Professional Documents
Culture Documents
Billing
Ref: No:
2012-BR-0006
Version Control:
Version No. 3.0
Effective Date:
April 2012
Revision Date:
August 2015
Nebulization
Adjudication Rule
Table of content
Abstract Scope Adjudication Policy
Page 1
Page 2 Page 2
Adjudication examples
Page 2
Denial codes
Page 2
Appendices
Page 3
Approved by:
Daman
Abstract
Responsible:
Medical Strategy &
Development Department
For Members
Billing Rules are the adjudication rules, which are in compliance with official CPT, ICDCM and HAAD/CCSC coding guidelines.
A billing rule defines the minimum requirements to be met when a service is claimed for
a Daman beneficiary in terms of frequency, duration etc.
It explains the minimum required documentation to claim a service. It also defines the
coverage of a service under a particular insurance plan administered by Daman.
Disclaimer
By accessing these Daman Adjudication Rules (the
AR), you acknowledge that you have read and
understood the terms of use set out in the
disclaimer below:
The information contained in this AR is intended to
outline the procedures of adjudication of medical
claims as applied by the National Health Insurance
Company Daman PJSC (hereinafter Daman).
The AR is not intended to be comprehensive,
should not be used as treatment guidelines and
should only be used for the purpose of reference or
guidance for adjudication procedures and shall not
be construed as conclusive. Daman in no way
interferes with the treatment of patient and will not
bear any responsibility for treatment decisions
interpreted through Daman AR. Treatment of
patient is and remains at all times the sole
responsibility of the treating Healthcare Provider.
This AR does not grant any rights or impose
obligations on Daman. The AR and all of the
information it contains are provided "as is" without
warranties of any kind, whether express or implied
which are hereby expressly disclaimed.
Under no circumstances will Daman be liable to
any person or business entity for any direct,
indirect, special, incidental, consequential, or other
damages arising out of any use of, access to, or
inability to use or access to, or reliance on this AR,
including but without limitation to, any loss of
profits, business interruption, or loss of programs
or information, even if Daman has been specifically
advised of the possibility of such damages. Daman
also disclaims all liability for any material contained
in other websites linked to Daman website.
This AR is subject to the laws, decrees, circulars
and regulations of Abu Dhabi and UAE.
Any
information provided herein is general and is not
intended to replace or supersede any laws or
regulations related to the AR as enforced in the
UAE issued by any governmental entity or
regulatory authority, or any other written
document governing the relationship between
Daman and its contracting parties.
This AR is developed by Daman and is the property
of Daman and may not be copied, reproduced,
distributed or displayed by any third party without
Damans express written consent. This AR
incorporates the Current Procedural Terminology
and Current Dental Terminology (CPT and CDT,
which is a registered trademark of the American
Medical Association (AMA), and the American
Dental Association (ADA) respectively), and the
CPT and CDT codes and descriptions belong to the
AMA. Daman reserves the right to modify, alter,
amend or obsolete the AR at any time by providing
one month prior notice.
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
Doc Ctrl No.:
TEMP/MSD-004
Version No.: 1
Revision No.:
Date of Issue:
08.05.2013
Page No(s).:
1 of 3
Nebulization
Scope
Adjudication Policy
Eligibility / Coverage Criteria
6.
Adjudication Examples
Example 1
Question: A 4 year old asthmatic girl holding a
Thiqa card presents to family physician with cough,
shortness of breath and wheeze. Physician
diagnosed it as asthma exacerbation and two
nebulizer treatments with ATROVENT 0.025% is
given .She clears up and breathing is easier, and
evidently better.
Answer:
Nebulizer administration - 94640 X 2 times
Nebulizer Medication
- 1317-1289-001
Example 2
Non-Coverage
Nebulizer treatments are not covered if not
medically necessary or noncompliant with coding
and billing rule.
Answer:
Nebulizer administration - 94644
Nebulizer Medication
- 2078-5925-001
Denial codes
Code
Code description
MNEC-004
PRCE-010
MNEC-005
CLAI-012
TEMP/MSD-004
Version No.: 1
Revision No.:
Date of Issue:
08.05.2013
Page No(s).:
2 of 3
Nebulization
Appendices
A. References
1. AMA CPT assistant
2. CPT coding book 2011
3. CCSC coding manual 2011
4. HAAD claims and adjudication rules
V2012
B. Revision History
Date
01-07-13
15-07-14
Change(s)
V 2.0: New template
1.
2.
3.
V 3.0
Disclaimer updated as per system
requirements
Restored original effective date
National Health Insurance Company Daman (PJSC) (P.O. Box 128888, Abu Dhabi, U.A.E. Tel No. +97126149555 Fax No. +97126149550)
Doc Ctrl No.:
TEMP/MSD-004
Version No.: 1
Revision No.:
Date of Issue:
08.05.2013
Page No(s).:
3 of 3