2001-043-RES AUTHORIZING EXECUTION OF GROUP BENEFITS SERVICES AGREEMENT

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