Page 23 - C.Journal 3rd edition

Claims Journal 3rd Edition Claims Journal 3rd Edition
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CR325 Claims Auto Adjudication Project “Cross Walks” has been deployed Do You Know !!

Objectives

It will increase the quality of adjudication & accuracy. Moreover, it will help us to monitor the quality

of diagnosis supplied by the provider. As you know during our adjudication, we are

Through a validation criteria will be applied. manually rejecting some services, as

Scope unbundling, unusual quantities of services,

Validation will be on line item level with ICD code matched age/gender mismatching .

against the Bupa code / CPT.
Exclusions

It will exclude ICD code H52 & K02 (optical and dental) and service type (CO) as well.

Validation Mechanism

So we can list the more frequent and time consuming shortfalls, we encountered during day to day
1. “Cross Walk Automation Validation table” with primary keys as Bupa Code, ICD Code has been cre-
work.
ated and stored in CAESAR.

2. If the Bupa Code of a line item is in the crosswalk table and the assigned ICD Code to the line item
Let us name the rationale behind these shortfalls as Rules.
is not the one indicated in the crosswalk table then a warning will be issued by turning the line color
We already had a workshop before regarding this,
to be colored RED. If medical adjudicator will not change the ICD then it will always be colored RED.

and there will be more workshops in the future.
If medical adjudicator will rework the case but will not change the ICD code then it will remain RED.
The best Rules you give will take place here in the journal.
Only when the medical adjudicator changes the ICD to the one matching with the BUPA Code in cross-
Each notice is valuable and can help in this process, so kindly send your suggestions to the following
walk table. Hence the ICD Code color will become black either during adjudication or rework.
email :

BA.RulesManagement@bupa.com.sa

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