Facility Claim Editing Expansion

  • July 1, 2021

    Premera will be expanding editing on facility claims, including but not limited to acute care facilities. The expansion will include additional edits to help promote correct coding of facility claims. This is in addition to the upcoming enhancement and expansion of professional claims editing in October 2021.

    The edits will assess both current claims and their relationship to historical claims experience in conjunction with the following sources:

    • Premera’s payment and medical policies
    • CMS medical coding policies
    • CPT and ICD-10 coding guidelines
    • National Uniform Billing Committee Official UB-04 Data Specifications Manual (NUBC)
    • National Uniform Claim Committee (NUCC)
    • Local and regional Medicare policies
    • Nationally recognized academy and society guidelines (coding and clinical)

    Some of the enhanced and expanded edits include but are not limited to the following:

    • Hospital procedure to procedure (PTP) NCCI edits
    • Medically unlikely edits (MUE)
    • Appropriate revenue codes
    • Appropriate bill types and related revenue codes
    • Device and supply criteria expansion (i.e., implants, imaging agents with/without an appropriate procedure)
    • Expanded Outpatient Code Editor (OCE) edits such as, but not limited to, correct modifier usage.

    We’ll provide more details as we get closer to implementation.

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