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<br />ED <br /> <br />[!J <br /> <br />III <br />m <br /> <br />[!] <br /> <br />[iJ <br /> <br />[!J <br /> <br />IT] <br /> <br />IT] <br /> <br />[!] <br /> <br />[iJ <br /> <br />o 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 detennine the need for <br />ca!i~ management. <br /> <br />D -~U~E #2'7 - ~IlliMI~TRY 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 ~ULF.3. ~29:~ 31 :NO RVJ..t:S CU~NTLYE~~ST <br /> <br />D RULE #32 ... NON..COV.E~n Bf:NEfll~ ORINV ALID CODES <br />Whenever a procedure code that represents a non~covered benefit is billed it will <br />dellY. <br /> <br />o RULE #33 - MULTIPLE DISALLOWED PROCEDURES <br />Whenever a physician bills for procedures beyond the frequency for which the <br />procedure could possibly be perfonned, it will deny, (i.e. more than 1 <br />hystc;rectomy). <br /> <br />o ~U~~ ~3.4_: D(JPLICATEPROCEDURES <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 />o 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 />o <br /> <br />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 />o 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 />o 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 />o RULE #40- PROVIDER CUSTOMIZATION <br />