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An example of potential rules
If diagnosis is B12, then the service codes 100 to 150 are not allowed. Reject other services.
If service code 112 is claimed, only item codes 200 to 210 are allowed. Reject if other items are.
Service code 225 and 325 cannot be claimed together. Reject both services.
So, if a claim has the following details:
Claim Details | ||
|---|---|---|
Patient ID | 9999999 | |
Diagnosis | B12 | |
Services | 1 | Service 123 |
2 | Service 345 | |
3 | Service 005 | |
Items | 1 | Item 01 |
2 | Item 02 | |
Service 1 would be rejected, and the remaining services and items would be accepted and sent forward for manual review.