06-B Health Insurance Contract - Laserfiche WebLink

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~ RULE #16 - RADIOLOGY UNBUNDLED Whenever more than one physician is hilling for the same radiology episode, the physicians are paid according to the correct component of the radiology service. YES NO ~ [~ RULE #17, MUTUALLY EXCLUSIVE PROCEDURES Whenever a physician bills for "mutually exclusive" procedures (can not be performed during the same operative episode). The procedure of the highest value is paid, the remaining procedure(s) are denied. ~ RULE #18 - POST-OP CARE, RULE#19~ PRE-OP CARE Whenever a physician is billing for care before or after a procedure that another physician has perfon'ned, and if the care is within the global fee period of the procedure and for a related condition, it will be denied. I-ri I'-1 RULE #20- MEDICAL PROTOCOL Whenever a physician bills for a procedure more frequently than is justified by the condition of the patient, it will pend for Utilization Review. [-'-] RULE #21-FRAGMENTED PROCEDURES Whenever a physician bills for multiple procedures on the same date of service (DOS) that are components of a major procedure for which there is a unique procedure code, the procedures are rebundled into the appropriate major procedure code. ]'--"l RULE #22 - SECONDARY PROCEDURE MANAGEMENT Whenever a physician bills for multiple procedures, all of which qualify for payment, the procedure of highest value is paid in full. The remaining second procedures are reduced to the specified amount allowed for that procedure, all other procedures are denied. ['~ RULE #23 - BILATERAL PROCEDURE MANAGEMENT Whenever a physician bills for a bilateral procedure, the payment is reduced to not exceed the n~aximum allowed for that procedure. 1~ RULE #24- UTILIZATION REVIEW Whenever a physician bills for certain procedures that usually signify upcoding, are of questionable appropriateness, or are inherently vague, and the patient's condition does not warrant it, it will pend for Utilization Review.