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<br />YES <br />[3J <br /> <br />[Z] <br /> <br />rn <br /> <br />NO <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 />[]J 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 />rn D 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 />rn <br /> <br />rn <br /> <br />rn <br /> <br />Signature: <br /> <br />D 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 />D 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 />D RULE #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 performed, it will be flagged for review. <br /> <br />Date: Aoril 9. 2001 <br /> <br />INTERNAL USE ONLY: <br /> <br />Auto Audit Plant: <br />