Scrubbing claims with billing rules

Billing rules live in Settings → Insurance → Billing Rules, where the settings card is described as Claim scrubbing rules and per-payer overrides. Use them to catch claim problems before submission and to keep payer-specific requirements in billing configuration instead of staff memory.

How do I review billing rules?

In the left sidebar, click Settings (at the bottom). In the settings menu, click Insurance. Under Insurance, click Billing Rules to see the rule scopes and the checks available for each scope.

The scope column (2) controls which rule set you are editing. Global rules (3) are the organization-wide defaults. Payer-type and payer scopes can override those defaults for more specific situations.

How do I set claim-scrubbing rules?

In the left sidebar, click Settings (at the bottom). In the settings menu, click Insurance. Under Insurance, click Billing Rules when you want Ona to flag missing or inconsistent claim information before submission.

1. Open Global rules in the scope column.
2. In Claim scrubbing, turn on the checks you want to use for most payers.
3. Set Plan of care signature to Required, Optional or Never.
4. Use a payer-type or payer scope for any rule that should behave differently for a subset of claims.

The claim-scrubbing rules available are:

Rule	What it checks
8-minute rule	Flags claims where timed CPT units do not satisfy Medicare's 8-minute rule.
Units on every billable CPT	Requires at least one unit on each billable CPT code before submission.
Diagnosis codes on every line	Requires every claim line item to have a linked diagnosis code.
Note required per visit	Requires at least one documentation note before a visit can be billed.
Prior authorization required	Preselects and locks the authorization-required flag on claims.
Medicare 60-unit monthly cap	Alerts when a visit would exceed 60 Medicare units in a calendar month.
Plan of care signature	Controls whether a signed plan of care is needed before billing.

A new empty rule set starts with the boolean scrubbing checks off. Plan of care signature starts as Optional.

How do I set limits and reminders?

In the left sidebar, click Settings (at the bottom). In the settings menu, click Insurance. Under Insurance, click Billing Rules to add limits and reminders that help claims stay complete and timely.

1. Open the scope you want to edit, such as Global rules.
2. In Limits & reminders, turn on the limit or reminder you want.
3. For Max billable units per visit, enter the maximum units and add any exempt CPT codes if needed.
4. For Progress note reminders, set the visit count, days, or both.
5. For Timely filing limit, enter the filing window in days from the date of service.

Max billable units per visit cannot be enabled without a max number of units. Timely filing limit cannot be enabled without a filing window in days.

How do I override rules for a payer type or payer?

In the left sidebar, click Settings (at the bottom). In the settings menu, click Insurance. Under Insurance, click Billing Rules when one payer type or one payer needs different rules than your global defaults.

Rules cascade from broad to specific: Global rules apply first, payer-type rules override global rules, and payer rules override both. Payer types include Commercial, Medicare, Medicaid, Workers' comp, Auto, Self-pay and Other.

Use a payer-type scope when a whole category behaves differently, such as Medicare rules that should not apply to commercial plans. Use a payer scope when one payer has its own requirement. A payer with no payer type is treated as insurance, not Self-pay.

How do I set up a custom billing rule?

In the left sidebar, click Settings (at the bottom). In the settings menu, click Insurance. Under Insurance, click Billing Rules when the built-in checks are not specific enough for a payer, coding pattern or workflow step.

A custom rule has three main choices:

Setting	What it controls
Stage	When the rule runs. Available stages are On schedule, On chart, On claim build, On resubmit and On payer response.
Severity	The type of result the rule creates: Block, Autofix, Warn or Suggest.
Enabled	Whether the rule runs. Enabled runs actions, Shadow evaluates and logs only, and Disabled skips the rule.

The Stage controls which actions are available.

Stage	Available actions
On schedule	Warn user, Suggest to user
On chart	Substitute CPT codes, Add modifier to procedures, Override place of service, Block chart save, Warn user, Suggest to user
On claim build	Substitute CPT codes, Add modifier to procedures, Override place of service, Block claim from submission, Move claim to bucket, Warn user, Suggest to user
On resubmit	Substitute CPT codes, Add modifier to procedures, Override place of service, Block claim from submission, Move claim to bucket
On payer response	Move claim to bucket, Warn user, Suggest to user

Condition fields are grouped under Primary insurance, Secondary insurance, Patient, Claim, Encounter, Rendering provider, Supervising provider, Referring provider, Site, Facility and Flags. Use Shadow when you want the rule to evaluate without changing the workflow, then switch it to Enabled when the rule is ready.

What can't I do here?

Open Billing Rules from the left sidebar: click Settings (at the bottom), click Insurance in the settings menu, then click Billing Rules under Insurance. Access and validation are limited in these ways:

• Staff and clinicians cannot manage billing rules from Settings.
• If insurance details are not enabled for the organization, Billing Rules is not shown.
• You cannot enable Max billable units per visit without entering a max number of units.
• You cannot enable Timely filing limit without entering the filing window in days.
• Custom rule actions are limited by the selected Stage.
• A payer with no payer type is not treated as Self-pay.

Common questions

Should I use a payer-type scope or a payer scope?

Use a payer-type scope when the rule applies to a category such as Medicare or Workers' comp. Use a payer scope when the rule applies to one specific payer.

Is Note required per visit on by default?

No. A new empty rule set starts with Note required per visit off. Turn it on if your practice requires documentation before a visit can be billed.

What does Shadow mean on a custom rule?

Shadow evaluates the rule and logs the result, but does not run the rule's actions. Use it to test a rule before enabling it.

What is the safest first setup?

Start with global rules that match your standard billing policy. Add payer-type or payer scopes only for exceptions. Add custom rules after you know which recurring rejection or workflow issue you want to prevent.

Where do I work claims that need follow-up?

In the left sidebar, click Claims to open the claims queue and review claims that need billing follow-up. See Working the claims queue and Correcting and resubmitting claims.