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<br />[iJ <br /> <br />III <br /> <br />[i] <br />[i] <br /> <br />III <br /> <br />[!] <br /> <br />[!] <br /> <br />[!] <br /> <br />[!] <br /> <br />[!] <br /> <br />[!] <br /> <br />D RULE #25 - CASE MANAGEMENT <br />Whenever a targeted procedure or diagnosis is identified, the patient's records are <br />flagged for a special report which is available for review to determine the need for <br />case management. <br /> <br />D 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 />D RULE #29 - 31 - NO RULES CURRENTLY EXIST <br /> <br />D 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 />D 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 I <br />hysterectomy) . <br /> <br />D RULE #34 - DUPLICATE PROCEDURES <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 />D 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 />D 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 /> <br />D 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 />.. <br /> <br />D 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 />D RULE #40 - PROVIDER CUSTOMIZA TION <br />