Rules for BIP Checker By Insurence

1. What does this feature do? (High-Level Overview)

This feature lets an insurance administrator define checker rules for a specific insurance so the BIP review can follow that payer’s documentation expectations more closely. It helps the team catch missing, incomplete, or too-short information when the BIP Checker runs, without turning those rules into product-wide save restrictions.

2. Who is this for? (Roles & Permissions)

• Superadmin: Can access and manage these rules when working in the insurance edit area.
• Admin: Can access and manage these rules when they have permission to manage insurances.
• Owner: Can access and manage these rules when they have permission to manage insurances.
• Manager: Can access and manage these rules when they have permission to manage insurances.
• RBT/Analyst: Does not use this configuration screen as part of normal clinical work.

Required permission:

• manage_insurances: Required to access the Insurance area where these rules are configured.

3. Business Rules & Enforcements

• Rule 1: Rules are saved per insurance. Each insurance can have its own checker requirements.
• Rule 2: Each rule is tied to one specific field from the available field list.
• Rule 3: These rules are used by the BIP Checker flow only. They do not change the normal BIP save behavior outside the checker review.
• Rule 4: The user can require a field, set a minimum expectation, set a maximum expectation, or combine those checks in the same rule.
• Rule 5: At least one validation choice must be selected before the rule can be saved.
• Rule 6: This screen does not allow the user to define the field’s data type. It only allows presence and size-style requirements that the backend accepts for insurance overrides.
• Rule 7: A field can only have one active custom rule per insurance. If the same field already has a rule, the user must edit the existing one instead of creating another.
• Rule 8: If an insurance rule matches a standard checker field, the insurance version takes priority for that insurance.
• Rule 9: If an insurance rule is created for a field that is not part of the standard checker list, it is added as an extra check for that insurance.
• Rule 10: When a patient has both primary and secondary insurance, the checker looks at the primary insurance first. If the primary insurance has any custom checker rules, that primary custom set is used and the secondary custom set is not combined into the same review.
• Rule 11: The secondary insurance is only used for checker-specific rules when the primary insurance has no custom checker rules at all.
• Rule 12: Deleting a rule requires confirmation before the rule is removed.
• Rule 13: Changes made here do not rewrite the BIP itself. They affect what the BIP Checker looks for the next time the checker runs.
• Rule 14: Checker results are recalculated each time the checker runs. The product does not keep a historical snapshot of older detailed rule results.
• Rule 15: Although backend supports conditional checker rules, conditional rule setup is not part of the current screen described in this document.

4. UI Placement

1. Sidebar > Insurance: Open the Insurance area.
2. Insurance List: Open the insurance you want to configure in edit mode.
3. Insurance Edit: Select the tab Rules for Checker.
4. BIP Checker Rules card: Review the current rule list or use Add Rule.

5. How-To Guide (Step-by-Step)

Scenario A: Add a new checker rule for an insurance

1. Navigate to Insurance from the main menu.
2. Open the insurance record you want to manage.
3. Select the Rules for Checker tab.
4. Click Add Rule.
5. Choose the field you want the checker to review.
6. Review the label and description that appear for that field.
7. Turn on the validation options you want to enforce, such as Required, Minimum Length, or Maximum Length.
8. Enter the minimum or maximum values if needed.
9. Click Create. The new rule will appear in the list for that insurance.

Scenario B: Update an existing checker rule

1. Open the insurance record and go to Rules for Checker.
2. Find the rule in the list.
3. Click the edit button.
4. Adjust the validation options or limits.
5. Click Update.
6. Review the list to confirm the rule now shows the updated requirement.

Scenario C: Remove a checker rule

1. Open the insurance record and go to Rules for Checker.
2. Find the rule you no longer want to use.
3. Click the delete button.
4. Review the confirmation message.
5. Click Delete to confirm. The rule is removed from that insurance.

6. What happens if…? (Edge Cases / FAQ)

• Q: What happens if there are no rules saved for this insurance?
  • A: The insurance does not contribute any extra checker rules from this screen. The BIP Checker first looks for rules on the patient’s primary insurance, then the secondary insurance if needed, and finally falls back to the standard rule set.
• Q: What happens if the user creates a rule for a field that already has a standard checker rule?
  • A: The insurance-specific version becomes the one used for that insurance’s checker review.
• Q: What happens if the user opens the dialog but does not select any validation options?
  • A: The rule cannot be saved. At least one requirement must be selected.
• Q: What happens if the same field is added twice for the same insurance?
  • A: The system rejects the duplicate and shows an error message instead of saving a second version. The expected workflow is to edit the existing rule.
• Q: What happens after a rule is deleted?
  • A: Future checker runs stop using that deleted custom rule immediately. The checker then falls back to the next applicable source, which may be another current insurance rule set or the standard global rule.
• Q: What happens if both primary and secondary insurance have custom checker rules?
  • A: The checker uses the primary insurance custom rule set. It does not mix primary and secondary custom rules together in the same run.
• Q: What happens if the user changes a rule after a checker result was already shown?
  • A: The old detailed result is not kept as a historical checker snapshot. The updated rules take effect the next time the checker runs.