Enhanced Claim Editing for Professional and Facility Claim Editing

  • July 1, 2021

    Starting on October 1, 2021, Premera will implement enhancements to our prepayment professional and facility claim editing processes to promote additional correct coding and billing practices. The implementation will include coding validation services provided by registered nurses and certified coders to review claims for correct coding in addition to the current automated claim editing systems.

    These enhancements take into consideration Premera’s historical claims experience, as well as policy guidelines from the following sources:

    • Premera’s payment and medical policies
    • CMS medical coding policies
    • CPT and ICD-10 coding guidelines
    • Local and regional Medicare policies
    • Nationally recognized academy and society guidelines (coding and clinical)

    Premera’s payment policies will continue to be enforced along with the enhanced editing such as:

    • National bundling edits including the Correct Coding Initiative (CCI)
    • Global surgery period
    • Co-surgeon and assistant surgeon policies
    • Multiple procedure reductions
    • Modifier usage
    • Add on code usage
    • Unit limitations
    • Age appropriateness
    • Cross providers claim duplicate

    Additional details will be published in a future article before enhanced editing begins.

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