​Enhanced Claim Editor Program: Frequently asked questions

November 2, 2020

This FAQ was revised on January 18, 2022.

The following frequently asked questions (FAQ) were developed to provide more detailed information about the implementation of a claim editing process that will ensure compliance with current industry standards and support the automated application of correct coding principles.* By applying these principles, AmeriHealth will be consistent with other payers in the region, follow principles that are national in scope, that are simple to understand, and comply with industry standard sources.

*Self-funded groups have the option to not participate in the enhanced claim edits; therefore, prepayment review may vary by plan. (Added 4/24/2018)

This FAQ document will be updated as additional information becomes available.

1. What changes is AmeriHealth making to the claim editing process? (Revised 11/2/2020)

AmeriHealth is implementing enhancements to its claim editing process during prepayment review that will follow national industry standards from sources that we currently use such as:

  • Centers for Medicare & Medicaid Services (CMS) standards such as the National Correct Coding Initiative (NCCI), modifier usage, and global surgery guidelines
  • American Medical Association (AMA) Current Procedural Terminology (CPT®) coding guidelines
  • CMS HCPCS LEVEL II Manual coding guidelines
  • ICD-10 Instruction Manual coding guidelines

To verify all providers are adhering to the AmeriHealth claim payment policies and the industry standard source guidelines listed above, starting February 1, 2021 , the AmeriHealth Enhanced Claim Editor Program will include coding validation performed by a team of Registered Nurses and Certified Professional Coders from our contracted vendor that will review select professional and outpatient facility claims in conjunction with patient claim history.

DME and P&O billing providers

AmeriHealth expanded the enhanced claim editing process to include additional rules specific to durable medical equipment (DME) and prosthetic and orthotic (P&O) billing providers effective for claims processed as of August 1, 2019. 

The industry standard sources specific to DME and P&O include the following:

  • National and Regional Centers for Medicare & Medicaid Services (CMS) policy
  • Durable Medical Equipment Regional Carries (DMERC) Manual
  • CMS HCPCS LEVEL II Manual coding guidelines
  • Medicare Claims Processing Manual

In addition to the above, AmeriHealth enforces CMS rules on modifier usage including the following modifiers:

  • A1 – A9, GY
  • AU, AV, AW, and AX
  • CG
  • FA – F9 and TA – T9
  • K0 –​ K4
  • KS, KX
  • KX, GA, or GZ
  • NU, UE, and RR
  • RT/LT

For detailed requirements related to these modifiers, please see this docum​ent.

Injectable drugs and biological agents

AmeriHealth expanded the enhanced claim editing process to include additional rules specific to various injectable drugs and biological agents effective for claims processed as of September 1, 2019. 

The industry standard sources specific to injectable drugs and biological agents are:

  • The manufacturer’s package insert (primary source: Food and Drug Administration [FDA]-approved indications)
    • Other compendia references include, but not limited to:
      • Thomson Micromedex® (DRUGDEX®, DrugPoints®)
      • National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium®
      • American Hospital Formulary System (AHFS®) Drug Information®
      • Elsevier Gold Standard Clinical Pharmacology
  • ICD-10 Instruction Manual coding guidelines
  • Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual

The enhanced claim editing process for injectable drugs and biological agents focuses on the following areas:

  • The diagnosis code(s) billed are consistent with the FDA-approved indications and approved off-label indications. If the ICD-10 code billed on the claim does not match the approved indication, the claim may reject.
  • The diagnosis code(s) billed are consistent with the ICD-10 Instruction Manual coding guidelines.
  • The dosage and frequency of administration is appropriate for the diagnosis for which it is being used.
  • The administration code(s) and hydration services are appropriately reported.

Professional reporting of hospital observation care

Observation care is a well-defined set of specific, clinically appropriate services that include short-term treatment, assessment, and reassessment, which are furnished to a patient while a decision is being made to determine if the patient will require admission as an inpatient or can be discharged.

  • Initial observation care codes. Initial observation care codes are for all care rendered by the ordering physician on the date the patient’s observation services began. Procedure codes 99218, 99219, and 99220 are per day codes and are only eligible to be reported once per day per patient by the ordering physician. All other physicians who provide services, evaluations, or consultations while the patient is receiving hospital observation care must bill the appropriate outpatient service codes.
  • Subsequent observation care codes. Similar to initial observation care codes, subsequent observation care codes are for all care rendered by the treating physician of record on the day other than the initial observation care or discharge date. Procedure codes 99224, 99225, and 99226 are per day codes. Only the treating physician of record is eligible to report observation care for the patient. All other physicians who provide services, evaluations, or consultations while the patient is receiving observation care must bill the appropriate outpatient service codes.
  • Example. A hospitalist orders observation services and then asks another physician to evaluate the patient. Only the hospitalist may bill the initial and subsequent observation care codes. The other physician who evaluates the patient must bill the appropriate new or established office or other outpatient visit code.

ICD-10-CM Excludes Notes

According to the ICD-10-CM Official Guidelines for Coding and Reporting, there are two types of Excludes Notes: Excludes1 and Excludes2. Each type has a different definition for use, but they are both similar in that they indicate that codes excluded from each other are independent of each other. For more information and the specific definition of each type of note, please see the previous article, ICD-10 in Action: Coding guidelines and conventions – Ex​cludes1 and Excludes2 notes

AmeriHealth reinstated a portion of the Excludes Notes edits for claims received on or after October 30, 2018. As we continue to align with industry standards, additional ICD-10-CM Excludes Notes edits will be applied and claims that are not billed in compliance with the ICD-10-CM Excludes1 and Excludes2 notes billing rules will be rejected.  If you have been submitting claims based on the ICD-10-CM industry standard coding guidelines as instructed in our various enhanced claim editor communications, you will not see any impacts. However, if your claims submissions have not been incompliance with these billing rules, please be advised that you may see an increase in rejections and/or claim denials. You can identify an Excludes Notes on your Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility) billing error when the line is rejected with the reason code E8038.

2. Why is AmeriHealth making these changes?

The AmeriHealth claim editing process enhances our ability to administer payment rules consistent with national standards established by CPT, CMS, and specialty societies. These changes should have little or no impact on practices billing in accordance with these guidelines.

3. When will these updates take place? (Revised 11/2/2020)

Claims received by Independence on or after June 10, 2018, are subject to our claim editing process during prepayment review and the review applies to professional claims and to outpatient facility claims (where applicable).

4. How have providers been notified about the new claim editing process? (Revised 2/22/2021)

On March 9, 2018, April 24, 2018, May 15, 2018, June 11, 2018, November 14, 2018, December 14, 2018, and November 20, 2019, the implementation of a new claim editing process was announced to providers via:

  • AmeriHealth Provider News Center;
  • AmeriHealth NaviNet® web portal (NaviNet Open) Plan Central in a message containing a summary.

On May 15, 2018, and August 17, 2018, a Provider Bulletin was sent via email to participating hospitals as a reminder of the alignment of enhanced claim edits with industry standard billing rules.

DME and P&O providers

On April 15, 2019, June 12, 2019, and August 5, 2019, the expansion of the claim editing process to include DME and P&O providers was announced to providers via:

On April 15, 2019, a Provider Bulletin was sent to participating DME and P&O providers as a notification of the expansion of the claim editing process.

Injectable drugs and biological agents

On June 3, 2019, August 5, 2019, and September 4, 2019, the expansion of the claim editing process to include various injectable drugs and biological agents was announced to providers via:

On June 3, 2019, a Provider Bulletin was also sent to providers as a notification of the expansion of the claim editing process.

Professional reporting of hospital observation care

On January 8, 2020, the enhanced claim editing process for professional reporting of hospital observation care claims was announced to providers via:

ICD-10 CM Excludes Notes

On April 3, 2020, information around CID-10 Excludes Notes was announced to providers via:

Coding validation program

On November 2, 2020, information around a new coding validation program was announced to providers via:

On February 4, 2021, information on how to request a claim review was announced to providers via our Provider News Center.

On February 22, 2021, information about the Coding Validator review and the reporting of manual therapy and chiropractic manipulative treatment (CMT) was announced to providers via our Provider News Center.

5. How will these changes affect the AmeriHealth claim system?

These enhancements will facilitate prepayment review and claim auto-adjudication in alignment with national industry coding standards versus retrospective claim audit adjustments.

6. Will all claims be affected?

No, not all claims will be affected by this claim editing process. In fact, most claims that are billed according to accepted standards will pass through our claim payment system without any coding issue.

7. Do these changes affect fee schedule rates?

No, these changes do not affect the fee schedule payment rates.

8. Can I expect claim delays due to the claim editing process?

AmeriHealth will continue to meet or exceed claims processing timelines as required by applicable law.

9. Will the Provider EOB or Facility Remittance change?

No, this process will not affect the format of the Provider EOB or Facility Remittance.

10. How can I tell if my claim has gone through the enhanced claim edit? (Revised 1/18/2022)

The edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB or Facility Remittance. Unique alpha-numeric codes and messages have been created that begin with E8. When the claim line contains an E8XXX code/message, it means it was affected by the enhanced claim editor. You can also find the E8XXX codes/messages within PEAR Practice Management by using the Claim Search transaction. Only E8XXX codes/messages are part of the Enhanced Claim Editor Program. All other codes/messages are unrelated to the program.

11. Why do I already see these types of denials in my claims experience? (Revised 5/15/2018)

While you may already see some claim outcomes that indicate denials for edits such as post-operative care or add-on codes not payable, our current claim payment system editing has been limited, requiring expansive back-end audits. This enhancement will allow for a more consistent and comprehensive prepayment review application of national coding standards. An additional example is that our system capabilities have been limited to applying the NCCI component tables. The enhanced claim editing process will look across the NCCI policy manual, not just the component tables. Information on NCCI edits is available on the CMS website.

12. Why am I receiving an enhanced claim editor denial when the service billed is preauthorized? (Revised 6/3/2019)

An authorization may not supersede a claim line from receiving an edit. For example, if an authorized injectable drug or biologic agent is billed with an ICD-10 diagnosis code(s) that is not consistent with the approved indication, your claim may still be denied.

13. What is the difference between Automated Edits and Coding Validator? (Added 1/18/2022)

  • Automated Edits are systematic edits automatically applied based on industry standard correct coding rules.
  • Coding Validator reviews are denials based on a thorough review of the claim coding by a Registered Nurse who is also a Certified Professional Coder (CPC) against pertinent information billed on the claim and the claims in the member's history. The majority of reviews focus on whether this information indicates appropriate billing of modifiers such as 59, XE, XS, XU, 79, etc.

14. How do I identify an Automated Enhanced Edit versus a Coding Validator denial? (Added 1/18/2022)

A Coding Validator edit claim line will contain an E819X denial, all other E8XXX codes/messages are Automated Edits. You can also find the E8XXX codes/messages within PEAR Practice Management by using the Claim Search transaction. From the Claim Details screen, if there is an E8XXX code, a Claim Editor link will appear. This link will show further detail in the rationale and description. If you see an E819X code/message, the further detail in the Rationale and Description section will also state “per Coding Validation review". This is an additional indication that the edit is related to Coding Validation and is not an Automated Edit. Only E8XXX codes/messages are part of the Enhanced Claim Editor program. All other codes/messages are unrelated to the program.

15. How do I request an automated edit claim review? (Revised 1/18/2022)

Providers should submit a Claim Investigation through the Claim Search transaction in PEAR Practice Management to ask questions or request an adjustment. Please provide any additional information, including reference claim numbers or corrections submitted to support your request, for reconsideration for approval.

16. How do I request a Coding Validator claim review? (Revised 8/31/2021)

Coding Validator E819X denials require clinical information to be submitted to dispute the denial. The clinical information should include all applicable medical records, notes, and tests along with a cover letter explaining the reason for the dispute.

To facilitate a review, submit the documents listed above via:

  • Mail:

AmeriHealth
Claim Coding Validation
1901 Market Street
Philadelphia, PA 19103​

Learn more

Review this Automated claim edits document for examples of the higher volume enhanced claim edits we continue to see.

If you cannot find the information you are looking for here and have further questions, please email us at ahclaimeditquestions@amerihealth.com.

The PEAR Practice Management application on the Provider Engagement, Analytics & Reporting (PEAR) portal replaced the NaviNet web portal as of July 1, 2021. Additional information and self-service training materials for the PEAR portal are available in the PEAR Help Center.

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