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I`NTTRNAIJ�ICISI'IONl�Y <br />1 <br />NN�yjyy J�1! 4 ,Ii II II' 9 <br />933 <br />! I IIkIIII I� �I''�'� I <br />i IIII�!NW, <br />IJlidlll p <br />p �i�!h' <br />Y +'S <br />NO <br />I <br />y <br />IIII <br />t <br />RULT, #38 - INAPPROPRIATE CODES <br />:AI <br />Whenever a procedure code that is not appropriate for the gender or age of the <br />is <br />patient is billed, it will deny. <br />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 />RULE #40 - PROVIDER CUSTOMIZATION <br />Whenever a physician or specialty has been customized to identify certain <br />procedures and /or diagnoses, they will be flagged for review. <br />u!.JNik'IF. <br />RULE #41 --PROCEDURE. AND DIAGNOSIS CODE COMPATIBILITY <br />Whenever a physician bills for a condition unrelated to a procedure which is also <br />being billed for, it is flagged for review. <br />RULE #42 - PRE - EXISTING CONDITIONS <br />Whenever a physician bills for services which are related to a pre- existing <br />` <br />condition for a new enrollee who is still in the grace period for coverage, it will be <br />flagged for review. <br />';`,:,obi'ir' <br />V; <br />RULE #43 - SECOND SURGICAL OPINION <br />- . - <br />Whenever a physician bills for a surgical procedure which requires a second <br />surgical opinion, and one has not been performed, it will be flagged for review. <br />Signature: <br />Eric S. Clifford, Mayor <br />Dater <br />February 9. 1998 <br />I`NTTRNAIJ�ICISI'IONl�Y <br />1 <br />NN�yjyy J�1! 4 ,Ii II II' 9 <br />a1�1 IIIII I "JG II ! <br />! I IIkIIII I� �I''�'� I <br />i IIII�!NW, <br />IJlidlll p <br />p �i�!h' <br />I <br />;I <br />