Page 9 - C.Journal 4th edition

Claims Journal 4th Edition Claims Journal 4th Edition

Common

QC Mistakes

Wrong ICD/ benefit was selected Unjustified shortfall was given
Scenario: Scenario:
A 64 years old patient visiting the hospital for doing regular investigations as he is IHD A patient coming for pre-operative investigations.
patient.

Adjudication Tips
Adjudicator Error - Kindly check the patient’s Adjudicator Error Adjudication Tips
Medical officer coded history, as in this claim patient
the claim as general suffers from chronic conditions Rejecting pre-operative tests Checking pre-op excluded &
check up (Z00). & taking chronic medications. with 84/5 included lists is a MUST before
adjudicating such claims. As in
- We shouldn’t select Z00 this example Bakhsh hospital is
(general checkup) unless it came one of pre-op excluded list.
as a package & it is
preautherized as in this claim he
is SABIC member.

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