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Service edit and adjustment

clsServiceEditor runs two passes per billed service line. EditService performs lightweight, non-adjusting validation and logging. For any service still flagged for re-audit (ReauditCode = "R"), AdjustService first normalizes the audited service (UpdateAuditService) and then runs two further rule groups that can generate full-charge disallowance adjustments and force the service out of the audit (ReauditCode = "X").

Field Value
Operation ID OP-AA-03
Trigger BillAuditEngine.AuditBill calls clsServiceEditor.EditService(Bill, Service) for every service, then AdjustService(Bill, Service) for services where Service.IsAuditable
Inputs clsBillAudit, clsBillAuditService for the current line (billed service + audited service + cached provider/NDC/fee state)
Outputs Boolean pass/fail (ErrorCount = 0) per call; normalized audited-service fields; ReauditCode transitions to "X" on disallowance; full-charge adjustments; audit messages
Primary components clsServiceEditor.EditService, clsServiceEditor.AdjustService, clsServiceEditor.UpdateAuditService
Entry point Business\SAIF.Business.Claim.Bill.AutomatedAudit\AuditUtilities\clsServiceEditor.vb

Steps

  1. EditService — set context and log. Store the current Bill, BillAuditService, and AuditedService. Log the service date and either the NDC code (pharmacy services) or the service code/type (all other services).
  2. EditService — run #VALIDATE_SERVICE_LINE#. Clear broken rules and execute the rule group (BR-004):
  3. cse_ServiceDateExists — if the service date is null: error "{0} Invalid service date" (BR-008) and set ReauditCode = "X".
  4. cse_ServiceDate_ReceivedDate — warning-only: warn "{0} Service date is after received date" if the service date is after the mailroom received date.
  5. cse_ServiceDate_ServiceEndDate — if ServiceEndDate < ServiceDate: error "{0} Service through date is before from date" (BR-009).
  6. cse_ValidSecondaryServiceCode — if a secondary service code is present but does not resolve: error "{0} Invalid secondary service code" (BR-013).
  7. ba_ValidatePharmacyPrescriberID — if PrescribingProviderCode = "01" (NPI qualifier) and the prescriber ID is not exactly 10 numeric digits: error "Prescriber ID must be 10 numeric digits for NPI qualifier ({0})." (BR-014).
  8. cse_ServiceTypeCode_IsRevenueCode — for InpatientHospital/OutpatientHospital bills, if neither the primary nor secondary service type is a revenue code: error "{0} Revenue code required" (BR-015).
  9. Return ErrorCount = 0 to the caller.
  10. AdjustService — normalize (UpdateAuditService).
  11. Reset the service wrapper's FeeScheduleCode to blank and clear TotalAdjustmentAmount, FeeScheduleAmount, and MCO eligibility/ID/admin-fee/rate.
  12. If ReauditCode = "R" and a charge amount exists: set AllowedAmount = ChargeAmount and OriginalBillCode = "O" as the starting point before adjustment.
  13. Normalize NDC/service-code precedence: if an NDC is already present, clear ServiceCode; if the service type is Pharmacy and the resolved national drug is valid, normalize NationalDrugCode and clear ServiceCode.

  14. If a secondary service code exists but has not resolved, attempt to resolve its type via the service reference lookup, using "U" (unknown) if it still does not resolve.

    Origin: Service type resolution is implemented by Service reference lookups in SAIF.Business.Claim.Bill. - If the resolved service requires nurse review, set BillAuditService.IsNurseReviewRequired = True. - Log when a service description could not be found for the service date. 4. AdjustService — run ADJUST_SERVICE#. Clear broken rules and execute the rule group (full-charge disallowance adjustments set ReauditCode = "X" and stop the service from further audit): - cse_ServiceDate_InjuryDate — if the service date precedes the claim's injury date: message "{0} Adjustment SE-disallow service before date of injury", full-charge SE adjustment (BR-010). - cse_ServiceDate_ReimbursementExpired — for non-federal Worker Reimbursement bills received more than 730 days after the service date: message "{0} Adjustment FN-disallow worker reimbursement", full-charge FN adjustment (BR-011). - cse_ServiceLocation_ValidPlaceOfService — for service types other than Ambulance, Dental, Pharmacy, or Worker Reimbursement, if the location is missing or inactive: message "{0} Service location is invalid or does not exist", full-charge TU adjustment (BR-012). - cse_ServiceQuantity_MinimumInterpreterMileage — for D0041 below the era-specific minimum billed quantity (60.01 units before 4/1/2012, 15 units on/after): message "{0} Adjustment IC-disallow service", full-charge IC adjustment (BR-016). - cse_ProviderServiceCode_ValidateService — dispatches by service type: - Pharmacy (ValidatePharmacyServiceType): if the national drug is valid, resolves NDC pricing effective on the service date; if pricing is missing, full-charge FA adjustment and ReauditCode = "X"; otherwise normalizes NationalDrugCode and blanks ServiceCode. - Non-pharmacy (ValidateNonPharmacyServiceType): if the service resolves, clears NationalDrugCode; if it does not resolve, message "{0} Adjustment FF-disallow unknown service code", full-charge FF adjustment. - ba_ValidatePharmacyInfo — for Pharmacy provider type PH bills missing prescriber ID, Rx-written date, or prescriber last name: message "Invalid pharmacy information ({0}).", full-charge GX adjustment (BR-017). - ba_ValidatePharmacyRXDate — for Pharmacy provider type PH bills where the Rx-written date is after the service date: message "Date rx written cannot be after the service date' ({0}).", full-charge GX adjustment (BR-017). - Full-charge adjustments are created via the shared GenerateAdjustment helper on clsBillAuditUtility, which caps the requested amount to the current AllowedAmount, logs the request/cap, and updates AllowedAmount/TotalAdjustmentAmount when the resulting amount is non-zero. 5. AdjustService — re-run #EDIT_SERVICE# if still auditable. If the service is still ReauditCode = "R" after the adjustment rules above (i.e., it was not disallowed), re-execute the #EDIT_SERVICE# group described in step 2 so validation reflects any normalization performed in step 3. 6. Return overall result. AdjustService returns ErrorCount = 0.

Process flow

flowchart TD
    Start([Per-service loop in AuditBill]) --> Edit[EditService:<br>#VALIDATE_SERVICE_LINE# rules]
    Edit --> Auditable{Service.IsAuditable?<br>ReauditCode = R}
    Auditable -->|No| Skip([No adjustment pass])
    Auditable -->|Yes| RemovePrior[Remove prior adjustments]
    RemovePrior --> Normalize[UpdateAuditService:<br>reset fee/MCO fields,<br>resolve NDC/service type]
    Normalize --> AdjustRules[ADJUST_SERVICE# rules:<br>DOI, reimbursement window,<br>place of service, mileage minimum,<br>service code, pharmacy info]
    AdjustRules --> Disallowed{Disallowed?<br>ReauditCode = X}
    Disallowed -->|Yes| Done([Service excluded from further audit])
    Disallowed -->|No| ReEdit[Re-run #EDIT_SERVICE#]
    ReEdit --> Done2([Return ErrorCount = 0])

Failure and edge-case behavior

  • EditService never itself sets ReauditCode = "X" except through cse_ServiceDateExists; most of its other checks are message-only and always allow the caller to proceed to AdjustService.*
  • Once a service is disallowed in the ADJUST_SERVICE# group (ReauditCode = "X"), it is excluded from #EDIT_SERVICE# re-validation and from all downstream steps of Bill audit rule execution that require ReauditCode = "R".
  • GenerateAdjustment silently caps an adjustment request larger than the current AllowedAmount, logging "Adjustment reduced to allowed." rather than raising an error — a caller expecting the full requested disallowance amount will not see it if the allowed amount was already reduced by an earlier step.
  • Because UpdateAuditService clears prior MCO/fee-schedule state on every adjustment pass, any MCO determination performed before this service's adjustment for the same run must be re-applied afterward by MCO determination and Bill audit rule execution.*

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\clsServiceEditor.vb
  • Business\SAIF.Business.Claim.Bill.AutomatedAudit\AuditUtilities\clsBillAuditUtility.vb
  • Business\SAIF.Business.Claim.Bill.AutomatedAudit\clsBillAuditService.vb