Appropriateness of treatment provided is determined by developing criteria that if unmet will prompt further investigation of a claim which are also called:

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These are called edits, which are rules programmed into computer systems used to process medical claims. They identify certain criteria that need to be met for a particular treatment or service to be considered appropriate, and if these criteria are not met, the claim will be flagged for further review. This helps ensure that insurers are only paying for services that are medically necessary and appropriate for the patient's condition.

Appropriateness of Treatment Provided Is Determined by Developing Criteria That