As previously communicated in a series of
Partners in Health UpdateSM articles, AmeriHealth is expanding the enhanced claim editing process to include additional rules specific to various injectable drugs and biological agents
effective for claims processed as of September 1, 2019.
Claims received by AmeriHealth on or after June 10, 2018, are subject to an enhanced claim editing process during prepayment review. This process ensures compliance with current industry standards and supports the automated application of correct national and regional coding principles.*
The industry standard sources specific to injectable drugs and biological agents are:
- The manufacturer’s package insert (primary source: U.S. Food and Drug Administration [FDA]-approved indications)
— Other compendia references include, but are 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
*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 injectable drugs and biological agents 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.
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).
Identifying claims that went through the claim editor process
If you have been submitting claims in accordance with industry standards, you will have no issues with the topics in this article. However, if you have not, please be advised that you may see an increase in claim rejections and/or denials due to the new claim edits. If your claim is 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.
Learn more
Please review the
Partners in Health Update article,
Reminder: Enhanced claim edits to support correct coding principles, which was posted December 14, 2018.
For further questions about the enhanced claim editing process, review our Claim edit enhancements: Frequently asked questions (FAQ), which can also be found in the Frequently Asked Questions archive on AmeriHealth NaviNet Open Plan Central or in the Quick Links menu 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 these resources, please send an email to
ahclaimeditquestions@amerihealth.com.
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