The Premera claims editor is located within Availity. Here you can learn more about how the claims editor works.
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First pass editor
Prepayment claim editing through Lyric-ClaimsXten. This editor enforces correct coding and billing practices as well as evaluate current claims against Premera historical claims for editing purposes using resources such as Premera payment and medical
policies:
- CMS medical coding policies
- CPT, HCPCS, and ICD-10 coding guidelines
- Local and regional Medicare policies
- Nationally recognized academy and society guidelines (coding and clinical)
Second pass editor
Prepayment claim editing through Cotiviti to ensure payment accuracy and risk adjustment.
Coding validation (CV)
Manual claims editing review by coding experts and certified nurses prior to claims payment.
Calypso
Post claims payment review and reprocessing
Ceris
Facility claim prepayment review
Carewise
Prepayment claims editor
Appeals process
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