Coding Resources

  • Payment integrity news and updates

    Payment integrity is the process of making sure healthcare claims are billed and paid accurately, both in pre-payment and post-payment steps of the claim adjudication process. Read the latest Premera Provider News and payment policy updates. To access claim status and claim editor tools, sign in to Availity.

    Payment policies

    Payment policies are primarily based on standard coding and billing guidelines. They are developed and maintained by the Premera Payment Integrity department. A OneHealthPort account is required to view payment policies.

    *Note: Payment policies don't address medical necessity criteria and are separate from medical policies. Medical necessity criteria are addressed though medical policies that are based on the highest level of available evidence for evolving technologies, drugs, services, or supplies, and are maintained by Premera healthcare professionals and certified professional coders. View medical policies.

    Payment Integrity Programs

    Premera conducts claim editing, prepayment reviews, and hospital bill audits which align with industry standards such as:

    • American Medical Association CPT Codebook
    • Center for Medicare and Medicaid (CMS) coding policies, local and national coverage determinations, and other related policies
    • Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes and guidelines
    • Diagnosis-related group (DRG) guidelines
    • International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) coding guidelines
    • Nationally recognized medical academies and society guidelines (coding and clinical)
    • National Uniform Billing Committee (NUBC)
    • Official UB-04 Data Specifications Manual
    • OPTUM Uniform Billing Editor
    • Premera payment policies

    Claim editing

    Premera uses multiple claim editors to analyze submitted claims against industry coding and billing standards and Premera payment policies. Each claim editor has an independent, distinct set of claim edits and claim exceptions.

    Hospital bill review (pre-payment)

    Premera conducts pre-payment hospital bill reviews to identify any potential errors, duplicate charges, capital equipment, routine services/supplies, unrelated charges, and non-separately billable charges. The outcome of the review may result in charges being disallowed.

    Note: A denial for high-dollar prepayment review are reflected on the explanation of payment (EOP) as "EA5: This claim requires a review." If you receive this edit, send the itemized bills to our third-party vendor. You'll receive a letter with instructions to send these documents to the vendor. (Premera doesn't handle the itemized bill reviews for these denials.)

    Hospital bill audit (post-payment)

    Similar to pre-payment bill review, Premera conducts hospital bill audits to ensure appropriate billing. Medical records or other documentation may be requested from you to perform an audit. If medical records or other documentation isn't received within the timeframe noted in the request letter (typically 90 days), the entire claim amount will be subject to a refund request and appeal rights will be forfeited. Facilities can request additional time to provide documents. The outcome of the audit may result in overpayment requests due to charges being disallowed or the diagnosis-related group (DRG) being recalculated.

    Coordination of benefits (COB)

    Investigators and auditors identify and pursue overpayments due to members’ missing or inaccurate other health coverage information. Premera utilizes questionnaires and interviews with providers, employers, and members, as well as advanced data mining, and reviews of medical records to determine if the health plan is primary or secondary insurer.

    Subrogation

    Subrogation permits the plan to recover payments when the negligence or wrongdoing of another causes a member personal illness or injury. Premera partners with an industry-leading subrogation firm to investigate third-party liability.

    Provider billing errors

    Post-payment editing programs, expert investigators, and auditors perform additional screens and tests where billing information is inconsistent with age, services rendered or where up-coding or unbundling of services appears.

    If you have any questions about Payment Integrity programs, contact your Provider Network Management representative or sign in to Availity for further details.

    Premera uses multiple claim editors to analyze submitted claims against industry coding and billing standards and Premera payment policies. Each claim editor has an independent, distinct set of claim edits and claim exceptions. This can result in different edits within each editor, due to differences in claim information and contract exceptions.

    Read the latest payment integrity edit updates in the Reminders and Updates section of Provider News.

    First pass editor

    Prepayment claim editing ensures correct coding and billing practices and evaluates current claims against historical claims for editing purposes. Premera provides a resource tool, C3 Claims Editor, to check for current editing scenarios which can be accessed securely through Availity. Note: The C3 Claims Editor doesn’t account for edits performed by the second-pass editor.

    Second pass editor

    Prepayment claim editing through Cotiviti ensures payment accuracy and risk adjustment. This effort complies with the Blue Cross Blue Shield Association (BCBSA) mandate to conduct secondary claim editing. It is applied after claims adjudication and prior to provider payment. The second pass editor may include but isn't limited to, the first pass edits if the edit is unable to be completed by the first pass editor.

    Coding validation (CV) edit

    A subset of claims may go through a coding validation process which are manual claim reviews. Professional and facility claims are edited by registered nurses and certified coders to promote correct coding and billing practices. This level of claim review takes into consideration historical claims experience to determine if the claim was coded correctly. Because these edits aren't automatic and involve a manual review, the outcome of coding validation may vary. If a provider disagrees with the outcome of the coding validation, they should submit an appeal and provide medical records supporting billed charges. Coding validation edits are easily identifiable on the explanation of payment (EOP) where the claim editing explanation details will indicate “Coding Validation”.

    Claim types where claim editing doesn't apply

    Premera doesn't apply claim editing to the following four claim types/categories:

    • Medicare Supplement
    • Prepaid claims (such as pharmacy benefit manager (PBM) claims)
    • BlueCard home claims
    • Dental claims

    Resources

    Appeals process for clinical edit denials

    Denials based on clinical edits may be appealed. Medical records must be submitted to support the billed services. When these medical records are submitted, all information, procedures, and services will be reviewed, including those billed on related claims that aren't being appealed.

    View provider appeal forms and instructions on how to submit an appeal.
    Sign in to Availity    .
    Watch a claims editor tutorial.

    Find everything you need to know about coding types and sources, special billing situations, and modifiers. View coding and billing guidelines.

    View training guides and tip sheets that can support you in caring for your patients and providing accurate coding and documentation.