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<br />YES <br />GJ <br /> <br />m <br /> <br />[!J <br /> <br />[i] <br /> <br />m <br /> <br />[i] <br /> <br />[!] <br /> <br />[!] <br /> <br />NO <br />D <br /> <br />D <br /> <br />D <br /> <br />D <br /> <br />D <br /> <br />D <br /> <br />D <br /> <br />D <br /> <br />RULE #06 - ASSISTANT SURGERY <br />Whenever assistant surgery is billed for a procedure that does <br />not warrant assistance, it will deny. <br /> <br />RULE #07 - OBSTETRICAL GLOBAL FEE <br />Whenever office visits are billed by physician who also bills for <br />the delivery procedure code, and the visits are within the global <br />fee period for the delivery, the visits will deny, unless the visit <br />is for a condition unrelatcd to the pregnancy. <br /> <br />RULE #08 - SURGICAL GLOBAL FEE <br />Whenever a physician bills office visits, consults or hospital <br />visits within the global fee period for the surgical procedure, <br />the visits will deny. There are exceptions to this rule, for instance, a <br />diagnostic procedure, as well as any visit which is for a <br />condition unrelated to the surgery. <br /> <br />RULE #09 - NEW PATIENT CODE <br />Whenevcr a physician bills morc than one new patient <br />procedure code for the same patient. it will deny, and insert a <br />more appropriate visit code associated with an established <br />patient and allow payment accordingly. <br /> <br />RULE #10 - INPATIENT IHMIDISCHARGE CODE <br />Whenever a physician bills more than one initiallHM code for <br />the same patient for the samc hospitalization, it will deny. <br /> <br />RULE #11 - ICU VISIT FREOUENCY <br />Whenever a physician bills more than a spccified number of <br />visits for the same patient for the same date of service (DOS), the <br />subsequent visit will pend for Utilization Review. <br /> <br />RULE #12 - IHM VISIT FREQUENCY <br />Whenever more than one physician bills for the same date of <br />service (DOS) for the same patient, and each is billing for a <br />condition within the same "body system", the later claims will <br />be denied. <br /> <br />RULE #13 - PHYSICIAN VISIT FREOUENCY <br />Whenever a physician bills for visits for the same patient for <br />the same date of service (DOS) (except leU), the visit of highest <br />value is paid and the other visits will deny. If the other visits are for <br />different diagnoses, however, they will be allowed. <br /> <br />2 <br /> <br />TML <br /> <br /> <br /> <br />GROUP BENF.FlTS RISK POOL <br />