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05-E TML Health Insurance Cnt
City-of-Paris
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05-E TML Health Insurance Cnt
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Entry Properties
Last modified
9/12/2012 10:21:29 AM
Creation date
4/3/2002 5:52:47 PM
Metadata
Fields
Template:
AGENDA
Item Number
5-E
AGENDA - Type
RESOLUTION
Description
TML Health Insurance Agreement
AGENDA - Date
4/8/2002
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Addendum B <br />HEALTHCHEX <br />Entity Name: CITY OF PARIS <br />Group APARISOl <br />Effective Date: 5/1/02 <br />Selections: CODE DESCRIPTIONS AND FUNCTIONS: <br />YES NO <br />RULE #00 - CANNOT PROCESS <br />Whenever the claim does not have the minimum of information required by the <br />system to perform its auditing functions, the claim will need to be placed on hold <br />for review. <br />RULE #Ol - OBSOLETE CODES <br />Whenever a procedure code is obsolete for the date of service (DOS) being billed, <br />it will deny. It will be replaced with the currenUsuggested code if one is available. <br />RULE #02 - EXPERIMENTAL PROCEDURES <br />Whenever a procedure code exclusively representing an experimental procedure is <br />billed, it will pend for Utilization Review. <br />r 7X ~ RULE #03 - DISCRETIONARY/COSMETIC PROCEDURES <br />Whenever a procedure code considered to be cosmetic or discretionary is billed, it <br />will pend for Utilization Review unless medically qualified. <br />RULE #04 - APPROPRIATE USE OF MODIFIERS <br />Whenever a modifier is used with a procedure code which should not be used with <br />that particular modifier, the procedure wili deny. <br />RULE #OS - SEPARATE PROCEDURES <br />Whenever a separate procedure, or a procedure considered to be included in the <br />major procedure is billed, it will deny. <br />RULE 406 - ASSISTANT SURGERY <br />Whenever assistant surgery is billed for a procedure that does not warrant <br />assistance, it will deny. <br />
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