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Claims Adjudication Rules Definition - Existence

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Overview

Check for the existence of certain properties.

Steps

  1. In the Procedure Code field, select a procedure code. Or, to select a procedure code group, choose an item from the Or Procedure Code Group field.

  2. In the next field, select whether the rule is inclusive or exclusive. Select Cannot Occur for an exclusive rule, select Must Occur for an inclusive rule.

  3. In the Within the Same field, select the relevant time period to check across.

  4. In the As the Following Procedure Code(s) field, select the procedure codes to compare against. If instead comparing procedure code groups, select the relevant entry from the Or Procedure Code Group drop-down list.

  5. In the For Same Provider field, select Yes if the service check is only for the same provider. Select No to run the check across all providers.

  6. In the Reciprocal field, select Yes if the rule is reciprocal. The rule is reciprocal if it should hold for both the initially selected procedure code/code group occurring along with the second procedure code(s)/code group, as well as the other way around. Select No to only run the test in one direction.