Grouping Claim Lines

Question 1

Define Claim grouping rules

Answer 1

The rule indicates how resolute handles procedures on claims

Question 2

Name three standard types of claim grouping rules:

Answer 2

Inpatient charge transfer
Radiation Therapy by procedure treatment level
Panel building

Question 3

True or false: You can create and edit claim grouping rules outside of Epic’s release range of 1 to 99,999

Answer 3

True

Question 4

True of False: Resolute automatically determines which procedures should be bundled under a single procedure code during claims processing.

Answer 4

True

Question 5

True or False: Medicare requires that certain combination of procedures be reported by using a single code

Answer 5

True

Question 6

What is the path for CGR (Claim Grouping Rule)?

Answer 6

Text: Forms Layout>Claims Grouping Rule

Question 7

What is the record type of a CGR? And can it be changed?

Answer 7

Grouping Type and No. Once you have chosen the grouping type you cannot change it.

Question 8

Describe what the “active” field does in CGR?

Answer 8

Indicates whether the system can currently employ the rule during claims processing.
If it is used in a claim grouping pointer that is associated with a benefit plan, payor, or service area. Enter Yes or No. The default is “no”

Question 9

Define Claim Grouping Pointers.

Answer 9

Claim Grouping Pointers are a method of organizing claim grouping rules to easily attaché multiple rules.

Question 10

Where can grp pointers be attached where…

Answer 10

Facility, Service Area, Payor, and Plan Level 2q

Question 11

In what order does resolute look for claim grouping pointers. Identify the levels.

Answer 11

Benefit Plan
Payor
Service Area
Facility

Question 12

In what order (of claim grouping rules) does resolute apply claim grouping rules

Answer 12

Type inpatient charge transfer
then if found unavailable
Radiation Therapy by procedure treatment level.
Again, any procedures that these rules bundle are unavailable for further claims bundling. But it is also very unlikely that you would ever want to include the same procedure in a radiation therapy rule and another rule of a different type

Question 13

True or false: Charge modification extensions are very similar to claim complete extensions, but they can only affect one line on a claim

Answer 13

True

Question 14

True or false: Claim grouping rules cannot be created, you must use the standard rules that come with Epic

Answer 14

False

Question 15

You have a claim grouping pointer attached to the facility profile and a different claim grouping pointer attached to a Medicare’s payor record. No other claim grouping pointers are attached anywhere. If claims are processed for “Allcare Insurers”, which pointer will the system use?

Answer 15

The pointer attached to the facility

Question 16

To be eligible for bundling, procedures must occur in the same____ on the same ____

Answer 16

Visit and Encounter

Question 17

When are claim grouping rules and pointers evaluated?

Answer 17

When the claim is processed.