August 2, 2018
The Claims Editor/What If tool allows you to test billing scenarios and code combinations against the claims editing software. By entering the codes and modifier combinations you plan to submit for reimbursement, you will know if you are likely to encounter an edit.
The Claims Editor is updated eight times throughout the year with additions, deletions, and revisions to CPT codes, HCPCS codes, ICD-10 CM Diagnosis codes and ICD-10 PCS procedure codes. In addition, updates and revisions in NCCI and MUE edits as released by CMS are also kept current. As a result, you may encounter different edits being applied to your submitted claims that were or were not present on prior claim submissions.
To learn whether these updates in the codes and NCCI and MUE edits may impact your submitted claim prior to submission, access the Claims Editor/What If tool.
The Claims Editor/What If tool is on Premera’s secure provider website and requires a One Health Port (OHP) user ID and password. It can be accessed using the following steps:
- Go to the provider landing page on www.premera.com
- ON the LEFT sidebar, click on TOOLS and then click on CLAIMS EDITOR
- You will be asked to sign-in to your OHP account
- After you sign into your account, the entry screen for the Claims Editor/What If tool will appear. Enter the following information: patient’s gender, date of birth, place of service, diagnosis type, diagnosis codes
- Then enter the procedure codes you plan to submit for reimbursement, any modifiers, units, diagnosis pointers and dates of service
- Choose “Submit Claim Inquiry” button at the bottom
- The next screen will show whether the services will encounter any edit. If so, the response will be highlighted in RED type to explain the edit. There will be a link labeled “See full explanation” which opens to a more detailed explanation
- If no edits are encountered, the code combinations will be accepted
DISCLAIMER: The Claims Editor/What If Tool does NOT apply member benefits, eligibility or provider contracting or reimbursement information and is NOT a guarantee of payment.