AmeriHealth has a variety of programs in place dedicated to ensuring claims are billed accurately and in accordance with industry standard coding principles, including:
- 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
In order to verify all providers are adhering to AmeriHealth claim payment policies and the industry standard source guidelines listed above,
as of February 1, 2021, the AmeriHealth Enhanced Claim Editor Program includes coding validation performed by a team of Registered Nurses and Certified Professional Coders that will review select professional and outpatient facility claims in conjunction with patient claim history.
Areas of focus
The AmeriHealth coding validation program focuses on the areas listed below:
- NCCI edits with modifier override allowed and an override modifier is on the claim line (excluding Modifier 25)
- AMA unbundling rules
- Multiple providers billing the same procedure, for the same member, on the same day
With the implementation of coding validation, claim lines found to be submitted with inappropriate coding may be denied. Providers will be notified via the Provider Explanation of Benefits (EOB) (professional) or Provider Remittance (facility), which will include a reason code for the claim line denial. This program should have little or no impact to billing practices for submission of claims that are in accordance with the guidelines listed above and national industry-accepted coding standards.
Identifying claims that went through the coding validator process
If your claim was affected by one of the coding validation reviews, the edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB or Provider Remittance. Unique alpha-numeric codes and messages have been created that begin with E819X. Should your claim line contain an E819X code/message, it means it was affected by the coding validation review. You can also find the E819X codes/messages on the Claim Status Inquiry Detail screen on the NaviNet® web portal (NaviNet Open).* To view, hover your mouse over the service line and select View Additional Detail. If you see an E819X code/message, the line went through coding validation. Only E8XXX codes/messages are part of the enhanced claim editor, which will include coding validation as of February 1, 2021. All other codes/messages are unrelated to the enhanced claim editor.
Request for coding validator claim review
While you may use NaviNet Open* to view detailed information on a coding validator E819X denial, clinical information is needed in order to dispute the denial. Please ensure that all applicable medical records, notes, and tests are submitted along with a cover letter explaining the reason for the dispute.
To facilitate a review, submit the documents listed above via:
AmeriHealth
Claim Coding Validation
1901 Market Street
Philadelphia, PA 19103
*If your organization has transitioned to use PEAR Practice Management on the Provider Engagement, Analytics & Reporting (PEAR) portal, you can use the Claim Search transaction to view this information.
Additional information and self-service training materials are available in the
PEAR Help Center.
For more information
For questions about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ).
Note: The FAQ will be updated as more information becomes available.
If you still have questions after reviewing the FAQ, please send an email to
ahclaimeditquestions@amerihealth.com.
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