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Claim edit enhancements: Frequently asked questions 

March 9, 2018    



This FAQ was revised on August 5, 2019.


The following frequently asked questions (FAQ) were developed to provide more detailed information about the implementation of a claim editing process that will ensure compliance with current industry standards and support the automated application of correct coding principles.* By applying these principles, Independence Blue Cross (Independence) will be consistent with other payers in the region, follow principles that are national in scope, that are simple to understand, and comply with industry standard sources.

*Self-funded groups have the option to not participate in the enhanced claim edits; therefore, prepayment review may vary by plan. (Added 4/24/2018)

Note: This FAQ document will be updated as additional information becomes available.

1. What changes is Independence making to the claim editing process? (Revised 6/3/19)

Independence is implementing enhancements to its claim editing process during prepayment review that will follow national industry standards from sources that we currently use such as:

  • 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

DME and P&O billing providers

Independence will be expanding the enhanced claim editing process to include additional rules specific to durable medical equipment (DME) and prosthetic and orthotic (P&O) billing providers effective for claims processed beginning August 1, 2019. 

The industry standard sources specific to DME and P&O include the following:

  • National and Regional Centers for Medicare & Medicaid Services (CMS) policy
  • Durable Medical Equipment Regional Carries (DMERC) Manual
  • CMS HCPCS LEVEL II Manual coding guidelines
  • Medicare Claims Processing Manual

In addition to the above, Independence will enforce CMS rules on modifier usage including the following modifiers:

  • A1 – A9, GY
  • AU, AV, AW, and AX
  • CG
  • FA – F9 and TA – T9
  • K0 – K4
  • KS, KX
  • KX, GA, or GZ
  • NU, UE, and RR
  • RT/LT

For detailed requirements related to these modifiers, please see this document.

Injectable drugs and biological agents

Independence will be expanding the enhanced claim editing process to include additional rules specific to various injectable drugs and biological agents effective for claims processed beginning September 1, 2019. 

The industry standard sources specific to injectable drugs and biological agents are:

  • The manufacturer’s package insert (primary source: Food and Drug Administration [FDA]-approved indications)
    • Other compendia references include, but not limited to:
      • Thomson Micromedex® (DRUGDEX®, DrugPoints®)
      • National Comprehensive Cancer Network (NCCN) Drugs & Biologics Compendium®
      • American Hospital Formulary System (AHFS®) Drug Information®
      • Elsevier Gold Standard Clinical Pharmacology
    • ICD-10 Instruction Manual coding guidelines
    • Centers for Medicare & Medicaid Services (CMS) Claims Processing Manual

The enhanced claim editing process for injectable drugs and biological agents will focus on the following areas:

  • The diagnosis code(s) billed are consistent with the FDA-approved indications and approved off-label indications. If the ICD-10 code billed on the claim does not match the approved indication, the claim may reject.
  • The diagnosis code(s) billed are consistent with the ICD-10 Instruction Manual coding guidelines.
  • The dosage and frequency of administration is appropriate for the diagnosis for which it is being used.
  • The administration code(s) and hydration services are appropriately reported.

2. Why is Independence making these changes?

Independence’s claim editing process will enhance our ability to administer payment rules consistent with national standards established by CPT, CMS, and specialty societies. This change should have little or no impact on practices billing in accordance with these guidelines.

3. When will these updates take place? (Revised 6/11/2018)

Claims received by Independence on or after June 10, 2018, are subject to these updates and will apply to professional claims and to outpatient facility claims (where applicable).

4. How have providers been notified about the new claim editing process? (Revised 8/5/2019)

On March 9, 2018, April 24, 2018, May 15, 2018, June 11, 2018, November 14, 2018, and December 14, 2018, the implementation of a new claim editing process was announced to providers via:

  • Partners in Health UpdateSM, our online provider newsletter;
  • Independence NaviNet® web portal (NaviNet Open) Plan Central in a message containing a summary.

On May 15, 2018, and August 17, 2018, a Provider Bulletin was sent via email to participating hospitals as a reminder of the alignment of enhanced claim edits with industry standard billing rules.

DME and P&O providers

On April 15, 2019, June 12, 2019, and August 5, 2019, the expansion of the claim editing process to include DME and P&O providers was announced to providers via:

  • Partners in Health Update;
  • Independence NaviNet Open Plan Central.

On April 15, 2019, a Provider Bulletin was sent to participating DME and P&O providers as a notification of the expansion of the claim editing process.

Injectable drugs and biological agents

On June 3, 2019, and August 5, 2019, the expansion of the claim editing process to include various injectable drugs and biological agents was announced to providers via:

  • Partners in Health Update;
  • Independence NaviNet Open Plan Central.

On June 3, 2019, a Provider Bulletin was also sent to providers as a notification of the expansion of the claim editing process.

5. How will these changes affect the Independence claim system?

These enhancements will facilitate prepayment review and claim auto-adjudication in alignment with national industry coding standards versus retrospective claim audit adjustments.

6. Will all claims be affected?

No, not all claims will be affected by this claim editing process. In fact, the vast majority of claims that are billed according to accepted standards will pass through our claim payment system without any coding issue.

7. Is this a change in fee schedule rates?

No, these changes do not affect the fee schedule payment rates.

8. Can I expect claim delays due to the claim editing process?

Independence will continue to meet or exceed claims processing timelines as required by applicable law.

9. Will the Provider Explanation of Benefits (EOB) change?

No, this process will not affect the format of the Provider EOB.

10. How can I tell if my claim has gone through an edit? (Revised 5/15/2018)

The edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB. 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.

11. How can I question or dispute an edit? (Revised 5/15/2018)

Providers should continue to use the Claim Investigation transaction via NaviNet Open to ask questions or request an adjustment on a specific claim. Please reference the enhanced claim editor in the Claim Investigation transaction if the question/comment is in reference to a code/message that begins with E8.

12. Why do I already see these types of denials in my claims experience? (Revised 5/15/2018)

While you may already see some claim outcomes that indicate denials for edits such as post-operative care or add-on codes not payable, our current claim payment system editing has been limited, requiring expansive back-end audits. This enhancement will allow for a more consistent and comprehensive prepayment review application of national coding standards. An additional example is that our system capabilities have been limited to applying the NCCI component tables. The enhanced claim editing process will look across the NCCI policy manual, not just the component tables. Information on NCCI edits is available on the CMS website.

13. Why am I receiving an enhanced claim editor denial when the service billed is preauthorized? (Added 6/3/2019)

An authorization may not supersede a claim line from receiving an edit. For example, if an authorized injectable drug or biologic agent is billed with an ICD-10 diagnosis code(s) that is not consistent with the approved indication, your claim may still be denied.

For more information

If you cannot find the information you are looking for here and have further questions, please email us at claimeditquestions@ibx.com.

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