As previously communicated, IBC is in the process of transitioning to a new
claims processing platform, which will offer greater capabilities, increased
flexibility in benefit design, and enhanced functionalities for an improved
overall customer experience.
As a result of this transition, there will be changes to the enforcement of
medical and claim payment policy. IBC's policies will be enforced on both the
current and new claims processing platforms; however, some differences in
claims processing and outcomes between the two systems may occur depending on
when members are migrated, as described in the following.
[
]Multiple Surgical Reduction Guidelines[
]
For professional providers, the calculation method used in applying Multiple
Surgical Reduction Guidelines on the new platform will be based on the
procedure reported "Allowed Amount" and not the derived "Surgical Ranking,"
which is used on the current platform.
Please review the Policy Notification for Claim Payment Policy #11.00.10:
Multiple Surgical Reduction Guidelines, which will be available on the [
Medical
Policy portal] after August 2, 2013. This policy, which will become
effective November 1, 2013, has been updated to reflect this change and to
disclose the different calculations being used within the two claims platforms.
[
]Clinical Relationship Logic[
]
Clinical Relationship Logic, or Code to Code Edits (e.g., incidental, integral,
component, mutually exclusive, etc.), applied to services reported on a
CMS-1500 claim form or electronic equivalent may differ depending on whether
the claim is processing on the current or new platform. The McKesson
ClaimCheck[
®] product will not be used on the new platform.
Clinical Relationship Logic, which is based on national standards, will be
applied to claims for IBC commercial members processed on the new platform.
Once IBC's Medicare Advantage HMO and PPO products are migrated to the new
platform, Medicare's NCCI edits will be applied to IBC's Medicare Advantage HMO
and PPO products.
Clinical Relationship Logic applied to professional claims will be disclosed
according to the following:
On the current platform. Clinical Relationship Logic applied to professional
claims processed on the current platform will continue to be disclosed through
IBC's current Clear Claim Connection[
TM] tool, which is available on
the NaviNet[
®] web portal or on the [
]IBC[] website.
On the new platform. Clinical Relationship Logic applied to professional claims
processed on the new platform will be made available on the IBC [
]Medical Policy[] website.
For the most up-to-date information about our transition to a new claims
processing platform, we encourage you to frequently visit our [
]Business
Transformation[] website. At this one central location, we will continue to
provide more detailed information as it becomes available about our Business
Transformation.
[
NaviNet® is a registered trademark of
NaviNet, Inc., an independent company.
]