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Clinical Editing Claims Processing Enhancement for All Lines of Business

Audience: Participating Providers, Hospitals and Facilities

Based on feedback from our participating providers, we are pleased to share advance notice of a new enhancement to claim processing. Later this year, we will move post payment audit recovery for Administrative Policy 31 – Related Services, to a prepayment clinical edit. This update pertains to all lines of business.

This update will allow for more accurate editing related to the code descriptors of a procedure, such as frequency limitations.  We will provide additional information on this update prior to implementation.

Important Reminders:

  • A service that has already been reimbursed can cause a service on a subsequent claim to be disallowed, regardless of which service is considered primary. As a result, you may see a difference in how an edit is applied when services are on the same claim versus on different claims. To avoid out-of-sequence editing:
    • Services performed on the same day should be submitted on the same claim
    • Services performed on different days may continue to be submitted on separate claims, but must be received and processed in date of service order
  • To dispute a clinical editing denial, a Clinical Editing Review Request form is no longer required. Simply correct your claim electronically on our website, > Claims & Payments tab.
  • Administrative and clinical editing policies are accessible on our website, > Policies & Guidelines tab (Secure log in required).

If you have questions, please contact your Provider Relations representative.

Thank you for the quality care and service you provide to our valued members.

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