IBCEMQC ;ALB/ESG - MRA EOB CRITERIA FOR AUTO-AUTHORIZE ; 11/1/06 10:34am
Source file <IBCEMQC.m>
| action | A | extended action | Ea | event driver | Ed | subscriber | Su | protocol | O | limited protocol | LP | run routine | RR | broker | B | edit | E | server | Se | P | screenman | SM | inquire | I |
| Name | Comments | DBIA/ICR reference |
|---|---|---|
| CRIT(IBEOB) | ; Function to determine if EOB entry meets the criteria for
; auto-authorization and secondary claim submission |
|
| CRITX | ;
|
|
| CAS(IBEOB,ADJFLAG,REASON) | ; This function determines if the EOB
; adjustment group codes and reason codes from file 361.1 (either ; claim level or line level or both) meet the criteria for auto- ; authorization and secondary claim submission. |
|
| CASX | ;
|
|
| ADJCHK | ; This procedure checks the adjustments for this EOB. The group codes
; and reason codes are in the EOBADJ array structures from file 361.1. |
|
| ADJCHKX | ;
|
|
| BUILD | ; This procedure builds the OKCOMBO array which identifies which
; combinations of group codes and reason codes are acceptable |
|
| BUILDX | ;
|
|
| OKCOMBO | ; This section lists OK combinations of adjustment category group codes
; and associated reason codes. ; The format is as follows - semi-colon delimiter ; [3] Adjustment category (group code) ; [4] List of acceptable reason codes - comma delimiter |
| FileNo | Call Tags |
|---|---|
| ^IBM(361.1 - [#361.1] | GET1^DIQ |
| Name | Line Occurrences (* Changed, ! Killed) |
|---|---|
| ^IBE(350.9 - [#350.9] | CRIT+48, CRIT+49 |
| ^IBM(361.1 - [#361.1] | CRIT+13, CRIT+14, CRIT+22, CRIT+24, CRIT+25, CRIT+41, CAS+29, CAS+39, CAS+41 |
| >> | Not killed explicitly |
| * | Changed |
| ! | Killed |
| ~ | Newed |
| Name | Field # of Occurrence |
|---|---|
| ADJFLAG | CAS~, CAS+19*, CAS+27, CAS+37 |
| ADJIEN | ADJCHK+6~, ADJCHK+7*, ADJCHK+8*, ADJCHK+9, ADJCHK+14, ADJCHK+15 |
| EOBADJ | CAS+16~, CAS+28!, CAS+29*, CAS+40!, CAS+41* |
| EOBADJ( | ADJCHK+8, ADJCHK+9, ADJCHK+14, ADJCHK+15 |
| GROUP | ADJCHK+6~, ADJCHK+9*, ADJCHK+10, ADJCHK+11*, ADJCHK+12, ADJCHK+18, ADJCHK+19, ADJCHK+22, ADJCHK+25, BUILD+3~ , BUILD+7*, BUILD+11 |
| IBEOB | CRIT~, CRIT+11*, CRIT+13, CRIT+14, CRIT+15, CRIT+23, CRIT+34, CRIT+38, CRIT+41, CRIT+42 , CAS~, CAS+18*, CAS+29, CAS+39, CAS+41 |
| IBIFN | CRIT+9~, CRIT+21*, CRIT+22, CRIT+42, CRIT+44 |
| IBM | CRIT+9~, CRIT+13*, CRIT+15, CRIT+17, CRIT+21 |
| IBM3 | CRIT+9~ |
| IBM5 | CRIT+9~ |
| IBPTRESP | CRIT+9~, CRIT+41*, CRIT+42*, CRIT+44*, CRIT+45 |
| LINE | BUILD+3~, BUILD+5, BUILD+6*, BUILD+7, BUILD+8 |
| LN | BUILD+3~, BUILD+5* |
| LNIEN | CAS+16~, CAS+38*, CAS+39*, CAS+41 |
| OK | CRIT+9~, CRIT+11*, CRIT+52*, CRITX+1, CAS+16~, CAS+23*, CAS+53*, CASX+1 |
| OKCOMBO | CAS+16~, BUILD+4!, BUILD+5 |
| OKCOMBO( | ADJCHK+12, ADJCHK+22, BUILD+11* |
| PATRESP | CAS+16~, CAS+21*, CAS+50, ADJCHK+25* |
| PCE | CRIT+9~ |
| R | BUILD+3~, BUILD+9*, BUILD+10 |
| REASON | CRIT+9~, CRIT+11*, CRIT+13*, CRIT+14*, CRIT+15*, CRIT+17*, CRIT+26*, CRIT+34*, CRIT+38, CRIT+45* , CRIT+48*, CRIT+49*, CRIT+52*, CRITX+1, CAS~, CAS+24*, CAS+50*, CAS+53*, ADJCHK+12*, ADJCHK+22* |
| REMC | CRIT+9~ |
| RSN | BUILD+3~, BUILD+10*, BUILD+11 |
| RSNCODE | ADJCHK+6~, ADJCHK+15*, ADJCHK+18, ADJCHK+19, ADJCHK+21*, ADJCHK+22 |
| RSNIEN | ADJCHK+6~, ADJCHK+13*, ADJCHK+14*, ADJCHK+15 |
| RSNLST | BUILD+3~, BUILD+8*, BUILD+9, BUILD+10 |
| STOP | CRIT+9~, CRIT+21*, CRIT+22, CRIT+27*, CRIT+29, CAS+16~, CAS+22*, CAS+34, CAS+39, CAS+47 , ADJCHK+8, ADJCHK+12*, ADJCHK+14, ADJCHK+22* |
| U | CRIT+15, CRIT+17, CRIT+24, CRIT+25, CRIT+41, CRIT+48, CRIT+49, CRITX+1, ADJCHK+9, ADJCHK+15 |
| Z | CRIT+9~, CRIT+21*, CRIT+22*, CRIT+23, CRIT+24, CRIT+25, CRIT+26 |
| Name | Field # of Occurrence |
|---|---|
| $T(OKCOMBO+LN | BUILD+6 |
