July 19, 2018
Premera continues to implement additional edits on outpatient claims submitted on a UB-04 claim form, both paper and electronic format.
These expanded edits for hospital outpatient care support accurate and correct billing and claims payment to facilities and Premera customers.
As mentioned in prior communications in December 2017, Premera currently applies a subset of the Outpatient Claims Editor (OCE) edits, the editing program used by the Centers for Medicare and Medicaid services, when processing claims. In addition to these OCE edits, Premera continues to expand and update the application of validation and consistency edits on all facility claims.
You may see some of these edits applied to individual billed service lines on your claim or applied to the entire claim. Review the edit to make sure you understand the circumstance that prompted the edit. Make note of the correction so future billed claims will result in correct reimbursement.