| SERIAL NUMBER | Procedure | 1st Qtr | Per Qtr (for next 3 Qtrs) | Requirements while submitting for follow-up Preauth | Requirements while submitting for follow-up Claims |
|---|---|---|---|---|---|
| 109 | FP0109 : Gastric Varices | 2,500 | 1,500 | Previous Discharge Summary | (Clinical Evaluation-Mandatory), Endoscopy, (Coagulation Profile-Mandatory) |
| 110 | FP0110 : Chronic Pancreatitis with severe pain | 2,500 | 1,500 | Previous Discharge Summary | (Clinical Evaluation, Serum Pancreatic Enzymes-Mandatory) |
| 111 | FP0111 : Cirrhosis with Hepatic Encephalopathy | 2,500 | 1,500 | Previous Discharge Summary | (Clinical Evaluation, LFT-Mandatory), Aptt/USG Abdomen |
| 112 | FP0112 : Cirrhosis with Hepatic renal syndrome | 2,500 | 1,500 | Previous Discharge Summary | (Clinical Evaluation, LFT, RFT -Mandatory), Aptt/USG |
