March 21, 2019
A denied claim is the last thing you want, but understanding the types of denials and tools available can help you get reimbursed the first time.
Like all health plans, Premera uses industry standard codes to represent medical services. These codes are created and maintained by the American Medical Association’s Current Procedural Terminology (CPT) codes, the Centers for Medicare and Medicaid Services (CMS) HCPCS codes, and the World Health Organization (WHO) ICD-10 CM Diagnosis and PCS Procedure codes, as well as guidelines from other medical professional colleges, organizations, and societies.
Whenever a claim is submitted to Premera, our claims system checks two key areas that may trigger a denial: medical necessity and correct billing and coding.
Medical Necessity Denials
Medical necessity denials occur when the medical service you’re billing doesn’t comply with the medically indicated criteria as stated in Premera’s medical policies. We develop and review our medical policies based on the review of current scientific literature. We consider research studies, clinical effectiveness data, evidence reviews by credible national and state research organizations, professional society guidelines, and local practice standards.
Claims Edit Denials
Even if a medical service is medically necessary and you’ve received prior authorization, the claim may still encounter a claim edit and be denied. If the service is billed or coded incorrectly and doesn’t follow the industry standard coding guidelines, the claim will receive an edit. You’ll have the option to correct the coding on the claim and resubmit for payment reconsideration. As noted above, Premera uses multiple industry standard coding and billing systems and guidelines as part of the Claims Editor. If you receive a claim edit denial, your Explanation of Payment message code will begin with J or K.
Use Our Tools
Premera offers a Claims Editor/What If tool to help you test billing scenarios and code combinations against the claims editing software before you submit the claim. It’s one of the easiest and best ways to help make sure you get reimbursed as soon as possible. Look for Explanation of Payment message codes in the Reference Info section of our library on the provider website.