing rules for a selected insurance carrier or plan that combine the lens base type and style addon fees and split the amount into two procedure codes based on existing split item billing rules.

For multitenant environments, the following setup must be completed for each company. The parent company setup is not automatically applied to individual companies.

To create billing rules to split style items

  1. Open the Company Information window. See To open the Company Information window.
  2. Click the Insurance Rules link for your company.
  3. In the Insurance Rules window, select the Billing Rules tab.
  4. Enter the carrier name in the Carrier Name drop-down list.
  5. Enter the plan name in the Plan Name drop-down list if necessary. If you do not select a plan, the billing rule you create applies to all plans for the selected insurance carrier.
  6. Click Create.
  7. In the Create Insurance Billing Rule window, select Split Items from the drop-down list.

    The fields for setting up the billing rule are displayed.

  8. Enter an effective date range for the billing rule in the Start Date and End Date fields. If you do not enter a start date, the billing rule takes effect immediately. If you do not enter an end date, the billing rule remains in effect until you enter an end date.
  9. Select Style Addon from the Item Type drop-down list.
  10. Select the Combine Base Type/Style before Split check box.
  11. Select an item group or item you want the billing rule to apply to from the Item Group or Item drop-down lists. Select an item group if you want the billing rule to apply to all items in the item group, or select an individual item if you want the billing rule to apply to an item.

  12. Select an option from the Modifier Action drop-down list to set how the billing rule modifiers will be included on claims:

    • Append Modifiers - Adds the billing rule modifiers to the modifiers from POS.

    • Replace Modifiers - Replaces the modifiers from POS with the billing rule modifiers.

      • If a billing rule has a modifier, replaces POS modifiers with the billing rule modifier.

      • If a billing rule has no modifier, overwrites POS modifiers with a blank modifier value.

    • Do Not Change Modifiers - Leaves POS modifiers as is. Does not overwrite or append billing rule modifiers.

  13. Select the base procedure code you want to display on the insurance claim in the Procedure Code drop-down list. If you want the default procedure code to appear, select Use Procedure Code Mapping.
  14. Select modifiers from the Modifier 1, Modifier 2, Modifier 3, or Modifier 4 drop-down lists if necessary.
    The modifier codes available in the drop-down lists are set up in the CPT Maintenance window in AcuityLogic Admin if you need to add additional codes.
  15. Select the style procedure code you want to display on the insurance claim in the Procedure Code drop-down list.
  16. Select modifiers from the Modifier 1, Modifier 2, Modifier 3, or Modifier 4 drop-down lists if necessary.
  17. Perform one of the following procedures to indicate the amount you want charged to the first procedure code:
    • Select Fixed Amount from the drop-down list, and enter a dollar amount in the field.
    • Select Percentage from the drop-down list, and enter a percentage in the field.
    • Select Base Item Price from the first drop-down list, and select an item from the second drop-down list. The price set up for the item you select from the second drop-down list will be charged.
      For billing rules that combine the lens base type and style addon fees, the only option available in the Split drop-down list is Charge amount to base and remainder will be added to style.
  18. Click Save.

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