# | Name | Location | Type | Details | Index | Description |
---|---|---|---|---|---|---|
.01 | rule number(+) | 0;1 | NUMERIC | B | This is the rule # given to identify this rule. Rules 1-99 are reserved for National EDI rules and are not editable. | |
.02 | earliest activate date | 0;2 | DATE-TIME | This is a date in the future when this rule will automatically be used. | ||
.03 | transmission type(+) | 0;3 | SET OF CODES | 1:EDI only 2:MRA only 3:Both EDI and MRA | This is the type of transmission that the rule will be executed for. | |
.04 | type of care(+) | 0;4 | SET OF CODES | 1:OUTPATIENT only 2:INPATIENT only 3:Both INPT and OUTPT | This is the type of care that the rule will be executed for. | |
.05 | form type(+) | 0;5 | SET OF CODES | 1:INSTITUTIONAL (UB-04) only 2:PROFESSIONAL (CMS-1500) only 3:Both INST (UB-04) and PROF (CMS-1500) | This is the form type that the rule will be executed for. | |
.06 | inactive date | 0;6 | DATE-TIME | This is the date on which this edit will not longer be used to determine 'transmittable' for a bill. | ||
.07 | insurance company option(+) | 0;7 | SET OF CODES | 1:APPLY ONLY TO SPECIFIC COMPANIES 2:DO NOT APPLY TO SPECIFIC COMPANIES 3:APPLY TO ALL COMPANIES | This is the option to determine which insurance companies to apply this rule to. If 1 or 2 are chosen, the list of insurance companies to be included or excluded should be entered in the appropriate multiple within this file. | |
.08 | short description | 0;8 | FREE TEXT | This is a short description of the rule used for identification purposes on lookup. | ||
.1 | bill type restrictions | BTYP;0 | MULTIPLE | 364.41 | ||
.11 | type of rule(+) | 0;11 | SET OF CODES | 0:LIMIT TO FORM TYPE 1:LIMIT TO SOME BILL TYPES 2:MRA REQUEST RESTRICTIONS 9:LOCALLY DEFINED | AC | This flag puts the rule into a 'type' category for conflict checking. It is also a flag that can indicate this rule needs to be executed to determine if an MRA request is valid for the MEDIGAP insurance that is next in line for COB or if the claim should be directly shuttled to the MEDIGAP carrier. TYPE OF RULE = 0 (LIMIT TO FORM TYPES) is used to further limit the transmission of PROFESSIONAL (CMS-1500) or INSTITUTIONAL (UB-04) form types. If you pick one form type, no bills of the other form type will be transmitted for: a) the insurance companies you selected to include OR b) the insurance companies not entered on the excluded list OR c) any insurance co if all insurance companies are selected. TYPE OF RULE = 1 (LIMIT TO SOME BILL TYPES) is used to further limit the transmission of the UB-04 equivalent of bill type (111,131,etc). These rules can be used to restrict transmissions to specific bill types or to allow all bill types except those specified (these are entered preceeded by a dash). A 'wild card' character of X can be used to indicate that a character in that position is included (ie 11X will allow 111,112,113,etc) The rule will not allow transmission of bills matching the EDI/MRA and PROF/INST parameters and insurance co restrictions (see rule 0 above) unless they match the allowed bill types and do not match any of the excluded bill types. TYPE OF RULE = 9 (LOCAL EDITS) are local edits. If this type of rule is used, the code entered for the edit must return a truth value of 1 if the bill should be transmitted or 0 if the bill should not be transmitted. The variable IBIFN is the internal entry # of the bill (file 399), the IB(x) array contains the value of fields #.03,.04,.05,.07,.11 for the rule where 'x' is the field #. IBDA is the ien of the rule (file 364.4). |
1 | rule code | 1;E1,245 | FREE TEXT | This is the MUMPS call that will execute the edit's logic and will set $T to 1 for edit passed or to 0 for edit failed. You can assume the following variables are available: IBIFN = ien of the bill in file 399 IB(.03) = Current value of the bill's transmission type IB(.05) = Current value of the bill's form type IB(.07) = Current value of the bill's insurance option | ||
2 | excluded insurance company | 2;0 | MULTIPLE | 364.42 | ||
3 | included insurance company | 3;0 | MULTIPLE | 364.43 | ||
4 | rule description | 4;0 | WORD-PROCESSING | |||
10.01 | rule added by | 10;1 | POINTER | 200 | This is the person responsible for adding this rule to this file. | |
10.02 | rule added date | 10;2 | DATE-TIME | This is the date this rule entry was first added to this file. | ||
10.03 | rule last edited by | 10;3 | POINTER | 200 | This is the name of the person who last edited this rule entry. | |
10.04 | rule last edited date | 10;4 | DATE-TIME | This is the last date this rule was edited. |
Not Referenced