Setting Up Insurance Billing Rules

This section explains how to set up insurance billing rules.

Insurance billing rules determine how items are displayed on insurance claims, including which procedure code is used and whether a modifier is necessary. Billing rules can apply to all of a carrier’s plans or to only specific plans. Plan-level billing rules override carrier-level billing rules.

Billing rules you can create include the following:

  • Change Procedure Code: Changes an item’s procedure code and adds modifiers to a claim.
  • Combine Item: Combines two items into one procedure code on a claim.
    For contact lens item types only, optionally changes the combined item's procedure code and modifiers.
  • Split Item: Splits one item into two procedure codes on a claim.
  • Combine Lens Components: Combines all lens components—including base type, material, style, and color—by base type into one procedure code on a claim.
  • Only users with the Admin/Company Setup/Company Setup-Ins Billing Rules access option assigned to their security roles can access the Billing Rules window.
  • For Spectera plans, the modifiers set up for items in the Partner Mapping windows in AcuityLogic Admin override modifiers set up in the Insurance Billing Rules window for the same items.
  • The following predefined billing rules exist for Spectera plans:
    • If a line item uses the V2781 procedure code, the first modifier is set to L5.
    • If a line item is for disposable contact lenses, the first modifier is set to ND.
    • If a line item is for nondisposable contact lenses, the first modifier is set to NC .
For multitenant environments, the following setup must be completed for each company. The parent company setup is not automatically applied to individual companies.

Topics include the following:

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