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Mapping Rules: Automating Adjustment Code Posting

Mapping Rules help you automate how adjustment codes are handled during ERA posting by Payer. Instead of manually mapping codes every time, you can define rules that apply automatically based on payer, role, and code.

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What are Mapping Rules?

Mapping Rules allow you to define how specific adjustment codes from specific payers should behave when posting payments.

For example, you can set a rule so that:

  • Code PR-1 is always assigned to patient responsibility

  • Code CO-119 is always mapped as a denial when payer is Medicare.

  • Code OA-23 should always be ignored when its a secondary claim.

How to Create a Mapping Rule

  1. Go to Settings → Mapping Rules

  2. Click + Add rule

  3. Fill in the required fields

Fields explained

  • Payer
    Select a specific payer or leave as Any payer to apply broadly.

  • Payer role (required)
    Choose whether the rule applies to:

    • Primary

    • Secondary

  • Group
    The adjustment group (e.g., CO, PR, OA)

  • Code
    Enter the specific adjustment code (e.g., 45, 1, 197)

  • Map as (required)
    Define how the system should handle the amount:

    • Write-off

    • Patient responsibility

    • Other mapping behavior (based on your setup)

  • Status
    Set the rule as:

    • Active → rule is applied

    • Inactive → rule is ignored

  1. Click Save

When And How Rules Are Applied

  • When a new ERA comes in, the system checks for matching rules and applies them automatically at that moment.

  • The mapping is based on the rule configuration at the time the ERA is processed.

  • The system checks for a matching rule based on:

    • Payer

    • Payer role

    • Group + Code

  • If a match is found, the mapping is applied automatically.

Important

  • Rules are not applied retroactively
    If you update or create a rule, it will only apply to new ERAs received after the change.

  • Existing ERAs are not affected
    Any ERA that was already received will keep the mappings that were applied at that time.

Important Behaviors

1. Rule priority

Specific payer rules override "Any payer" rules

Example:

  • Rule A: Any payer + CO-45 → Write-off

  • Rule B: Aetna + CO-45 → Patient responsibility

👉 For Aetna, Rule B will be applied

2. Duplicate rules

The system prevents creating conflicting rules with the same:

  • Payer

  • Role

  • Group

  • Code

3. Inactive rules

Inactive rules are ignored during ERA posting.

✅ Tips

  • Use "Any payer" for common mappings across all payers

  • Use specific payer rules when behavior differs

  • Keep rules active only when needed to avoid confusion

  • Review your rules periodically to ensure accuracy

Why this matters

Mapping Rules help you:

  • Reduce manual work during ERA posting

  • Ensure consistent financial data

  • Minimize posting errors and rework

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