Page 11 - C.Journal 4th edition

Claims Journal 4th Edition Claims Journal 4th Edition

Common

QC Mistakes

Approving service has no indication/ irrelevant to condition Unjustified shortfall was given
Scenario: Scenario:
A 27 years old female coming for her regular ANC visit. 31 yrs old male suffering from renal stone.

Adjudicator Error Adjudication Tips Adjudicator Error Adjudication Tips

Calcium & HCV Abs are not Rejecting KUB & ultrasound Since the claim is coded N20
Approving the whole part of ANC profile and it for the patient so, KUB & u/s should be
tests done in the claim. should be rejected by 77. approved in this case.
Only tests included in ANC
profile should be approved for
normal pregnant woman.
otherwise PA is required

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