Business Rules

Rule 1: High-Value Claims Review Business Logic: Any claim exceeding $50,000 requires manual review

Rule 2: Emergency Room Validation Business Logic: Emergency room claims (POS 23) must have appropriate emergency diagnosis codes (head injury S06 or heart attack I21)

Rule 3: Inpatient Admission Codes Business Logic: Inpatient claims must include one of the standard admission procedure codes

Rule 4: Complex Combination Rule Business Logic: Professional claims over $10,000 in office settings are handled differently based on whether they're preventive care (which should be rejected) or other services (which need review)

Rule 5: Outpatient Surgery Validation Business Logic: Outpatient surgical procedures (POS 24) should not have amounts below $100, which likely indicates a billing error

All business rules combined