|
SERIAL NUMBER
|
Procedure
|
1st Qtr
|
Per Qtr (for next 3 Qtrs)
|
Requirements while submitting for follow-up Preauth
|
Requirements while submitting for follow-up Claims
|
|
109
|
FP0109 : Gastric Varices
|
2,500
|
1,500
|
Previous Discharge Summary
|
(Clinical Evaluation-Mandatory), Endoscopy, (Coagulation Profile-Mandatory)
|
|
110
|
FP0110 : Chronic Pancreatitis with severe pain
|
2,500
|
1,500
|
Previous Discharge Summary
|
(Clinical Evaluation, Serum Pancreatic Enzymes-Mandatory)
|
|
111
|
FP0111 : Cirrhosis with Hepatic Encephalopathy
|
2,500
|
1,500
|
Previous Discharge Summary
|
(Clinical Evaluation, LFT-Mandatory), Aptt/USG Abdomen
|
|
112
|
FP0112 : Cirrhosis with Hepatic renal syndrome
|
2,500
|
1,500
|
Previous Discharge Summary
|
(Clinical Evaluation, LFT, RFT -Mandatory), Aptt/USG
|
|
