As previously communicated, claims received by AmeriHealth on or after June 10, 2018, are subject to the new claim editing process during prepayment review to ensure compliance with current industry standards and support the automated application of correct national coding principals.* 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.

Claim Editor link

When claims are rejected as a result of the new claim editing process, additional details can be viewed via a new Claim Editor link available within the Claim Status Inquiry transaction on the NaviNet web portal. Note: The Claim Editor link will only display when one or more service lines are rejected with a code message beginning with E8.

The new Claim Editor link can be found on the Claim Status Details screen under Claim and Service Line Details: 

More information

We have updated the Claim Status Inquiry Guide to include this new link, which can be found in the NaviNet Resources section. If you have additional questions on the Claim Status Inquiry transaction, please call the eBusiness Hotline at 609-662-2565 for AmeriHealth New Jersey or at 215-640-7410 for AmeriHealth Pennsylvania.

For more information on the claim editing process, please read, Enhanced claim edits to support correct coding principles.

*Self-funded groups have the option to opt out of the enhanced claim edits, therefore, your outcomes may vary by plan.

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