What QA rules do

QA (quality audit) rules are checks that run automatically when a claim is created or updated. Each rule looks for a specific problem — missing patient DOB, wrong diagnosis code, transport without mileage — and writes a flag on the claim when the condition is hit. Flags show up on the QA work queue for someone to resolve.

Where to find it

  1. Go to Settings → Agencies and click View on the agency.
  2. Open the Quality Audit tab.
  3. The rules live in the QA Rules panel. You can see both this agency's rules and the built-in system rules (system rules cannot be deleted).

Creating a rule

  1. Click New Rule.
  2. Fill in Name, Flag Code (a short code like MISS_SIG), and Description.
  3. Pick a Trigger Event — when the rule should run.
  4. Pick a Severity: Critical, Warning, or Informational. Any open Critical flag blocks the claim from being submitted until it is resolved or dismissed.
  5. Pick a Category: Clinical, Coding, Compliance, AR, Posting, Demographics, or Narrative. Categories drive which QA work queue the flag lands in.
  6. Set Payer Scope to All Payers or Specific.
  7. Optionally enter a Condition Expression in JSON to describe what the rule checks for.
  8. Leave Active on and click Save.

Adjusting or disabling a rule

Use the row actions on the QA Rules panel to edit, delete (custom rules only), or toggle Active on a rule. Turning Active off keeps the history of past flags but stops the rule from generating new ones.

Example

You notice claims are going out without the loaded mileage, which is costing you denials. Open the agency's Quality Audit tab, click New Rule, name it "Transport miles missing," pick Severity Critical and Category Coding, set Payer Scope to All Payers, and save. From then on, claims with zero or blank miles get a critical flag and are blocked from submission until a biller sees and fixes them.

Tips

  • Start with the built-in system rules and layer custom ones on top. You do not have to rebuild everything.
  • If a rule is being dismissed more than resolved on the QA work queue, it is probably too strict — re-open it and adjust.