June 1, 2023
We announced in April that we’re replacing our prepayment claim editor, Optum’s Claim Editing System (CES), with Lyric’s ClaimsXten® editor. The new claim editor will continue to enforce correct coding and billing practices as well as evaluate current claims against Premera’s historical claims for editing purposes.
Background
Our current Claims Editor/What if Tool is accessed through the secure My Premera provider portal and is used to enter a hypothetical claim to see which code combinations will be approved or denied for payment. The current tool isn’t specific to member benefits, doesn’t include any benefit limitations, and only looks for coding and clinical edits based on our current first-pass editor (CES). NOTE: It doesn’t account for the second-pass editor (Cotiviti).
What’s changing
On July 8, 2023, we’re transitioning to Lyric ClaimsXten. Edits may perform differently than they do today, as ClaimsXten allows for more complex editing. Our current Claims Editor/What If Tool will be replaced with Clear Claim Connection or C3. The new tool will reflect the ClaimsXten edits and be accessed through an SSO link within the Availity payer space. The new claims editor user experience will be similar, but the tool will look different.
The current Claims Editor/What If tool will no longer be accessible on the secure Premera provider portal as of July 8. Users will be redirected to the new tool located within the Availity payer space.
Key changes to note
- Edits may perform differently than they do today, as ClaimsXten allows for more complex editing.
- ClaimsXten codes begin with a lower-case f (i.e., fa9), while current CES codes begin with uppercase J & K (i.e., J77).
- Current Claims Editor/What If tool will be replaced with Clear Claim Connection (C3) and will be accessible in the Availity payer space.
NOTE: The Federal Employee Program (FEP) and Lifewise Assurance are included in this effort, but not LifeWise Health Plan of Washington and Medicare Advantage.
Read more background details in the April 6 article.