Rules Engine Management

Flag claims where billing NPI taxonomy code does not match NPPES registry

Block 837P claims for CPT 90834–90837 to Aetna without pre-authorization number in field 2300.REF

Require Modifier 26 or TC on technical/professional component codes when billed together to UHC

Require highest specificity ICD-10 code — reject unspecified codes when more specific variant exists

Cross-reference claim procedure against Medicaid frequency tables before submission

ML model detects likely duplicate submissions based on patient ID, service date, and procedure within 30-day window

Validate POS codes against approved CMS POS table and flag invalid/deprecated codes

Flag potentially non-covered Medicare services without ABN documentation flag in claim notes