Audit Rules — eKlotho Nexus

Rule Name	Match Fields	Window	Claim Types	Action
Exact Duplicate	Patient, Provider, DOS, CPT, Amount	90 days	All	Deny
Partial Duplicate	Patient, Provider, DOS, CPT	30 days	837P, 837I	Pend
Same-Day Duplicate	Patient, Provider, DOS	Same day	837P	Pend
Provider Mass Duplication	Provider submits >50 identical claims in 24h	24 hours	All	Flag+Pend
Resubmission Check	Same CLM control# with different amount	180 days	All	Pend

Rule Name

Match Fields

Window

Claim Types

Action

Status

Exact Duplicate

Patient, Provider, DOS, CPT, Amount

90 days

All

Deny

Partial Duplicate

Patient, Provider, DOS, CPT

30 days

837P, 837I

Pend

Same-Day Duplicate

Patient, Provider, DOS

Same day

837P

Pend

Provider Mass Duplication

Provider submits >50 identical claims in 24h

24 hours

All

Flag+Pend

Resubmission Check

Same CLM control# with different amount

180 days

All

Pend

Rule Name	Code Set	Validation Type	Effective Date	Action
ICD-10-CM Validity	ICD-10	Code exists in active CMS ICD-10 table	2025-01-01	Reject
CPT Age/Gender Edits	CPT	CPT code appropriate for member age/gender	2025-01-01	Deny
Mutually Exclusive Codes	CPT	NCCI edit pairs — bundled procedures	2025-01-01	Pend
Revenue Code Validity	UB-04	Revenue code valid for institutional claim type	2025-01-01	Reject
Modifier Validation	CPT	Modifier applicable to base procedure code	2025-01-01	Pend

Rule Name

Code Set

Validation Type

Effective Date

Action

Status

ICD-10-CM Validity

ICD-10

Code exists in active CMS ICD-10 table

2025-01-01

Reject

CPT Age/Gender Edits

CPT

CPT code appropriate for member age/gender

2025-01-01

Deny

Mutually Exclusive Codes

CPT

NCCI edit pairs — bundled procedures

2025-01-01

Pend

Revenue Code Validity

UB-04

Revenue code valid for institutional claim type

2025-01-01

Reject

Modifier Validation

CPT

Modifier applicable to base procedure code

2025-01-01

Pend

Rule Name	COB Type	Description	Priority Order
Primary Payer Required	Header COB	Claim with secondary must include primary EOB	Birthday Rule
Medicare Secondary Payer	MSP	Apply MSP rules for employer group health plans	MSP Regulation
COB Overpayment Check	Line COB	Total payment must not exceed allowed amount	Non-Duplication
Dental COB Cap	Dental COB	Dental benefits cap total paid at UCR fee	Maintenance of Benefits

Rule Name

COB Type

Description

Priority Order

Status

Primary Payer Required

Header COB

Claim with secondary must include primary EOB

Birthday Rule

Medicare Secondary Payer

MSP

Apply MSP rules for employer group health plans

MSP Regulation

COB Overpayment Check

Line COB

Total payment must not exceed allowed amount

Non-Duplication

Dental COB Cap

Dental COB

Dental benefits cap total paid at UCR fee

Maintenance of Benefits

Audit Rules provide three categories of claim integrity checks: detecting duplicates, validating codes against reference tables, and enforcing COB (coordination of benefits) rules.

Duplicate rules use configurable match fields and lookback windows to identify claims that have already been paid. Exact match blocks, partial match pends for review.

ICD-10 codes validated against CMS annual tables
NCCI edits prevent unbundling of procedures
Age/gender edits for clinical appropriateness
Modifier rules for correct billing

Use "Test Rule" to run any rule against a sample of recent claims without applying the action. Displays match count and sample matches for validation before enabling.