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<br />Entity Name: <br /> <br />Group #: <br /> <br />Attachment "B" <br /> <br />HEALTHCHEX <br /> <br />City of Paris, Paris, Texas <br /> <br />Effective Date: <br /> <br />Selections: <br /> <br />YES <br />[!] <br /> <br />[!] <br /> <br />[!] <br /> <br />[!] <br /> <br />[i] <br /> <br />[!] <br /> <br />NO <br />D <br /> <br />D <br /> <br />D <br /> <br />D <br /> <br />D <br /> <br />D <br /> <br />May 1, 1996 <br /> <br />CODE DESCRIPTIONS AND FUNCTIONS: <br /> <br />RULE #00 - CANNOT PROCESS <br />Whenever the claim does not have the minimum of <br />information required by the system to perform its auditing <br />functions, the claim will need to be placed on hold for review. <br /> <br />RULE #01 - OBSOLETE CODES <br />Whenever a procedure code is obsolete for the date of service <br />(DOS) being billed, it will deny. It will be replaced with the <br />current/suggested code if one is available. <br /> <br />RULE #02 - EXPERIMENTAL PROCEDURES <br />Whenever a procedure code exclusively representing an <br />experimental procedure is billed, it will pend for Utilization <br />Review. <br /> <br />RULE #03 - DISCRETIONARY/COSMETIC PROCEDURES <br />Whenever a procedure code considered to be cosmetic or <br />discretionary is billed, it will pend for Utilization Review <br />unless medically qualified. <br /> <br />RULE #04 - APPROPRIATE USE OF MODIFIERS <br />Whenever a modifier is used with a procedure code which <br />should not be used with that particular modifier, the procedure <br />will deny. <br /> <br />RULE #05 - SEPARATE PROCEDURES <br />Whenever a separate procedure, or a procedure considered to <br />be included in the major procedure is billed, it will deny. <br /> <br />TNfL <br /> <br /> <br /> <br />GROUP BENEFITS RISK POOL <br />