Business\SAIF.Business.Claim.Bill.AutomatedAudit\BillAuditEngine.vb (AuditBill) and Business\SAIF.Business.Claim.Bill.AutomatedAudit\AuditUtilities\clsBillEditor.vb (EditBill)
Business\SAIF.Business.Claim.Bill.AutomatedAudit\BillAuditEngine.vb (AuditBill) and Business\SAIF.Business.Claim.Bill.AutomatedAudit\AuditUtilities\clsServiceEditor.vb (EditService, AdjustService)
BR-005: DRG code required for most inpatient hospital bills¶
Field
Value
Statement
An inpatient hospital bill with a UB bill type code of 0111–0118 must have a valid DRG code, unless a billed service code starts with 002 or the billing provider is a critical-access hospital.
BR-006: Diagnosis and procedure codes must be valid and effective¶
Field
Value
Statement
Every diagnosis and procedure code on the bill must resolve to a known, effective code as of the statement-through date; a billing provider type that requires a diagnosis must have at least one, and outpatient hospital bills need at least one diagnosis of type R.
Trigger
Bill audit rule execution — AuditBill rule group
Enforcement
clsBillAuditor.ValidateDiagnosisandProcedureCode
Outcome
Warning "One or more diagnosis code is not valid." or "One or more procedure code is not valid."; all services disallowed with adjustment code GW
BR-016: Interpreter mileage service lines must meet minimum quantity thresholds¶
Field
Value
Statement
An interpreter mileage service (D0041) must meet the minimum billed quantity in effect for its date of service (60.01 units before 4/1/2012, 15 units on/after).
Trigger
Service edit and adjustment — ADJUST_SERVICE# rule group
BR-017: Pharmacy bills require prescriber ID, Rx-written date, and prescriber last name¶
Field
Value
Statement
A service billed by a Pharmacy provider type (PH) must include a prescriber ID, a Rx-written date that is not after the service date, and the prescriber's last name.
Trigger
Service edit and adjustment — ADJUST_SERVICE# rule group
Enforcement
clsServiceEditor rules ba_ValidatePharmacyInfo and ba_ValidatePharmacyRXDate
Outcome
Messages "Invalid pharmacy information ({0})." or "Date rx written cannot be after the service date' ({0})."; full-charge GX adjustment created and ReauditCode set to X
BR-019: Non-MCO provider services past the grace period may be disallowed¶
Field
Value
Statement
For a claim with mandatory-MCO status, a service performed more than 14 days after the MCO effective date, by a non-anesthesiology servicing provider, and not already subject to MCO withhold, may be fully disallowed.
Trigger
Bill audit rule execution — AuditBill rule group (FinalAuditChecks)
BR-020: Late-filed bills are subject to time-based payment reductions or disallowance¶
Field
Value
Statement
An original (non-rebill) service billed past its era's filing deadline is reduced or fully disallowed: before 4/1/2006 (or Vocational Rehabilitation any time), 10% per month after 60 days, with Vocational Rehabilitation fully disallowed after 180 days; from 4/1/2006–6/30/2007, a compounding 10% monthly reduction after 90 days; after 6/30/2007, full disallowance after 365 days. Worker-reimbursement bills are exempt.
Trigger
Bill audit rule execution — AuditBill rule group (FinalAuditChecks)
Enforcement
clsBillAuditor.CheckForLateFiling
Outcome
Reduction or full disallowance applied with adjustment code FD (reduction) or SO (Vocational Rehabilitation full disallowance)
BR-021: Duplicate services are reduced to the unpaid remainder or flagged¶
Field
Value
Statement
A service matching a historical or current duplicate pattern (same provider/date/service/charge, or equivalent pharmacy/NDC match) is marked as a definite (D) or possible (U) duplicate on OriginalBillCode, linked to the original bill/service, and reduced by the amount already paid.
Trigger
Bill audit rule execution — AuditBill rule group (FinalAuditChecks)
Enforcement
clsBillAuditor.CheckForDuplicates
Outcome
Adjustment code PA (original fully paid), PB (no prior allowed amount found), or PC (original incomplete but prior payment exists); warning message "{code} Possible duplicate" or "{code} Dup. with positive allowed amt" / "{code} Duplicate service"
Note: Statements marked with * were inferred from code structure, naming conventions, or
contextual evidence where direct confirmation was not available in source artifacts. Statements
marked with ** could not be confirmed; treat as unknown until verified.