Billing rules overview

billing rules determine which billing profile , fee schedule , and payment provider are applied to each encounter rules are evaluated in priority order and matched based on encounter context such as payer, location, provider, visit type, and jurisdiction h ow billing rules work billing rules are grouped inside rulesets rulesets are evaluated by priority (lower number = higher priority) within a ruleset, each rule is evaluated top to bottom the first matching rule determines billing profile fee schedule payment provider configuration if no rules match, billing falls back to default behavior no guessing no magic just deterministic logic r ulesets a ruleset is a container for related billing rules c reating a ruleset 1 go to settings → billing → rules 2 click add ruleset 3 enter name (required) priority (lower = evaluated first) active status 4 click save a ruleset can exist without rules, but it won’t do anything useful until at least one rule is added c reating a billing rule inside a ruleset, each rule defines when it should apply (conditions) what it should apply (billing configuration) r ule fields name a descriptive name to explain what the rule does priority controls evaluation order inside the ruleset lower numbers are evaluated first active inactive rules are ignored during evaluation m atching conditions important limitation (read this carefully) (read this carefully) billing rules currently support all matching only this means a rule matches only if all configured conditions are met there is no “any” / or logic this cannot be changed in the ui if multiple conditions are added, every condition must match for the rule to apply a vailable condition types you can add conditions based on jurisdiction state visit type service location rendering provider supervising provider telehealth payer tags (any) tags (all) each condition uses an equals comparison n o conditions behavior if no conditions are added the rule applies to all encounters this is commonly used as a fallback rule b illing configuration (rule actions) when a rule matches, it sets one or more of the following billing profile fee schedule payment provider configuration any field left as not set will fall back to the next applicable rule or default system behavior decision preview the decision preview helps you test rule behavior before billing occurs f rom context simulates billing selection using manually entered details such as service date jurisdiction state service location visit type providers payer tags f rom encounter tests rule evaluation using a specific encounter id select from encounter enter the encounter uuid click run preview b est practices use specific rules first , general rules later keep rule names descriptive and scenario based use ruleset priority to simulate or logic when needed always include a fallback rule with no conditions test changes using decision preview before relying on them in production