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You’re an HMO director. You would like to ensure that you managed care plan is meeting industry standards. What’s one way that you can do this?

You work for a third-party payer performing medical records review. Your job is to match codes that were submitted on the claim to documentation in the medical record. You notice that a code has been input for colonoscopy procedure, but you don’t see the procedure report anywhere in the record. As the third-party payer representative, what will your action are regarding the code that was submitted on the claim form?

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