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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.
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