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Bill edit validation

clsBillEditor.EditBill runs the bill-header, diagnosis, and procedure rule groups in order, stopping as soon as any group produces a fatal error. Unlike the downstream audit engine, most of its rules only append audit messages to the bill; a small number of rules return False to EditBill and are treated as fatal, aborting the audit before any service-level work begins.

Field Value
Operation ID OP-AA-02
Trigger BillAuditEngine.AuditBill calls clsBillEditor.EditBill(Bill) after GenerateAuditData succeeds
Inputs Populated clsBillAudit (header fields, diagnoses, procedures, resolved Claim and BillingProvider)
Outputs Boolean pass/fail (ErrorCount = 0); audit messages appended to the bill via GenerateError/GenerateWarning; broken rules propagated to BillAuditEngine
Primary components clsBillEditor.EditBill, clsBillEditor.AddBusinessRules
Entry point Business\SAIF.Business.Claim.Bill.AutomatedAudit\AuditUtilities\clsBillEditor.vb

Steps

  1. Header group. Start the "Header" rule group, clear broken rules, and run CheckRules("Header") (BR-003):
  2. val_fe_CheckReceiptDateWithDOI — fatal: if Bill.MailRoomReceivedDate < Bill.Claim.InjuryDate, generate error "Bill data - received date is before date of injury".
  3. val_fe_CheckForNCE — fatal: if Bill.Claim.IsNCE, generate error "Bill data - claim is for non-compliant employer".

  4. val_fe_ClaimExists — fatal: if Bill.ClaimID = 0 or the claim is invalid, generate error "Invalid claim number" (with broken-rule data for Claim/ClaimNumber/ClaimCheckValue). If the claim is void and replaced, it re-resolves via AuditEngine.GetClaim(Claim.ReplacedClaimID) and errors with "The merged claim is invalid" if the replacement is also invalid; otherwise it updates Bill.Claim to the resolved claim.

    Origin: The underlying claim lookup is implemented by Retrieve claim summary data in SAIF.Business.View.Claim. - val_fe_ValidateBillingProvider — fatal: for a non-zero ProviderLocationID, requires a valid BillingProvider; if a bill-level ProviderTaxID is present, it must appear in the provider's tax-ID list or the rule fails with "Bill data - invalid billing provider location". A zero ProviderLocationID is only an error unless BillType = WorkerReimbursement.

    Origin: Bill.BillingProvider is resolved via Retrieve provider location in SAIF.BOF.Business.View.Provider. - val_fe_ValidAdjuster — fatal: if Bill.Claim.AdjusterMailID is blank, generate error "Bill data - missing responsible adjuster". - val_me_BillTypeRequired — message-only: for InpatientHospital/OutpatientHospital bills, the UBBillTypeCode must be at least 4 characters with numeric, non-zero characters in positions 2 and 3, else generate error "Bill data - invalid type of bill" (this rule always returns True, so it never aborts the group by itself). - val_me_MissingAdmissionDate / val_me_MissingStatementFromDate — for InpatientHospital bills, generate errors "Bill data - missing admit date" / "Bill data - missing statement from date" when the respective date is null. - val_me_ValidAdmissionDate — for InpatientHospital bills, error "Bill data - admit date after received date" if MailRoomReceivedDate < AdmissionDate. - val_me_ValidDischargeDate — for InpatientHospital bills, error "Bill data - discharged before admitted" if DischargeDate < AdmissionDate. - val_me_ValidStatementFromDate / val_me_ValidStatementThruDate — for InpatientHospital bills, error if the statement-from date precedes the admission date, or the statement-thru date precedes the statement-from date. - val_me_ValidStatementFromThruDateSpan — if the bill has diagnoses (or its billing provider type requires them), error "Bill data - Statement from and thru dates cannot span over 10/01/15." when the from/thru span crosses the hard-coded ICD-10 cutoff date of October 1, 2015, unless the bill is an inpatient institutional bill with a UB bill type prefix of 011, 018, 021, or 032. - val_w_FederalClaimCheck — warning-only: if Bill.Claim.IsFederal, generate warning "Bill data - bill is for federal claim". - If ErrorCount > 0 after the Header group, EditBill returns False immediately — Diagnoses and Procedures are never checked. 2. Diagnoses group. Start the "Diagnoses" group, clear broken rules, and run CheckRules("Diagnoses"). Registered diagnosis rules (val_me_ValidDiagnosisCode) generate an error per diagnosis whose code does not resolve, and a separate error "Bill data - no diagnosis code" when the billing provider type requires a diagnosis and none is present. If ErrorCount > 0, return False immediately. 3. Procedures group. Start the "Procedures" group, clear broken rules, and run CheckRules("Procedures"). Registered procedure rules (val_me_ValidProcedureCode) generate an error per procedure whose service does not resolve. If ErrorCount > 0, return False. 4. Return overall result. If all three groups completed without accumulating errors, return True (ErrorCount = 0).

Process flow

flowchart TD
    Start([EditBill invoked]) --> Header[Header rule group:<br>DOI/NCE/claim/provider/adjuster,<br>admission/statement dates]
    Header --> HErr{ErrorCount > 0?}
    HErr -->|Yes| Fail([Return False])
    HErr -->|No| Diag[Diagnoses rule group]
    Diag --> DErr{ErrorCount > 0?}
    DErr -->|Yes| Fail
    DErr -->|No| Proc[Procedures rule group]
    Proc --> PErr{ErrorCount > 0?}
    PErr -->|Yes| Fail
    PErr -->|No| Pass([Return True])

Failure and edge-case behavior

  • Only the Header-group rules listed as fatal above can stop the pipeline; every other listed rule always returns True from its function even when it records an error message, so EditBill only fails when a Header-group fatal rule fires or a later group accumulates any generated error.*
  • val_me_BillTypeRequired explicitly Return True even on a detected invalid bill type, so an invalid UB bill type code produces an audit message but does not, by itself, abort the Header group.
  • The claim-merge resolution inside val_fe_ClaimExists can silently repoint Bill.Claim to a different claim mid-validation; subsequent rules in the same group see the updated claim.
  • The October 1, 2015 ICD-10 span cutoff and its four UB bill-type-prefix exceptions are hard-coded in clsBillEditor, so any future exception codes require a code change rather than configuration.

Note: Statements marked with * were inferred from code structure, naming conventions, or contextual evidence where direct confirmation was not available in source artifacts.

Sources

  • Business\SAIF.Business.Claim.Bill.AutomatedAudit\AuditUtilities\clsBillEditor.vb