Overview
Billing rules in Onvelas allow you to automate modifier assignment and apply payer-specific requirements without requiring staff to remember them for every claim. Rules run automatically when a claim is created from an appointment.
Accessing Billing Rules
- Go to Settings → Billing Rules.
- You will see a list of all existing rules. Active rules are applied during claim creation.
- Click Add Rule to create a new one.
Rule Structure
Each rule has:
- Trigger condition — when does this rule apply? (CPT code, payer, provider role, place of service, or a combination)
- Action — what does it do? (add modifier, set units cap, require field, flag for review)
- Priority — when two rules apply, the higher priority rule wins
Common Auto-Modifier Rules
HO Modifier (BCBA Services)
Many payers require modifier HO when a BCBA renders 97155. Create a rule:
- Trigger: CPT = 97155 AND Rendering Provider Role = BCBA
- Action: Add modifier HO in position 1
HN Modifier (BCaBA Services)
- Trigger: CPT = 97153 AND Rendering Provider Role = BCaBA
- Action: Add modifier HN in position 1
HM Modifier (RBT/Paraprofessional)
- Trigger: CPT = 97153 AND Rendering Provider Role = RBT
- Action: Add modifier HM in position 1
Telehealth Modifier (95 or GT)
- Trigger: Place of Service = 10 (Telehealth)
- Action: Add modifier 95 (or GT for payers that require it) in last modifier position
Payer-Specific Rules
You can scope a rule to a single payer. For example, if Sunshine Health requires modifier U1 on all 97153 claims:
- Trigger: Payer = Sunshine Health AND CPT = 97153
- Action: Add modifier U1
Testing Your Rules
After creating a rule, create a test claim (without submitting it) to confirm the modifier is being applied correctly. Check the line item modifiers in the claim detail view.
Tips
- Rules are applied in priority order — if multiple rules add modifiers, the highest-priority rule fills modifier position 1, and so on (up to 4 modifiers per line).
- If a staff member manually adds a modifier on the claim, it takes precedence over auto-modifier rules for that line.
- Review your rules quarterly — payer requirements change, and an outdated rule can cause claim rejections.
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