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<br />YES NO <br />[!] D RULE #22 - SECONDARY PROCEDURE <br /> MANAGEMENT <br /> Whenever a physician bills for multiple procedures, all of <br /> which qualify for payment, the procedure of highest value is <br /> paid in full. The remaining second procedures are <br /> reduced to the specified amount allowed for that procedure, <br /> all other procedures are denied. <br />GJ D RULE #23 - HILA TERAL PROCEDURE MANAGEMENT <br /> Whenever a physician bills for a bilateral procedure, the <br /> payment is reduced to not exceed the maximum <br /> allowed for that procedure. <br />m D RULE #24 - UTILIZATION REVIEW <br /> Whenever a physician bills for certain procedures that usually <br /> signify upcoding, are of questionable appropriateness, or are <br /> inherently vague, and the patient's condition does not warrant <br /> it, it will pend for Utilization Review. <br />m D RULE #25 - CASE MANAGEMENT <br /> Whenever a targeted procedure or diagnosis is identified, the <br /> patient's records are flagged for a special report which is <br /> available for review to determine the need for case <br /> management. <br />GJ D RULE #26 - ASSISTANT SURGERY UCR <br /> Whenever assistant surgery is qualified for payment, payment <br /> is reduced to not exceed a specified amount allowed for that <br /> procedure. <br />GJ D RULE #27 - CHEMISTRY LAB UNBUNDLED <br /> Whenever a physician bills for more than one chemistry <br /> procedure code, they are rebundled into the appropriate <br /> chemistry panel. <br />GJ D RULE #28 - UCR/FEE SCHEDULE <br /> Whenever a physician bills for a procedure, payment is <br /> reduced to the maximum allowed for that procedure. <br />GJ D RULE #29 - 31 - NO RULES CURRENTLY EXIST <br /> <br />4 <br /> <br /> <br />GROUP BJ,;NI-:nTS RISK POOL <br />