Setting claim rules

Claim rule automations allow you to customize how claims are populated for different billing scenarios. Setting claim rules is optional, but recommended if your practice submits claims using different billing information depending on the clinician, insurance payer, office location, or CPT code.

Note: Claim rules replace billing profiles, which were previously available on the Plus plan. Claim rules are available on all SimplePractice plans and offer additional customization options. Any billing profiles you’ve added will automatically convert to claim rules using the same conditions. For more information, see What happened to my billing profiles? 

In this guide, we’ll cover: 

• Reviewing your default billing information 
• Adding claim rules 
• Disabling and deleting claim rules 
• Billing under supervision using claim rules 
• FAQs

Note: Claim rules are being released in phases. If you don't see this feature in your account yet, it'll become available as the rollout continues.

Reviewing your default billing information

If no claim rules are set, your default billing information will populate all claims. You can review this information by navigating to Settings > Client billing and Insurance > Insurance billing.

On this page, the Claims and superbills section displays:

• Your Tax ID/SSN, which populates box 25 on claims
• Your organization NPI, which populates box 33 if you bill as a group practice

Scroll down to the Default billing provider info section to review the rest of your insurance billing information.  

If no claim rules are set, the information in this section will populate the following fields in box 33 for all claims: 

• First and last name (if billing as an individual)
• Organization name (if billing as an organization)
• Billing address
• NPI (box 33a)
  • This will be your Type 1 NPI for individual providers or a Type 2 NPI for organizations.
• Taxonomy code (box 33b)
  • Taxonomy codes are specific to NPIs. If you’re not sure what your taxonomy code is, see Identifying your taxonomy code for claims.

Click Edit next to either section to adjust your default insurance billing information. 

Adding claim rules

Claim rules allow you to automate when different information should be used on claims. 

Every claim rule has two parts:

• IF: Determines when the rule applies.
• THEN: Determines which billing information overrides your default billing information when the rule applies.

Every claim rule requires that you set at least one of the following IF conditions: 

• Which clinician(s) the rule is for
• Which insurance payer(s) the rule is for 
• Which office location(s) the rule is for 
• Which CPT code(s) the rule is for

To add a claim rule:

1. Navigate to Settings > Client billing and Insurance > Insurance billing
2. Scroll to Claim rule automation, then click Create rule or Add rule

3. Enter a Rule name 
   • This name is for your own reference and won’t appear on claims

Next, complete the IF and THEN sections to define when the rule applies and what billing information it overrides. 

IF

The IF section determines when the claim rule applies. You can set one condition or combine multiple based on the clinician, payer, location, or CPT code. 

In the example below, the Telehealth claim rule applies to any services provided at the Video Office location with CPT code 90834. 

Only the conditions you set are used to determine when the rule applies. If you leave a condition blank, the rule isn’t limited by it, and will apply to all options listed in the dropdown. 

For example, if you’re part of a group practice and don’t specify a clinician, the rule will apply to claims for all clinicians as long as the other IF conditions are met. In the example below, the claim rule applies to all clinicians when the claim is submitted to one of the selected Aetna payer IDs, regardless of the office location or CPT code.

Similarly, if you set a location or CPT for the IF conditions, and leave the payer field blank, the rule will apply to all payers you submit claims to. 

THEN

The THEN section of a claim rule automates how certain claim boxes populate differently from your default billing information. These changes only apply when the rule’s associated IF conditions are met. 

Click Add field to choose which claim box should populate with the unique billing information.  

At least one THEN action is required, and you can add multiple fields. 

In the example below, the claim rule populates designated claims with billing provider info (box 25 & 33) that’s different from the default billing information.

After configuring the IF conditions and THEN actions, click Save rule. 

Disabling and deleting claim rules

You can delete or disable existing claim rules at any time. 

Unless a claim rule was added in error, we recommend disabling it instead of deleting it. Disabled rules can be re-enabled at a later time. To disable a rule, use the toggle next to it.

Use the trash icon to permanently delete a claim rule. 

Billing under supervision using claim rules

Billing insurance while under supervision is known as incident-to-billing, and formatting requirements vary by payer and state. Typically, box 24j needs to list either:

• The supervisee’s name and the supervisor’s credentials, or 
• The supervisor’s name and credentials

We recommend confirming your payer’s formatting requirements before submitting these claims. You can then create a claim rule to automate how these claims are populated. To do this:

1.  Add a new claim rule
2.  Select the clinician who is under supervision

3.  Click Add field > Rendering provider info

4.  Choose whose name and credentials should appear in box 24j
   • Existing clinician allows you to choose a team member from your practice and the credentials listed in their profile 

• Custom clinician allows you to enter the clinician’s name, NPI, and taxonomy code

5. Click Save rule 

FAQs

• Can I see where claim rules are applied?
• Why can’t I edit claim rules?
• What happened to my billing profiles?
• Why can’t I search for a payer when adding a claim rule?
• Which team members can add a claim rule?

Can I see where claim rules are applied?

If one or more claim rules were applied to a claim, you’ll see Claim rules followed by a number at the top of the claim. Click this to open a flyout showing the conditions for each rule that was applied.

Why can’t I edit claim rules?

Claim rules can’t be edited after they’re created. If you need to update an existing rule, we recommend duplicating it and making changes to the copy.

To do this: 

1. Click the duplicate icon next to an existing rule

2. Update the title, IF, and THEN conditions
3. Click Save rule
4. Disable or delete the original rule to avoid overlapping rules

What happened to my billing profiles?

Billing profiles previously allowed you to customize billing scenarios based on clinicians or payers. 

Claim rules replace billing profiles and offer additional customization options. Any billing profiles in your account have been carried over as claim rules as part of this update.

To review these rules, navigate to Settings > Client billing and Insurance > Insurance billing and click any claim rule with billing profile in its name.

Claim rules can’t be edited, so if you’d like to rename or update a converted rule, we recommend duplicating and updating it. You can then disable or delete the original rule.

Why can’t I search for a payer when adding a claim rule?

A payer must be added to your Payers list before you can create a claim rule for it. To do this:

1. Navigate to Settings > Client billing and insurance > Payers
2. Click Add payer > Payer search

4. Enter the name of the payer
5. Click + Add

Which team members can add a claim rule?

The following team members can create claim rules:

• Clinicians with entire practice access
• Practice managers
• Practice billers