As a reminder, claims received by Independence on or after June
10, 2018, are subject to a claim editing process during
prepayment review to ensure compliance with current industry standards and
support the automated application of correct national coding principles.* By
applying these principles, we will be consistent with other payers in the
region and will apply claim payment principles that are national in scope,
simple to understand, and continue to comply with industry standard sources,
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
Please be advised that as guidelines from these sources are updated, our
claim edits will be reviewed and additional claim edits will be implemented as
applicable. In addition to the above, Medicare Advantage plans comply with the
National Coverage Determinations (NCD).
*Self-funded groups have the option to not participate in
the enhanced claim edits; therefore, prepayment review may vary by health plan.
Areas of focus
The enhanced claim editing process for our Medicare Advantage lines of
business will continue to focus on ensuring compliance with CMS coverage
policies and reporting guidelines. Medicare Advantage plans are subject to
edits that comply with clinical and correct coding criteria as defined in CMS
publications including but not limited to, the following:
- Medicare NCD Manual
- Medicare Claims Processing Manual
- Medicare NCD Coding Policy Manual and Change Report (ICD-10-CM): Clinical
Diagnostic Laboratory Services
In addition to the above, Independence enforces CMS rules on appropriate
modifier usage including, but not limited to the following:
With the implementation of these claim edits, claims submitted with
inappropriate coding will be returned or 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 return or
denial. Any returned claims must be corrected prior to resubmission. These
changes 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.
Claim review requests
We recognize there may be times when you have questions regarding the
outcome of a claim edit. As with all claim review requests, these questions
should be submitted using the Claim Investigation transaction on the
NaviNet® web portal (NaviNet Open). Claim lines that have
gone through the editor can be identified by the alpha-numeric codes and
messages beginning with E8 on your Provider EOB or Provider Remittance. Refer
to the box below for more information.
Identifying claims that went through the new claim
editor process
If your claim was affected by one of the new claim edits, 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 E8. Should your claim line contain
an E8XXX code/message, it means it was affected by the enhanced claim editor.
You can also find the E8XXX codes/messages on the Claim Status Inquiry Detail
screen in NaviNet Open. To view, hover your mouse over the service line and
select View Additional Detail. If you see an E8XXX code/message,
the line went through an edit. Only E8XXX codes/messages are part of the
enhanced claim editor. All other codes/messages are unrelated to the enhanced
claim editor. Many of these rejections can be resolved by sending a corrected
claim submission. Please ensure it follows the procedures outlined in the
Partners in Health UpdateSM article, Claim
investigation and corrected claim submission procedures.
Automated claim edits
Here are some examples of the higher volume enhanced claim edits we continue
to see:
ICD-10 coding
- Excludes 1 Notes: Claim lines reported with mutually
exclusive code combinations according to the ICD-10-CM Excludes 1 Notes will be
denied.
- When a code from range H73.0 – H73.099 (Acute myringitis) is
associated to the same claim line as a code in either the range H65 –
H65.93 (Nonsuppurative otitis media) or the range H66 – H66.93
(Suppurative and unspecified otitis media), then the claim line will be
denied.
- Laterality: The Diagnosis-to-Modifier comparison assesses
the lateral diagnosis associated to the claim line to determine if the
procedure modifier matches the lateral diagnosis. If it does not match, the
claim line will be denied.
- DIAG1: H60.332 (Swimmer's ear, left ear)
- CPT: 69000 (Drainage external ear, abscess, or hematoma; simple)
- MOD: RT
- Primary diagnosis code reporting: Certain diagnosis codes
cannot be reported as the only or primary diagnosis code on a claim. If one of
the following codes is reported as the only or primary diagnosis, then the
claim line will be denied:
- Manifestation codes
- External causes (i.e., "V – Y" codes)
- Secondary codes (e.g., Z33.1)
Evaluation and Management services
- Only one new patient visit will be allowed to the same group practice and
specialty within three years.
- Only one initial inpatient hospital visit and inpatient hospital discharge
will be allowed per hospital stay.
- Accurate reporting of initial, subsequent, and observation discharge care.
Only the admitting physician is eligible to bill the observation care.
Surgical services
- Accurate reporting of modifiers for the billing of surgical services
rendered by one or more providers.
Learn more
For questions about the claim editing process, please review our Claim edit enhancements:
Frequently asked questions (FAQ), which can also be found in the
Frequently Asked Questions archive on Independence NaviNet Open Plan Central or
in the Quick Links section on the right-hand side of this page. The FAQ will be
updated as more information becomes available.
If you still have questions after reviewing the FAQ, please send an email
to claimeditquestions@ibx.com.
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