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<br />~ <br /> <br />rlI...:....:.'......,.,..'...!....'.. <br />~ <br /> <br />1?1 <br />~ <br /> <br />r-7m.......................,..... <br />~ <br />1?'1...'.i. <..,..... <br />~ <br /> <br />d................... <br />~ <br /> <br />~.' <br />~ <br /> <br />r:d'I.................'......... <br />~ <br /> <br />Ii] <br /> <br />~ <br /> <br />NO <br />':'.":::"'1 RULE #26 - ASSISTANT SURGERY UCR <br />Whenever assistant surgery is qualified for payment, payment is reduced to not <br />exceed a specified amount allowed for that procedure. <br /> <br />~,::!i'::":,:l RULE #27 - CHEMISTRY LAB UNBUNDLED <br />Whenever a physician bills for more than one chemistry procedure code, they are <br />rebundled into the appropriate chemistry panel. <br /> <br />~':i.i:i:'1 RULE #28 - UCR/FEE SCHEDULE <br />Whenever a physician bills for a procedure, payment is reduced to the maximum <br />allowed for that procedure. <br /> <br />liiii'"..'1 RULE #29 - 31 - NO RULES CURRENTLY EXIST <br /> <br />Ii..":' I RULE #32 - NON-COVERED BENEFITS OR INVALID CODES <br />Whenever a procedure code that represents a non-covered benefit is billed it will <br />deny. <br /> <br />1:;':,,:+::.1 RULE #33 - MULTIPLE DISALLOWED PROCEDURES <br />Whenever a physician bills for procedures beyond the frequency for which the <br />procedure could possibly be performed, it will deny, (i.e. more than 1 <br />hysterectomy). <br /> <br />I']i:i"i~ RULE#34-DUPLICATEPROCEDURES <br />Whenever a physician bills the same procedure code more than once for the same <br />patient on the same date of service (DOS) it will deny. <br /> <br />1;"",:[,1:' RULE #35 - MANDATORY OUTPATIENT PROCEDURES <br />Whenever a physician bills for a procedure that is generally accepted as being <br />done only in an ambulatory setting, however is done on an inpatient basis, it is <br />flagged for investigation. <br /> <br />1:::,( RULE #36 - POTENTIAL COORDINATION OF BENEFITS <br />Whenever a physician bills for a diagnosis that is representative of possible motor <br />vehicle accident origin or workers' compensation, it is flagged for review. <br /> <br />I;!,,!,[,I RULE #37 - OFFICE VISIT UPCODING <br />Whenever a physician bills for an extensive or comprehensive office visit that is <br />in excess of the appropriate frequency for that diagnosis of the patient, it is <br />flagged for review. <br />