August 3, 2023
Premera implemented advanced claims editing on Nov. 15, 2021. This effort complies with the Blue Cross Blue Shield Association (BCBSA) mandate to conduct secondary claim editing. Premera extended the advanced claims editing to additional lines of business on July 24, 2023.
The second-pass editor is applied after claims adjudication and prior to provider payment. Premera's Payment Integrity team determined the edits that will ensure correct coding/billing and align with Premera's existing payment policies.
Professional and facility claims are edited to promote correct coding and billing practices including coding validation edits which are reviewed 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.
Additional coding and billing guidelines from the following sources are included as part of this claim edit expansion:
- Premera's payment and medical policies
- CMS coding policies
- CPT and ICD-10 coding policies
- Nationally recognized academy and society guidelines
- National Uniform Claim Committee billing guidelines (CMS-1500)
- National Uniform Billing Committee Official UB-04 Data Specifications Manual
Some of the enhanced edits include but aren’t limited to the following:
- Additional National Correct Coding Initiative edits
- Global surgical periods
- Co-surgeon and assistant surgeon billing guidelines
- Multiple procedure reductions
- Correct modifier usage
- Correct add-on and primary code usage
- Unit limitations
- Medically unlikely (MUE) edits
- Appropriate coding on UB-04 claims including revenue codes, bill types, condition codes, value codes, etc.
- Device and supply criteria expansion
Review the prior articles published in the Provider News announcing these edit enhancements: