Page 9 - C.Journal 3rd edition

Claims Journal 3rd Edition Claims Journal 3rd Edition

Common

QC Mistakes

Attached wrong PA number Unjustified shortfall was given
Scenario: Scenario:
Patient complaining of ear disorder, assigned for surgery and coming to do Pre-Operating tests. A patient with hyper function of pituitary glands coming for doing certain tests.

Adjudication Tips Adjudicator Error Adjudication Tips
Adjudicator Error NEVER attach IP PA to any When a claim having
Rejecting both tests as the
Attaching PA for inpa- OP claim, if the procedure re- whole claim is greater than consultation, tests & medi-
tient claim. quested in OP claim & the PA 1000 SR. cations. Each one of them
is for IP then attach it in the shouldn’t exceed the limit
INTERNAL NOTE. according to the special
handling of each patient.
Ex: if a claim having tests
exceeding 1000 SR, tests ONLY
should be rejected by 140/ 7.

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