| 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 |
|---|---|---|---|---|---|
| 2 | FP0002 : Portocaval Anastomosis | 4,000 | 2,000 | Previous Discharge Summary | (LFT, Clinical Evaluation, USG ,Doppler-Mandatory) |
| 4 | FP0004 : Splenorenal Anastomosis | 4,000 | 2,000 | Previous Discharge Summary | LFT, (Doppler, CBC including peripheral smear-Mandatory) |
| 6 | FP0006 : Spleenectomy + Devascularisation + Spleno Renal Shunt | 4,000 | 2,000 | Previous Discharge Summary | (LFT, Clinical Evaluation, Doppler, CBC including peripheral smear-Mandatory) |
| 5 | FP0005 : Warren Shunt (Next 3 Qtrs) | 4,000 | 2,000 | Previous Discharge Summary | (LFT, Clinical Evaluation, Doppler, CBC including peripheral smear-Mandatory) |
| 7 | FP0007 : Lap - Pancreatic Necrosectomy | 3,500 | 1,500 | Previous Discharge Summary | Serum Pancreatic Enzymes, Tolerance To Food, (Blood Glucose Levels, Clinical Evaluation-Mandatory) |
| 8 | FP0008 : Pancreatic Necrosectomy (open) | 3,500 | 1,500 | Previous Discharge Summary | Serum Pancreatic Enzymes, Tolerance To Food, (Blood Glucose Levels, Clinical Evaluation-Mandatory) |
