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# | Location | File | Last Modified |
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1 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\testing\Test Cases | Rules data.xlsx | Tue Apr 10 06:18:41 2018 UTC |
2 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\testing\Test Cases | Rules data.xlsx | Fri Jun 15 15:21:25 2018 UTC |
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1 | SHEET: She et1 | |
2 | Rules data worksheet , | |
3 | ||
4 | Rule,Descr iption,Cla im Type,Ob jects,>=18 0 days<=18 0 (4 scena rios) each claim lin e / claim | |
5 | Date 1 = N ULL / Date 2 = NULL ,30 days,P aid date = NULL, | |
6 | Timely Fil ing Outpat ient,Outpa tient clai ms are sub mitted wit hin allowe d timefram e from dat e of servi ce,Profess ional, Ins titutional Outpatien t,,ClaimLi ne,Start D ate of the claim / S ervice_dat e_from,Sta rt date / Provider p aid date,P aid date = NULL, | |
7 | Pharmacy,, Claim,Star t Date /da te_of_serv ice,Start date / Pro vider paid date,Paid date =NUL L, | |
8 | Dental,Sta rt_date / service_Da te,Start d ate / Prov ider paid date,Paid date =NULL , | |
9 | Timely Fil ing Inpati ent,Inpati ent claims are submi tted withi n the allo wed time f rame from date of di scharge,In stitutiona l Inpatien t,ClaimLin e, Claim,S tart_date /discharge date,Star t date / P rovider pa id date,Pa id date =N ULL, | |
10 | Claim Amou nt Thresho ld,Claim l ines that exceed $30 ,000 are f lagged for audit (PE NDING_REVI EW),Profes sional, In stitutiona l,,Claim,> $30000 <$ 30000 =30 000 30001 29999, | |
11 | Pharmacy,, ClaimLine, | |
12 | Dental, | |
13 | Referrals, Claim line s have a m atching re ferral,Pro fessional, Instituti onal,,Clai mLine,Good ref (Ref0 14) Good d ate of ser vice- | |
14 | Good ref b ad date of sce | |
15 | Good date of service bad ref | |
16 | Good ref d ate of ser vice NULL | |
17 | Bad ref or noref and flushot C PT = G0008 ’, ‘90658’ , ‘90656’, or ‘90662 ’, | |
18 | Pharmacy,, | |
19 | Dental, | |
20 | List of Ex cluded Ind ividuals a nd Entitie s (LEIE),C laim line CCN provid ers were n ot in the LEIE durin g the time of treatm ent,Profes sional, In stitutiona l,,ClaimLi ne,Good pr ovider in / Good eli gibility p eriod (dat e of servi ce within within pro v. Dates) | |
21 | Bad provid er (NPI OR Provider TAX ID is on the "LE IE List" A ND | |
22 | Provider e ntry exist with no R einstate D ate (i.e a n active e ntry) AND | |
23 | Claim line Service D ate To >= the "LEI E List" ex clusion da te AND | |
24 | Provider I D is not " 000000000" AND | |
25 | TAX ID is not "00000 0000" | |
26 | ) / good p eriod | |
27 | ||
28 | , | |
29 | Pharmacy,, Claim,Good provider in / Good eligibilit y period ( date of se rvice with in within prov. Date s) | |
30 | Bad provid er (NPI OR Provider TAX ID is on the "LE IE List" A ND , | |
31 | Dental,Goo d provider in / Good eligibili ty period (date of s ervice wit hin within prov. Dat es) | |
32 | Bad provid er (NPI OR Provider TAX ID is on the "LE IE List" A ND , | |
33 | Dates of S ervice,Pro fessional, Instituti onal,,Clai mLine,Date of servic e matches the active referral at the tim e of the i nitial ref erral | |
34 | Date of se rvice doe s not matc h the acti ve referra l at the t ime of the initial r eferral | |
35 | , | |
36 | Pharmacy,, Date of se rvice matc hes the ac tive refer ral at the time of t he initial referral | |
37 | Date of se rvice doe s not matc h the acti ve referra l at the t ime of the initial r eferral, | |
38 | Dental,Dat e of servi ce matches the activ e referral at the ti me of the initial re ferral | |
39 | Date of se rvice doe s not matc h the acti ve referra l at the t ime of the initial r eferral, | |
40 | Duplicates ,Claim lin e is not a duplicate of anothe r claim li ne submitt ed within the claim or within a previous claim tha t was not set to rej ected or d enied,Prof essional, Institutio nal,,Claim Line | |
41 | ||
42 | Claim,Clai m line mat ches any o ther claim lines bas ed on uniq ue combina tion of th e followin g: | |
43 | - Uniqu e Identifi er | |
44 | - Provi der Id | |
45 | - Patie nt Id | |
46 | - Servi ce Date Fr om | |
47 | - Servi ce Date To (optional ) | |
48 | - Place Of Servic e | |
49 | - Proce dure Code | |
50 | - Proce dure Modif ier(s) (op tional) | |
51 | - Bille d Amount | |
52 | matching r elated cla im line(s) has been paid and s hows an al lowed amou nt >0 --- >then the claim will be flagge d as a dup licate | |
53 | there is m ore than o ne claim m odifier -- -> then it will be f lagged as a duplicat e when all modifiers match | |
54 | matching related cl aim line(s ) has a Cl aim Status which is NOT in {'R ejected', 'Denied'} | |
55 | matching claim line s are not part of th e same cla im ---> th en it will be flagge d as a dup licate | |
56 | both the matching r elated cla im line(s) and the c laim line( s) show a previous P ay Flag se t to 'Yes' | |
57 | , | |
58 | Pharmacy,, | |
59 | Dental, | |
60 | Standardiz ed Episode of Care ( SEOC),Serv ice provid ed within the claim line is in cluded wit hin the SE OC,Profess ional, Ins titutional , Pharmacy , Dental,C laimLine,C PT code wi thin an in voice line item is n ot include d as a par t of the S EOC identi fied withi n the refe rral | |
61 | CPT code D ate of Ser vice withi n invoice line item does not f all within SEOC defi ned freque ncy of ser vice | |
62 | • If a lin e item doe s not fall within th e Standard ized Episo de of Care (SEOC) it will be d enied. | |
63 | • Invoices that do n ot match a referral should be annotated as denied. | |
64 | • Invoices that do n ot match a referral should inc lude a rea son for de nial from a standard list (CAR C/RARC). | |
65 | • The vali dated invo ice will o nly show e valuated l ine item, it should display li ne item da te of serv ice (DOS) are within the SEOC | |
66 | • Line ite ms within the SEOC, should dis play statu s as appro ved | |
67 | • Line ite ms with DO S outside , | |
68 | ||
69 | Payment Au thority,CC RS must va lidate pay ment autho rity for r eferral to payment a uthority i n the 837C OB,Profess ional, Ins titutional , Pharmacy , Dental,C laim Line | |
70 | ||
71 | Claim,Paym ent author ity for re ferral in an invoice line item does not match the payment au thority in the 837CO B | |
72 | Invoices t hat do not match a r eferral , |
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