06-B Health Insurance Contract - Laserfiche WebLink

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YES NO ~ ~ 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. [~ ~ULE #08 .y ~._RGICALGLOBAL~_F_EE Whenever a physician bills office visits, consults or hospital visits within the global foe p~riod for the surgical procedure, the visits will deny. There are exceptions to this nde, for i~stance, a diagnostic procedure, as well as any visit which is tbr a ¢ondition unrolated to th~ surgery. /Tq ~ RULE//09; N~ _E..w_.pAT[E~ir_ COpE · ' 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. [--'] RULE #10- INPATIENT IHM/DISCHARGE CODE Whenever a physician bflls more than one initial 1HM code for the same patient for the same hospitalization, it will deny. 17'1 I--i RULE #n-Ice VISIT FaEQUZNCY Whenever a Physician bifi~ 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. 15'3 F-'I RULE #12-i.n VISIT FREQUENCY 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. ['-'] RULE #13- PHYSICIAN VISIT FREQUENCY whenever a physician bill~ 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 tile other visits are for different diagnoses, however, they will be allowed. F-'! RULE #,4-.EPEAT PROCEDURES Whenever a physician bills for repeating a procedure within a specified period of time after the original procedure, it will deny.