🎟️ How to Create Appointment Rules and Suggested Charge (formerly Pre-Visit) Rules – Athelas

At a Glance

Creating Appointment Rules and Suggested Charge Rules can save your staff a lot of time on the administrative tasks related to appointments.

💡

Appointment Rules can instantly apply the correct Service Type Codes (STCs) to certain kinds of appointments. They can also set particular appointments as primary care, based on your organization’s best practices.

💡

Suggested Charge Rules (formerly Pre-Visit Rules) can determine things like suggested copay, coinsurance, the prioritization of deductible or copay, etc. based on criteria set by your organization.

💡

Both types of rules function based on Actions and Conditions set by you, the user. Actions are the specific steps that will be carried out based on the Conditions, or criteria, that you set.

Walkthrough: How to Set Appointment Rules

From the Appointments page, open PR Settings and click on the Appointment Rules tab.

Click on Add Rule.

The modal shown below will pop up. Give your rule a name and assign priority if you’d like (with 1 being top priority. Rules with Priority set at 1 will override potentially conflicting rules of lesser priority).

For this example, say that you want a rule that applies a Diagnostic X-Ray Service Type Code (STC) to all appointments at Facility 3 in which the Rendering Provider’s ID is greater than or equal to 10. Let’s pretend that any such ID at that facility belongs exclusively to Diagnostic X-Ray Technicians.

In the Actions box, you’ll decide what outcome this rule should produce. For this example, you want to make a rule that will Set Service Type Codes for appointments that match the criteria.

You’ll then choose which STC you would like to apply from a drop-down menu. Use the Search function to quickly narrow down results, so that you don’t have to wade through all 150+ options.

(If instead you chose to Set Appointment as Primary Care, you would continue to the Conditions block. You can also click on + Add Action to produce multiple results from the same rule.)

In this example, we’ll set STC 4 - Diagnostic X-Ray.

Now, you’ll set the conditions through which this Action will be applied. You can choose to have the rule apply to appointments that meet Any of your criteria, or only to appointments that meet All of your criteria (think of Any as an “or” statement, and All as an “and” statement).

For this example, we’ll say the appointment must meet All criteria in order to apply.

Next, you can choose the Variable in question, the Operator, and the Value.

For this example, say this rule applies if the Facility ID is equal to 3, then click on Add Statement, and then in the new statement say that the Rendering Provider ID must be greater than or equal to 10.

Click Save. You’ll see your rule in the Rules list, and you can edit or copy it from here.

Walkthrough: How to Set Suggested Charge Rules

Currently, you can set Suggested Charge Rules via the Suggested PR Rules tab in Patient Responsibility Settings. Click Add Rule.

As with Appointment Rules, give your rule a name and optional level of priority, with 1 being the highest priority.

For this example, imagine you want a Suggested Charge Rule that will set a $10 copay and prioritize any remaining family deductible for patients over 65 years of age with a Diagnostic X-Ray appointment.

In the Actions block, choose to Set Copay Amount in USD Cents and enter 1000 to equal $10.

Then, click Add Action and select Prioritize Family Deductible.

Now, add the conditions that must be met to activate this rule.

Under Condition Type, choose All, so that all criteria must be met and not just one (as would be the case by choosing Any).

Under Variable, choose Patient Age and set it greater than 65.

Click Add Action

For this Variable, choose Appointment Reason and set it equal to 4 (the STC for Diagnostic X-Ray. Be sure to look up and enter the proper STC for your rule if you use this or a related variable).

Click Save. Now you can view your rule in the Rules list, and edit, copy or archive it from there.

Suggested Charge Rules: Actions and Conditions Reference List

Below is a list of all Actions and Conditions currently available for Suggested Charge Rules. If you would like more options, please contact your account manager.

Action	Definition
1. Copay Filter In	Pulls in the chosen text from the eligibility response to be displayed as a payment recommendation. Example: If the input text is PCP, then it will display the charge associated with the copay for PCP from the eligibility response on the appointment.
2. Copay Filter Out	Excludes the chosen text from the eligibility response so it is not displayed as a payment recommendation. Example: If the input text is PCP, then it will not display the charge associated with the copay for PCP from the eligibility response on the appointment.
3. Copay Filter Place of Service	Filters in the amount to be collected based on the input place of service. Example: If the input place of service is Hospital - Outpatient, then it will display the copay associated with Hospital – Outpatient from the eligibility response.
4. Find Limitations and Set Charges	Finds the input limitations from the eligibility response and defaults to the chosen charge Example: If the input limitation is for a maximum of 6 sessions and the chosen copay is $50 for anything above that, then it will display that charge as a suggested amount to be collected.
5. Notify	Leaves a message on the patient’s appointment for the front desk to read.
6. Prioritize Copay	Prioritizes copay to be collected over coinsurance or deductible.
7. Prioritize Family Deductible	Prioritizes the family deductible to be collected over coinsurance or copay.
8. Set Coinsurance Amount in USD Cents	Input a specific coinsurance amount to be collected.
9. Set Copay Amount in USD Cents	Input a specific copay amount to be collected.
10. Set Deductible Amount in USD Cents	Input a specific deductible amount to be collected.
11. Set Self-Pay Amount in USD Cents	Input a specific amount to be collected if patient is self-pay.

Conditions

Appointment Reason

Appointment Type

Coinsurance Percentage

Copay in USD Cents

Facility

Has QMB Insurance

Limitations Payer Notes

Patient Age

Patient Date of Birth

Primary Group Name

Primary Input Insurance Name

Primary Insurance Company Type

Primary Member ID

Primary Payer

Primary Payer Patient Is Dependent

Primary Plan Description

Remaining Deductible in USD Cents

Remaining Family Out of Pocket in USD Cents

Remaining Out of Pocket in USD Cents

Secondary Input Insurance Name

Secondary Insurance Company Type

Secondary Member ID

Secondary Payer

Further Assistance

📢 We’re here to help! Please contact your account manager if you would like help with all this.