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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\docs\Rule_Specification\word_format | referral_rule_specification.docx | Tue Apr 10 06:18:41 2018 UTC |
2 | CCRS.zip\CCRS\CCRS-BUSRULES-v1.5.3.zip\CCRS-BUSRULES-v1.5.3-436e6fff1115001d614ccd45b469ad60a9bdb27b\docs\Rule_Specification\word_format | referral_rule_specification.docx | Fri Jun 15 14:54:22 2018 UTC |
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1 | Referral R ules | |
2 | Descriptio n | |
3 | Automatica lly match invoices t o existing active re ferrals wi thin CCRS, so only m atched inv oices are processed. Deny invo ices that have no ma tching ref erral or i f the refe rral is no longer ac tive, so t hat denial s can be s tored and communicat ed. Approv e invoices that do n ot include referral numbers if the servi ce provide d was a fl u shot. | |
4 | Validation Descripti on | |
5 | Valid Refe rral | |
6 | Any claim that is no t a flu-sh ot must ha ve a valid referral | |
7 | Date of Se rivce | |
8 | The Claim line's ser vice date must fall within a r eferral's valid date range | |
9 | Logic | |
10 | Valid Refe rral & Dat e of Seriv ce - Appli es to INST -IO, PROF, DENT: | |
11 | IF (the Cl aim.referr alNumber d oes NOT ma tch a Refe rral) THEN { F OREACH (Cl aimLine re lated to t he Claim) { I F (the Cla imLine.Pro cedure.Cod e does NOT match 'G0 008' OR '9 0658' OR ' 90656' OR '90662') T HEN { cre ate Valida tionFailur e: validRe ferral, CA RC: 288, R ARC: N475 for Claim } }} OTHER WISE { FOREACH (C laimLine r elated to the Claim) { IF (the ClaimLine. serviceDat e is NOT ( before the Referral. referralEx pirationDa te AND equ al OR afte r the Refe rral.refer ralDate)) THEN { c reate Vali dationFail ure: refer ralDateOfS ervice, CA RC: 165, R ARC: N335 for ClaimL ine } } } | |
12 | Notes | |
13 | Data Eleme nts: | |
14 | BRENGINE | |
15 | CCRSDB | |
16 | Claim.refe rralNumber | |
17 | DIM_VA_CLA IM.referra l_number | |
18 | Claim.prof ClaimLines ** | |
19 | F_PROFESSI ONAL_MEDIC AL_CLAIM_D ETAILS | |
20 | ClaimLine. serviceDat e | |
21 | F_*_CLAIM_ DETAILS.se rvice_date | |
22 | Claim.clai mLines** | |
23 | F_*_CLAIM_ DETAILS | |
24 | ProfClaimL ine.isFluS hot** | |
25 | F_PROFESSI ONAL_MEDIC AL_CLAIM_D ETAILS | |
26 | ProfClaimL ine.Proced ure.code | |
27 | DIM_PROCED URE_CODE.p rocedure_c ode | |
28 | BRENGINE | |
29 | CCRSDB | |
30 | Referral.r eferralExp irationDat e | |
31 | ccra.REFER RAL.Referr alExpirati onDate | |
32 | Referral.r eferralDat e | |
33 | ccra.REFER RAL.Referr alDate |
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