Ambulatory Surgical Centers (ASC) Rates
Institutional Rates
Procedure Code Rates
Revenue Code Rates
Rules Management's primary function is to maintain the supporting data required for claims processing, pricing, and adjudication. It also maintains information used by Benefit Plan Administration, Service Authorizations, and Event Text Management. Also included is the information used throughout the ND MMIS, such as line of business, system lists, system parameters, data elements, and valid values.
The majority of the supporting information maintained in the Rules Management function is part of the Reference functional area.
Information that is considered part of the Reference functional area is listed below. All of the information can be viewed from the North Dakota MMIS Web Portal using the Rules Management menu. Most reference information can be added or edited but some is view-only.
Procedure and Service Codes - Health Care Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT), American Dental Association (ADA), and Non-Medicaid procedure or service codes and all associated supporting data to support claims adjudication and pricing are maintained by the Reference Functional Area.
Surgical Procedure Codes - Surgical procedure codes and all associated related data are maintained by the Reference Functional Area.
Revenue Codes - Revenue Codes are maintained primarily for processing UB-92 claims.
Rates - Rates and fee schedules required to price claims are maintained by the Reference Functional Area. This includes rates from Clinical Laboratory Improvements Amendment (CLIA) and Medicare, as well as North Dakota specific rates maintained at various levels such as provider/procedure code/modifier rates.
Diagnosis Codes - International Classification of Diseases (ICD) Diagnosis codes and related data are maintained to support claims processing and Diagnostic Related Groupings (DRG) assignment.
DRG Codes - Diagnosis Related Group (DRG) data is maintained primarily to support pricing inpatient hospital claims.
Claim Exception Codes - The Reference Functional Area maintains data to support the posting, reporting, and resolution of claims processing exceptions.
Text - Text for Explanation of Benefits (EOB) codes, Explanation of Medicare Benefits (EOMB) codes, location codes, remark codes, adjustment reason codes, service authorization reason codes, and remittance messages is maintained online through the Reference Functional Area.
Utilization Review (UR) Criteria - Utilization Review Criteria data is maintained in order to support the utilization review (UR) editing (frequency limitations, quantity limitations, service conflicts, etc.) function of claims processing.
These functions on the Pharmacy menu, open in PBM OS+:
Service Authorization (SA) Exceptions - The Reference Functional Area maintains data to support the posting, reporting, and resolution of service authorization exceptions.
SA Letter Assignment - Service Authorization (SA) maintains data to support the notification letters which provide official notice of service authorization status changes, changes to previously approved SA records, and requests for additional information from providers.
Lines of Business - A line of business (LOB) identifies for each ND MMIS customer who has the overall responsibility for processing and paying claims for its members. It is used by all functions.
System Lists - System lists, which are date-sensitive lists of data element values, are used throughout ND MMIS in areas such as Claims Pricing and Benefit Plans.
System Parameters - Date-sensitive system parameters are maintained online to control and manage various processes within the functional areas.
Data Element/Valid Values - The Reference functional area maintains the valid values for all data elements used throughout ND MMIS.
Event Text Management - The ND MMIS Security Administrator or System Manager maintains the business event messages for ND MMIS.
Information supporting other functional areas, such as Benefit Plan Administration and Service Authorizations is stored and maintained under Rules Management. For example:
What Is Service Authorization Exception?
What Is Data Element/Valid Value?
What Is Event Text Management?
Version as of 5/16/14.
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