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<br />DRAFT 6-6-01 <br />YES NO <br />D D RULE #24 - UTILIZATION REVIEW <br />Whenever a physician bills for certain procedures that usually signify upcoding, <br />are of questionable appropriateness, or are inherently vague, and the patient's <br />condition does not warrant it, it will pend for Utilization Review. <br /> <br />D D RULE #25 - CASE MANAGEMENT <br />Whenever a targeted procedure or diagnosis is identified, the patient's records are <br />flagged for a special report which is available for review to determine the need for <br />case management. <br /> <br />D D RULE #26 - ASSISTANT SURGERY UCR <br />Whenever assistant surgery is qualified for payment, payment is reduced to not <br />exceed a specified amount allowed for that procedure. <br /> <br />D D RULE #27 - CHEMISTRY LAB UNBUNDLED <br />Whenever a physician bills for more than one chemistry procedure code, they are <br />rebundled into the appropriate chemistry panel. <br /> <br />D D RULE #28 - UCR/FEE SCHEDULE <br />Whenever a physician bills for a procedure, payment is reduced to the maximum <br />allowed for that procedure. <br /> <br />D D RULE #29 - 31 - NO RULES CURRENTLY EXIST <br /> <br />D D RULE #32 - NON-COVERED BENEFITS OR INVALID CODES <br />Whenever a procedure code that represents a non-covered benefit is billed it will <br />deny. <br /> <br />D RULE #33 - MULTIPLE DISALLOWED PROCEDURES <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 />D D RULE #34 - DUPLICATE PROCEDURES <br />Whenever a physician bills the same procedure code more than once for the same <br />patient on the same date of service (DOS) it will deny. <br /> <br />D D RULE #35 - MANDATORY OUTPATIENT PROCEDURES <br />Whenever a physician bills for a procedure that is generally accepted as being <br />done only in an ambulatory setting, however is done on an inpatient basis, it is <br />flagged for investigation. <br />