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Claims Adjudication Rules Definition - Limit

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Overview

Measure when a value for a service exceeds an amount.

Steps

  1. In the Sum/Total of field, select the quantity to measure.

  2. In the Within the Past field, select the period over which the measurement takes place.

  3. In the For the Following Procedure Code/Or Procedure Code Group fields, select either the procedure code or procedure code group from the drop-down lists.

  4. In the Must Be field, select the type of comparison to evaluate:

  • <= - Less than/Equal to: The selected item is less than or equal to the specified value.

  • <> - Not Equal to: The selected item does not equal the specified value.

  • < - Less than: The selected item is less than (and not equal to) the specified value.

  • = - Equal to: The selected item is the same as the specified value.

  • >= - Greater than/Equal to: The selected item is greater than or equal to the specified value.

  • > - Greater than: The selected item is greater than (and not equal to) the specified value.

  1. In the Following Value field, specify a numerical value for the comparison.

  2. In the For Same Provider field, select Yes to only check against services for the same provider. Select No to check across all providers.

  3. In the Pay Partial Claim field, designate whether or not to pay partial claims for services that exceed the defined limit.

  4. In the For Diagnosis field, specify a diagnosis if the limit rule applies to a specific diagnosis.
    File:myAvatar/Avatar_MSO/Avatar_MSO_2011_-_Online_Help/DL0/note-3L.png Users may enter all or part of a diagnosis code or description to perform a search for the specific diagnosis.