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<br />YES NO <br />~ [iill RULE #38 - INAPPROPRIATE CODES <br />Whenever a procedure code that is not appropriate for the gender or age of the <br />patient is billed, it will deny. <br /> <br />I xiii 1<:1'::::1 RULE #39 - SENTINEL EVENTS <br />Whenever a physician bills for a procedure or diagnosis that is representative of a <br />possible quality of care issue, it is flagged for review. <br /> <br />~~:/I I:i,,:l RULE #40 - PROVIDER CUSTOMIZATION <br />Whenever a physician or specialty has been customized to identify certain <br />procedures and/or diagnoses, they will be flagged for review. <br /> <br />I~l li,,:i:L,i 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~II l:::!!1 RULE #42 - PRE-EXISTING CONDITIONS <br />Whenever a physician bills for services which are related to a pre-existing <br />condition for a new enrollee who is still in the grace period for coverage, it will be <br />flagged for review. <br /> <br />I~ll li:':i:~ii:il RIlLE #43 _ SECOND SURGICAL OPINION <br />Whenever a physician bills for a surgical procedure which requires a second <br />surgical opinion, and one has not been perfoffi1ed, it will be flagged for review. <br /> <br />Signature: <br /> <br />Eric S. Clifford, Mayor <br />February 9. 1998 <br /> <br />Date: <br /> <br />