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Approve/Pend/Deny Rules Definition

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Define approval, pending approval, and denial rules for a funding source.

These rules define the action to be performed when there is a difference between a rendered service and the service authorization. When claims are adjudicated rules set up in this form are applied to the claims associated with the funding source. The following takes place:

  • Approve - the service is approved.
  • Pend - the claim is not processed until the claim is approved or denied.
  • Deny - the service is denied.
  1. Go to: Avatar MSO > System Maintenance > Approve/Pend/Deny Rules Definition
  2. In the Funding Source Name field, enter the funding source. Choose Select Funding Source and then, Ok.
    Note: In the Approve, Deny, and Pend fields, select the action to perform when there is a difference between how a service is rendered and how it is defined in the service authorization, or benefit plan.
  3. In the Days Permitted Prior To Authorization Begin Date field, enter the number of days a service can be approved before the authorization start date.
  4. In the Days Permitted Beyond Authorization End Date field, enter the number of days a service can be approved after the authorization end date.
  5. In the Pay Total Charge If Lower Than Fee Table Amount field:
    • Select Yes to pay the total service amount if the total service amount is lower than the provider fee.
    • Select No to pay the provider fee.
  6. In the Maximum Number of Days Prior to 'Date Claims Received' Date of Service is Permitted field, define the number of days a service can be included in a batch before a batch is created (Date Claims Received field, Batch Creation form).
  7. In the Days Prior to 'Date Claims Received' Exceeded for Replacement Claims field, select the action to perform if the maximum number of days before the date the claim is received is reached.
  8. Third Party Coverage Found For Unknown Payer - This rule applies to third party payers that are not covering guarantors for a client when there is a Third Party Amount Paid associated with a claim and an Amount Paid associated with the third party payer. If the guarantor is in the system but is not a covering guarantor for the client, the rule will still be applied.
  9. In the Duration Per Unit For Procedure Code Is Incorrect field, select the action for when the duration per unit for the procedure code is wrong.
  10. In the Duplicate Service Parameters field, select which fields will be used to match services together.
    Note: myAvatar will consider two services a match on a parameter where the value for both services is blank. For example, when Performing Provider is the only parameter selected in the Duplicate Service Parameters field, if two services match on all of the parameters above and both have no performing provider included, the second parameter will be considered a duplicate. 
    • When searching for duplicate services, the following parameters will be considered for matching services:
      • Claim Status = "Approved"
      • Contracting Provider
      • Date of Service
      • Procedure Code
      • Procedure Code Type - Any parameters checked off on this field will be included when searching for duplicate services.
  11. In the Number of Services Per Claim Allowed field, enter the maximum number of services permitted on a claim.
  12. In the Number of Services Per Claim Allowed Exceeded field, select the action to perform when the number of services exceeds the maximum amount allowed for a claim, as specified in the previous field. This rule checks the number of services attributed to the claim inside the 837.
    • For professional claims (837P), a service is not counted as part of this rule if it is an Add-On or Interactive Complexity Code, as configured in the CPT Code Category field in the CPT Code Definition form.
  13. In the Ignore Number of Services Per Claim Allowed Exceeded for manually entered services field, select whether or not the system should ignore the maximum for services that were entered manually.
  14. Maximum Units Per Day Exceeded - Controls the Claim Status of services which exceed the Maximum Units Per Day defined in the Revenue Code Definition and CPT Code Definition forms. When a code has a Maximum Units Per Day value, the number of approved units for a service is calculated by finding the approved units for all services with the following fields in common:
    • Member ID
    • Procedure Code Type
    • Procedure Code
    • Date of Service
    • Contracting Provider
    • Funding Source
      Note: The Use Funding Source For Maximum Units Check registry setting controls the use of Funding Source in the Maximum Units Per Day check.
    • Plan
    • Performing Provider
    • Performing Provider Type
    • Level of Care
  15. In the Third Party Coverage Found and Service Not Fully Covered by Authorization field, select the claim status for these services. 
    This adjudication rule will be evaluated for all services that contain third party payments but are not fully covered by the identified authorization. In cases where the service includes Service Level Payment/Adjustment Information and the corresponding/selected service authorization does not fully cover the service liability, the service is set to the claim status indicated in this field.
  16. In the Contracting Provider Program Not Valid For Authorization field, select status to override the claim status for a service that was denied because the service contracting provider program does not match the contracting provider program for the selected authorization. (Applies if the Contracting Provider Program field is defined for the applicable Service Authorization.)
  17. In the 'Overall Plan Limitations' fields, define the action when there is a difference between how a service is rendered and how that service is set up in the benefit plan (Plan Definition form).
  18. In the 'Liability Level Plan Limitations' fields, define the action when there is a difference between how a service is rendered and how that service is set up for the benefit plan level (Plan Definition form, Plan Coverage Definition section).
  19. When finished, select Submit.
► Registry Settings
► SQL Tables
  • SYSTEM.table_app_pen_den_rules