The Enhanced Claim Editor Program supports our commitment to ensure compliance with correct coding principles as endorsed by national and regional industry sources, such as the Centers for Medicare & Medicaid Services (CMS), American Medical Association (AMA), and ICD-10-CM. The program upholds criteria and guidelines consistent with the AmeriHealth medical and claim payment policies.
AmeriHealth continues to evaluate and review industry standard sources, specialty societies, and our medical and claim payment policies to identify additional claim edits. These additional claim edits will continue to be implemented as part of the ongoing administration of this program. Areas of focus for the latest edits include:
- Compliance with the appropriate level of service (inpatient or outpatient) when reporting evaluation and management services.
- Principal diagnosis requirement of N18.6 for members receiving dialysis treatment for end-stage renal disease (ESRD).
- Enforcement of policy criteria for extracorporeal photopheresis, diabetic supplies, infusion pumps, glucose monitors, and hypoglossal nerve stimulation. To learn more about these policies, please visit the Medical and Claim Payment Policy Portal.
For additional resources on our enhanced claim editing process, please review the Enhanced Claim Editor Program: Frequently asked questions (FAQ). The FAQ includes additional information on our automated claim edits and coding validator reviews.