Laserfiche WebLink
<br />YES NO <br />IJI:E] 1"1 RULE #38 - INAPPROPRIATE CODES <br />Whenever a pTocedure code that is not appTopriate for the gender or age of the <br />patient is billed, it will deny. <br /> <br />I,~I I" I RULE #39 - SENTINEL EVENTS <br />Whenever a physician bills for a proceduTe or diagnosis that is Tepresentative of a <br />possible quality of care issue, it is flagged for review. <br /> <br />I'W:I 1,1 RULE #40 - PROVIDER CUSTOMIZATION <br />WheneveT a physician or specialty has been customized to identify certain <br />procedures and/or diagnoses, they will be flagged for review. <br /> <br />IAI Iii RULE #41 - PROCEDURE AND DIAGNOSIS CODE COMPATIBILITY <br />Whenever a physician bills for a condition unrelated to a procedure which is also <br />being billed for, it is flagged for review. <br /> <br />I:"\,il 1,1 RULE #42 - PRE-EXISTING CONDITIONS <br />WheneveT a physician bills for services which are related to a pre-existing <br />condition for a new enrollee who is still in the grace peTiod for coveTage, it will be <br />flagged for review. <br /> <br />1-\....1 1'.:1 RULE #43 - SECOND SURGICAL OPINION <br />Whenever a physician bills for a surgical procedure which TequiTes a second <br />surgical opinion, and one has not been performed, it will be flagged for review. <br /> <br />Signature: <br /> <br />Eric S. Clifford, Mayor <br /> <br />Date: <br /> <br />luly 14 lqq7 <br /> <br />