Overview
What tools are available for scrubbing claims in the EHR?
Elation’s AI Billing solution also provides claim-scrubber-style feedback on the bill before submission, including support for the following areas:- insurance eligibility issues
- Quality reporting requirements
- NCCI rules
- missing drug codes
- Clearinghouse validations
- custom payer-specific rules
Why are the benefits of scrubbing claims?
Scrubbing claims identifies potential rejection or denial issues upfront so you don’t spend time fixing claims later.What will the claim scrubber look for automatically?
| Agent | Scrubs for… |
|---|---|
| Insurance Eligibility | Verifies patient has insurance information on file. • Verifies active primary insurance coverage at the claim level. • Identifies any potential secondary insurance indicated in the eligibility response. |
| NCCI Rules | Flags when the units/quantity for a CPT code on a single Date of Service exceeds CMS limits for that code. • Flags invalid or mutually exclusive CPT code combinations on the same claim and when a modifier is required to bill those CPT Codes together. |
| Clearinghouse Rules | Verifies patient has an address on file. • Verifies there are no duplicate service lines. • Verifies there are no $0 charge lines. • Verifies diagnosis codes exist on all charge lines. • Flags if modifier 95 is associated with the wrong place of service. |
Setup
Enabling the claim scrubber
The claim scrubber must be enabled by an Admin Level User by following these steps:| 1 | Click Settings -> Billing . |
|---|---|
| 2 | Go to the AI Billing section and set the Billing Analysis toggle to green (ON) . |
Creating custom rules for claim scrubbing
To create custom rules for claim scrubbing:.| 1 | Click Settings -> Billing . |
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| 2 | Go to the AI Billing section and click + Add Validation . |
| 3 | Select the Claim Scrub Agent you would like 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. |
Sample Custom 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 custom rule to flag any claim that matches these conditions before it gets denied. To do so:| 1 | Go to the AI Billing section and click + Add Validation . |
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| 2 | Select Payer under Claim Scrub Agent . |
| 3 | Select all Cigna Payers that are tied to this rule. You can only select Payers that are in your Insurance Carriers list in the EHR. |
| 4 | Put the following instructions in the Condition field: 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. |
Workflow Instructions
Scrubbing a claim
| 1 | Click + Add Billing Information or Edit Bill to open the bill. |
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| 2 | Trigger the claim scrubber using one of the following workflows: Clicking the Generate Codes/Apply Codes button that triggers AI Coding. • Clicking the Reanalyze with latest changes button at the top of the Billing Analysis section of the bill. |
| 3 | Areas with errors will have a red Error label. Review errors by clicking Show Logs . |
| 4 | Adjust what is needed based on the described errors. |
| 5 | Click Reanalyze with latest changes button to verify your adjustments passed claim scrubbing. |
| 6 | Repeat steps 2- 5 until all errors are corrected. |
You don’t need to resolve all errors before signing the visit note or bill — you can sign and come back to make corrections later, as long as the bill remains in the EHR. Any errors associated with a bill can be viewed from the Billing Home .