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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 | duplicate_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 | duplicate_rule_specification.docx | Fri Jun 15 14:50:38 2018 UTC |
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1 | DuplicateR ules | |
2 | Descriptio n | |
3 | Automatica lly identi fy the dup licate lin e item sub mitted wit hin the co ntracted r eimburseme nt invoice using the unique co mbination of invoice line data so that i mproper pa yments can be preven ted. | |
4 | Validation Descripti on | |
5 | Duplicate Profession al | |
6 | There must not exist two claim s with equ al values for all of the follo wing eleme nts:-Patie nt ID-Prov ider NPI-P rocedure C ode-Place of Serivce -Service D ate From-B illed Amou nt-Procedu re Modifie rs | |
7 | Duplicate Institutio nal Inpati ent | |
8 | There must not exist two claim s with equ al values for all th e followin g elements :-Statemen t To Date- Statement From Date- Patient ID -Provider NPI | |
9 | Duplicate Institutio nal Outpat ient | |
10 | There must not exist two claim s with equ al values for all th e followin g elements :-Patient ID-Provide r NPI-Proc edure Code -Service D ate-Billed Amount-Pr ocedure Mo difiers | |
11 | Duplicate Dental | |
12 | There must not exist two claim s with equ al values for all th e followin g elements :-Patient ID-Provide r NPI-Proc edure Code -Service D ate-Teeth Serviced | |
13 | Logic | |
14 | Duplicate Profession al - Appli es to PROF : | |
15 | FOREACH (P rofessiona lClaimLine pcl relat ed to the Claim) { IF (ther e exists a nother Pro fessionalC laimLine w ith the fo llowing eq ual elemen ts to pcl Pro fessionalC laimLine.c laim.patie nt.memberI d P rofessiona lClaimLine .providerO fInterest. npi Professio nalClaimLi ne.procedu re.code Profe ssionalCla imLine.pla ceOfServic e.code Profes sionalClai mLine.serv iceDateFro m Profession alClaimLin e.chargeAm t P rofessiona lClaimLine .modifiers ) THEN { crea te Validat ionFailure : , CARC: 18, RARC: 18 for Pro fessionalC laimLine }} | |
16 | Duplicate Institutio nal Inpati ent - Appl ies to INS T-I: | |
17 | FOREACH (I nstitution alClaimLin e icl rela ted to the Claim) { IF (the re exists another In stitutiona lClaimLine with the following equal elem ents to ic l I nstitution alClaimLin e.claim.in stClaim.st atementToD ate Instituti onalClaimL ine.claim. instClaim. statementF romDate Insti tutionalCl aimLine.cl aim.patien t.memberId In stitutiona lClaimLine .providerO fInterest. npi) THEN { c reate Vali dationFail ure: , CAR C: 18, RAR C: 18 for Institutio nalClaimLi ne }} | |
18 | Duplicate Institutio nal Outpat ient - App lies to IN ST-O: | |
19 | FOREACH (I nstitution alClaimLin e icl rela ted to the Claim) { IF (the re exists another In stitutiona lClaimLine with the following equal elem ents to ic l I nstitution alClaimLin e.claim.pa tient.memb erId Institut ionalClaim Line.provi derOfInter est.npi Insti tutionalCl aimLine.pr ocedure.co de Institutio nalClaimLi ne.service Date Institut ionalClaim Line.charg eAmt Institut ionalClaim Line.modif iers) THEN { create Val idationFai lure: , CA RC: 18, RA RC: 18 for Instituti onalClaimL ine }} | |
20 | Duplicate Dental - A pplies to DENT: | |
21 | FOREACH (D entalClaim Line dcl r elated to the Claim) { IF ( there exis ts another DentalCla imLine wit h the foll owing equa l elements to dcl Denta lClaimLine .claim.pat ient.membe rId DentalCla imLine.pro viderOfInt erest.npi Den talClaimLi ne.procedu re.code Denta lClaimLine .serviceDa te DentalClai mLine.clai m.dentClai mTeeth) TH EN { create Validation Failure: , CARC: 18, RARC: 18 for Dental ClaimLine }} | |
22 | Data Eleme nts | |
23 | BRENGINE | |
24 | CCRSDB | |
25 | Claim.prof ClaimLines ** | |
26 | F_PROFESSI ONAL_MEDIC AL_CLAIM_D ETAILS | |
27 | Claim.sour ceSystem | |
28 | DIM_VA_CLA IM.source_ system | |
29 | Claim.pati ent.member Id | |
30 | DIM_PATIEN T.member_i d | |
31 | Claim.inst Claim** | |
32 | DIM_INSTIT UTIONAL_CL AIM | |
33 | Claim.inst ClaimLines ** | |
34 | F_INSTITUT IONAL_MEDI CAL_CLAIM_ DETAILS | |
35 | Claim.dent ClaimLines | |
36 | F_DENTAL_C LAIM_DETAI LS | |
37 | Claim.dent ClaimTeeth ** | |
38 | CLAIM_TOOT H_STATUS | |
39 | Profession alClaimLin e.placeOfS ervice | |
40 | DIM_PLACE_ OF_SERVICE | |
41 | Profession alClaimLin e.placeOfS ervice.cod e | |
42 | DIM_PLACE_ OF_SERVICE .pos_code | |
43 | Profession alClaimLin e.provider OfInterest .npi** | |
44 | DIM_PROVID ER.npi | |
45 | Profession alClaimLin e.procedur e.code | |
46 | DIM_PROCED URE_CODE.p rocedure_c ode | |
47 | Profession alClaimLin e.serviceD ateFrom | |
48 | F_PROFESSI ONAL_MEDIC AL_CLAIM_D ETAILS.ser vice_date_ from | |
49 | Profession alClaimLin e.chargeAm t | |
50 | F_PROFESSI ONAL_MEDIC AL_CLAIM_D ETAILS.cha rge_amount | |
51 | Profession alClaimLin e.modifier s** | |
52 | CLAIM_LINE _MODIFIER | |
53 | Profession alClaimLin e.serviceD ateTo | |
54 | F_PROFESSI ONAL_MEDIC AL_CLAIM_D ETAILS.ser vice_date_ to | |
55 | Institutio nalClaim.s tatementFr omDate | |
56 | DIM_INSTIT UTIONAL_CL AIM.statem ent_from_d ate | |
57 | Institutio nalClaim.s tatementTo Date | |
58 | DIM_INSTIT UTIONAL_CL AIM.statem ent_to_dat e | |
59 | Institutio nalClaimLi ne.provide rOfInteres t.npi** | |
60 | DIM_PROVID ER.npi | |
61 | Institutio nalClaimLi ne.procedu re.code | |
62 | DIM_PROCED URE_CODE.p rocedure_c ode | |
63 | Institutio nalClaimLi ne.service Date | |
64 | F_INSTITUT IONAL_MEDI CAL_CLAIM_ DETAILS.se rvice_date | |
65 | Institutio nalClaimLi ne.chargeA mt | |
66 | F_INSTITUT IONAL_MEDI CAL_CLAIM_ DETAILS.ch arge_amoun t | |
67 | DentalClai mLine.prov iderOfInte rest.npi** | |
68 | DIM_PROVID ER.npi | |
69 | DentalClai mLine.proc edure.code | |
70 | DIM_PROCED URE_CODE.p rocedure_c ode | |
71 | DentalClai mLine.serv iceDate | |
72 | F_DENTAL_C LAIM_DETAI LS.service _date | |
73 | DentalClai mLine.modi fiers** | |
74 | CLAIM_LINE _MODIFIER | |
75 | Modifier.c ode | |
76 | CLAIM_LINE _MODIFIER. modifier_c ode |
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