Enhanced Claim Editor Program: Upcoming areas of focus

March 25, 2021

As previously communicated in a series of Partners in Health UpdateSM articles, claims received by Independence on or after June 10, 2018, are subject to an enhanced claim editing process during prepayment review. The Enhanced Claim Editing Program supports our commitment to ensure compliance with reporting requirements and guidelines endorsed by national and regional industry sources, including but not limited to:

  • Centers for Medicare & Medicaid Services (CMS) standards such as:
    • National Coverage Determinations (NCDs)
    • Local Coverage Determinations (LCDs)
    • Medicare Claims Processing Manual
    • Durable Medical Equipment Regional Carries (DMERC) Manual
    • CMS HCPCS LEVEL II Manual coding guidelines
  • American Medical Association (AMA) Current Procedural Terminology (CPT®) coding guidelines
  • ICD-10-CM Official Guidelines for Coding and Reporting
  • U.S. Food and Drug Administration (FDA)
  • Nationally recognized specialty societies such as:
    • National Comprehensive Cancer Network (NCCN)
    • American College of Obstetricians and Gynecologists (ACOG):
    • American Society of Anesthesiologists (ASA)
    • American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM)
    • U.S. Preventive Services Task Force (USPSTF)

Independence continues to evaluate and review industry standard sources, specialty societies, and Independence claim payment policies to identify additional claim edits that are consistent with these standards. Additional claim edits will continue to be implemented as applicable.

New areas of focus

Areas of focus that have been identified and for which automated edits have been implemented through our review process include, but are not limited to:

  • Inappropriate use of general or monitored anesthesia for certain spinal injections used for pain management (CMS LCD, Independence policy, ASA)
  • Pelvic ultrasound reported with saline infusion sonohysterography modifier requirements (ACOG Coding Manual)
  • Initial versus follow-up examinations when reporting obstetric ultrasounds and fetal echocardiographies (AMA CPT code definition)
  • Criteria and frequency of screenings such as HPV, ECGs, AAAs, etc. for individuals (ACOG, USPSTF, Medicare Claims processing manual, and Independence policy)
  • Reporting requirements for Modifiers QM and QN for ambulance services
  • Criteria for pulmonary diagnostic testing (CMS LCD, Independence policy)

Learn more

For questions about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ). Note: 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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