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Overview

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What are AI Billing rules?

AI Billing rules are instructions your practice writes for how it wants bills handled. AI Billing applies them alongside its own checks, so a rule can affect both the codes AI Coding generates and the results of claim scrubbing. These rules are also called custom rules or payer rules. In your EHR settings they appear as AI Billing Rules, or as Custom Rules with a + Add Validation button. They are separate from the Billing Rules settings page in Elation Billing, which controls which fields appear on the Superbill. A rule does one of two things, and Elation determines which one fits from the rule you describe:
  • Changes the bill — for example, adding a modifier, adjusting a code, or setting a provider field.
  • Flags the bill for review — the flag appears in the Billing Analysis section of the bill. A flag never changes codes and never prevents you from saving the bill, signing the visit note, or submitting the claim.

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What can a rule check?

Rules work from the bill, the claim, and the visit note context available to billing analysis. This includes service and diagnosis codes, modifiers, units, National Drug Code (NDC) information, service location, and the payer, provider, and patient details on the bill. A rule can apply to every payer or be limited to specific payers and providers. Currently, rules cannot check information outside billing analysis, such as scheduling or an external payer portal, and cannot read images, scanned documents, or attachments. Rules also do not change clinical documentation or make a clinical judgment on a clinician’s behalf. To review what rules can and cannot check in Elation, click the information (i) icon in the AI Billing Rules section of your EHR settings.

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Setup

Creating rules requires AI Billing. An Admin Level User can turn it on by clicking Settings > Billing, going to the AI Billing section, and setting the Billing Analysis toggle to green (ON). Your practice’s AI Billing settings include one of two ways to create rules. Check which one appears before you start:
  • AI Billing Rules — describe the rule you want in a chat box, and Elation drafts it for you.
  • Custom Rules — build the rule yourself using the + Add Validation button.

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Describing a rule in AI Billing Rules

  1. Click Settings → Billing.
  2. Go to the AI Billing section and find AI Billing Rules.
  3. Describe the billing behavior you want in plain language, then send your message. Be as detailed and as specific as you can.
  4. Read the response. Elation drafts a rule, explains whether it can enforce that rule today, and identifies any data the rule would need.
  5. Review the drafted title and wording under Rule to create. Use Applies to to limit the rule to specific payers, or leave it empty to apply the rule to all payers. You can only select Payers that are in your Insurance Carriers list in the EHR.
  6. Click Save rule.
Saved rules appear under Your Practice’s Rules, along with a count of how many are active.

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Adding a rule with Add Validation

  1. Click Settings → Billing.
  2. Go to the AI Billing section and click + Add Validation.
  3. Select the Claim Scrub Agent you want to create a rule for:
    • Payer — create a rule for specific Payers listed.
    • Eligibility — create a rule based on the patient’s insurance eligibility.
    • NCCI validation — create a rule based on NCCI rules.
    • Clearinghouse validation — create a rule based on Clearinghouse rules.
  4. Select Payers that are tied to this rule, if applicable. You can only select Payers that are in your Insurance Carriers list in the EHR.
  5. Specify the Condition you want the rule to look for. Be as detailed and as specific as you can.

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Sample rule

Cigna will administratively deny claims when ICD-10-CM Z diagnosis codes Z02.0-Z02.6, Z02.71, Z02.79, Z02.82-Z02.83, Z02.89-Z02.9, Z13.9, Z56.1, Z62.21, or Z63.6 are the only codes on the claim. Knowing this, you can create a rule to flag any claim that matches these conditions before it gets denied. In AI Billing Rules, describe the rule in the chat box: For patients with Cigna as their insurance, alert me if diagnosis codes Z02.0-Z02.6, Z02.71, Z02.79, Z02.82-Z02.83, Z02.89-Z02.9, Z13.9, Z56.1, Z62.21, or Z63.6 are the only codes on the claim. Select your Cigna payers under Applies to, then click Save rule. In Custom Rules, click + Add Validation, select Payer under Claim Scrub Agent, select all Cigna Payers that are tied to the rule, and enter the same instructions in the Condition field.

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Managing your practice’s rules

Each rule listed under Your Practice’s Rules has the following controls:
  • The Enabled switch turns the rule on or off. A rule that is off stays in your list and is not applied to bills.
  • The edit (pencil) icon changes the rule’s title and the payers it applies to.
  • The remove (trash) icon deletes the rule.
To change a rule’s wording, describe the change you want in the chat box. Elation proposes an updated version and shows you what changed. Review it, then click Update this billing rule.

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Creating a rule while reviewing a bill

The same chat box appears in the Billing Analysis section of the bill, so you can describe a rule based on the bill in front of you.
  1. Click + Add Billing Information or Edit Bill to open the bill.
  2. Describe the rule you want in the chat box in the Billing Analysis section.
  3. Review the drafted rule and click Save rule.
Rules you create here are added to Your Practice’s Rules in Settings > Billing.

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Frequently Asked Questions

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Why can’t I change the wording of a rule I created?

The rule text is the instruction Elation sends to the billing AI, so it stays as it was written when the rule was saved. You can change a rule’s title and the payers it applies to with the edit (pencil) icon. To change the wording, describe the change in the chat box and Elation proposes an updated version for you to review.

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Why can’t I turn on a rule?

A rule that changes the Billing Provider or Supervising Provider field can only be turned on while that field is visible in the bill. Turn the field on first — see Collaborative Billing Fields — then turn on the rule. If Elation reports that the rule’s enforcement details are missing, describe the rule again in the chat box to create a version it can apply.

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Can everyone at my practice create rules?

If your practice restricts billing settings to Admin Level Users, non-Admin users can see your practice’s rules but cannot create, change, or remove them.