January 6, 2022
Several of the enhanced edits activated in November use the specialty and tax identification number (TIN) of the rendering provider(s) to determine whether to apply the edit or not.
The specialty is based on the provider taxonomy code as identified by the Health Care
Provider Taxonomy listing from the National Uniform Claim Committee (NUCC). Taxonomy codes are assigned to every provider contracted with Premera or those who submit claims to Premera for reimbursement. These taxonomy codes are grouped into common
specialty classifications which are utilized as part of the editing process.
A service can be denied if there is a claim with the same or related service in the member’s history that was submitted by the same provider. Two rendering providers might be considered the same provider if they share the same specialty and TIN.
Some of the edits using this definition of the same provider include but aren’t limited to the following edit categories:
- Services rendered in global surgical periods (00, 10, 90 days)
- Duplicate claim determinations
- Multiple evaluation and management (E&M) office visits on the same date
- Repeat tests
- National Correct Coding Initiative (NCCI) edits
- Co- and team surgeons
Review your explanation of payment (EOP) document carefully for a full explanation of the enhanced edits now being applied.