Price Rules

Price Rules

Price Rules - flexible fee schedules

Price Rules let you create unlimited fee schedules that override the CPT Master price when their conditions are met. Use rules to price by Bill To, Bill Type, Payer, Client, or Patient without changing the base CPT price.

What you can target

  • CPT Code (and base charge)
  • Bill To (e.g., Insurance, Client, Patient)
  • Bill Type (e.g., Medicare, Medicaid, Commercial Insurance)
  • Payer (insurance company)
  • Client (ordering account)
  • Patient (employee discounts, specific patient pricing, if allowed)

Key behaviors

  • Overrides: When a rule matches, its price replaces the CPT Master file price.
  • Specificity wins: If multiple rules applicable, the rule with the highest level of detail (most fields specified) is applied.
  • Tie-breaker: If two rules are identical in scope, the newest rule is applied.
  • Overlap alert: The system warns you when adding a rule that overlaps an existing one.

šŸ“˜ Create a Price Rule

  1. Go to Billing ā†’ Price Rules.
  2. Complete all required fields.
  3. Enter the CPT Code and set the Price, Units.
  4. Add targeting as needed: Bill To, Bill Type, Payer, Client, Patient.
  5. Save.


Info
Tip: Use Clone to copy an existing rule, then adjust only the fields that differ to speed setup.

Best practices

  • Keep CPT Master prices as your baseline; use rules only where exceptions are required.
  • Prefer payer- or client-specific rules over patient-specific pricing unless contractually required.
  • Document rationale in the rule notes (e.g., contract name, effective date).
  • Periodically audit for overlapping or stale rules; retire rules that are no longer needed.

Troubleshooting

  • ā€œWrongā€ price applied: Check for a more specific rule that supersedes others (specificity > general; newest wins on ties).
  • Overlap warning: Review the existing rule; either edit it or refine the new ruleā€™s scope.
  • No rule triggering: Confirm the CPT, Bill To/Bill Type, and Payer/Client/Patient fields match the orderā€™s billing data exactly.

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