Billing rules and claim scrubbing

Claim scrubbing means checking a claim for problems before it goes out. A rejection costs days of turnaround; a rule that catches the same problem before submission costs nothing. This page is where those rules live.

Global rules

Go to Settings → Billing Rules — "organization-wide defaults with insurance-type and payer overrides".

The column on the left sets scope. Global rules are "defaults for all payers", and apply "to every payer unless overridden".

Claim scrubbing

• 8-minute rule — flags claims where timed CPT units don't 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. On by default.
• 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 — whether a signed plan of care is needed before billing. Three settings: Required, Optional, Never. Defaults to Optional.

Note required per visit is the one that shapes daily work. With it on, a clinician who hasn't written the note is blocking the claim — which is usually what you want, since billing without documentation is what audits look for.

Limits & reminders

• Max billable units per visit — caps units in a single visit, with exempt CPT codes and a custom alert.
• Progress note reminders — reminds clinicians when a progress note is due, by visit count or days.
• Timely filing limit — warns when a claim approaches the payer's filing deadline, counted in days from date of service.

Timely filing limit is worth turning on early. Every payer sets a deadline — often 90 or 180 days from service — and a claim submitted after it is simply unpayable, regardless of merit. The warning is the only thing standing between a busy month and written-off revenue.

Custom rules

Custom rules let you "define custom rules to warn users, fix codes, or block submissions". Use New rule to add one. Note the three severities: a rule can warn, silently correct, or stop a claim entirely.

Overrides

The scope column also offers Add insurance type and Add payer.

Rules cascade: global defaults apply unless a more specific scope overrides them. Set an insurance-type override where a whole category behaves differently — Medicare rules that don't apply to commercial plans. Set a payer override where one payer has its own requirement.

This is what keeps the global set clean. Rather than loosening a global rule because one payer is unusual, leave the global rule strict and add a payer override.

A practical order

If you're setting these up for the first time:

1. Leave Note required per visit on.
2. Turn on Timely filing limit and set it to your shortest payer deadline.
3. Turn on the coding checks — Units on every billable CPT, Diagnosis codes on every line.
4. Add 8-minute rule and the Medicare 60-unit cap if you bill Medicare.
5. Add payer overrides as you learn each payer's quirks, usually from rejections.

Rejections are the feedback loop here. When one recurs, the fix is a rule, not a habit — see the History tab on a rejected claim for the payer's reason, then encode it. The claims queue covers reading those responses.