Coding Resources

  • Coding and billing guidelines

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

    Payment integrity news and updates

    Payment integrity is the process of ensuring healthcare claims are billed and paid accurately, both in a pre-pay and post-pay claims environment. Read the latest Premera Provider News and payment policy updates.

    Payment policies

    Payment policies* are based on industry standard coding and billing guidelines. The policies are maintained by the Premera payment integrity team of certified professional coders. 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.

    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. That's why not every claim is edited with the same claim edit(s) due to different edits within each editor, different information on each claim, and different provider or employer group contract exceptions.

    Premera uses the following sources as the basis for claim editing:

    • Premera payment policies
    • Center for Medicare and Medicaid (CMS) coding policies
    • Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes and guideline
    • International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) coding guideline
    • Local and national Medicare policies
    • Nationally recognized medical academies and society guidelines (coding and clinical)

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

    First pass editor

    Prepayment claim editing is handled through Lyric-ClaimsXten. This editor ensures correct coding and billing practices and evaluates current claims against Premera historical claims for editing purposes. Lyric provides a resource tool to check for current editing scenarios which can be accessed securely through Availity. Note: ClaimsXten doesn’t account for the second-pass editor, Cotiviti.

    Second pass editor

    Prepayment claim editing through Cotiviti ensures payment accuracy and risk adjustment. Premera implemented advanced claim editing on November 15, 2021. This effort complies with the Blue Cross Blue Shield Association (BCBSA) mandate to conduct secondary claim editing. The second-pass editor is applied after claims adjudication and prior to provider payment. The Premera payment integrity team determines the edits that will ensure correct coding/billing and align with our existing payment policies.

    Coding validation (CV) edit
    A manual claims review by experts within Cotiviti was additionally implemented called “coding validation (CV) edit.” Professional and facility claims are edited to promote correct coding and billing practices by registered nurses and certified coders. This level of claim review takes into consideration historical claims experience to determine if the claim was coded correctly.

    CERIS

    Starting August 1, 2020, Premera joined with CERIS to conduct high-dollar prepayment reviews. This review process identifies any potential errors, duplicate charges, capital equipment, routine services/supplies, unrelated charges, and non-separately billable charges on facility claims for inpatient and outpatient services, on a prepayment basis. In addition to the claim editing sources noted above, facility claims should be billed and appropriately coded according to policies along with industry standards for the bill type such as:
    o American Medical Association (such as the AMA Uniform Billing (UB) Editor)
    o Diagnosis-related group (DRG) guidelines
    o Other CMS guidelines 

    Carewise Health

    Premera works with Carewise Health to perform hospital bill audits. Hospital bills are audited to check billing appropriateness and ensure Premera was billed correctly. Carewise may need to obtain medical records or other documentation to perform an audit. If medical records or other documentation isn't received within the timeframe noted in the request letter (typically 90 days), Carewise will submit the claim to Premera, and 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 through Carewise. If you have any questions, contact your Provider Network Management representative or call Carewise at 502-326-4526.

    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.

    For denials specific to coding validation, the first level of appeal is reviewed by registered nurses and certified coders through Cotiviti.

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

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