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RULE #25 - CASE MANAGEMENT <br /> Whenever a targeted procedure or diagnosis is identified, the patient's records are <br /> flagged for a special report wbich is available for review to determine the need for <br /> case management, <br /> <br /> RULE #27_-._CHF~ _MI~STRY LAB UNBU~I}LED <br /> Whenever a physician bills I~or more than one chemistry procedure code, they are <br /> rebundled into the appropriate chemistry paoel. <br /> <br /> RULE #Z9- - U CUa [V <br /> <br /> RULE ~32, NON.COV ~D BENEFITS OR lNVALID CODES <br /> Wheoever a procedure code that represents a non-covered benefit is billed it will <br /> <br /> RULE g33 - MULTIPLE DISALLOWED PROCEDU~S <br /> Whenever a physician bills for procedures beyond the frequency for which the <br /> procedure could possibly be performed, it will deny, (i.e. more than 1 <br /> hysterectomy). <br /> <br /> RULE ~34, DUPLICATE pROCEDURES <br /> When~v~ ~ PhYsi6i~n bills the same procedure code more than once for the same <br /> pat tnt on the same date of s~ice (DOS) it will deny. <br /> <br /> RULE g36 - POTENTIAL COORDINATION OF BENEFITS <br /> Whenever a physician bills for a diagnosis that is representative of possible motor <br /> vabiclc accident origin or workers' compensation, it is flagged for review. <br /> <br /> RULE ~37 - OFEICE VIS1T UPCODING <br /> Whenever a physician bills Cot an extensiw or comprehensive office visit that is <br /> in excess o~ tba appropriate frequency for that diagnosis of the patient, it is <br /> flagged for review. <br /> <br /> RULE g38-INAPPROP~ATE CODES <br /> Whenever apr°cerium code that is not appropriate for the gender or age of the <br /> patient is billed, it will deny. <br /> <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 />~-1 ~'1 RULE #40 - PROVIDER CUSTOMIZATION <br /> <br /> <br />