Updates to Claims Editor/What If Tool

  • September 17, 2020

    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, there are updates and revisions to National Correct Coding Initiative (NCCI) edits and Medically Unlikely Edits (MUE) as released by CMS that are also kept current. As a result, you may encounter different edits being applied to your submitted claims that may or may not be present on prior claim submissions.

    To determine if your professional claim will encounter edits, the Claims Editor/What If tool allows you to test professional claim billing scenarios and code combinations against the current claims editing software. By entering the codes and modifier combinations you plan to submit for reimbursement, you’ll know if the claim will likely encounter an edit.

    The Claims Editor/What If tool is on Premera’s secure provider website and requires a OneHealthPort (OHP) user ID and password.

    Here’s how to access the tool:

    1. Go to the provider landing page.
    2. In the left menu, select Tools, then Claims Editor.
    3. Sign in to your OHP account.
    4. After you sign in, 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.
    5. Then enter the procedure codes you plan to submit for reimbursement, any modifiers, units, diagnosis pointers and dates of service.
    6. Choose “Submit Claim Inquiry” button at the bottom.
    7. The next screen will show whether the services will encounter any edit. If so, the response will be in red, explaining the edit. You’ll see a link labeled “See full explanation” which opens to a more detailed explanation.
    8. If no edits are encountered, the code combinations will be accepted.

    To learn whether the CPT and HCPCS code updates or ICD-10 code updates along with NCCI and MUE edits may impact your submitted professional claim prior to submission, check by accessing the Claims Editor/What If tool.

    Disclaimer: Note that the Claims Editor/What If Tool is only applicable to professional claims. The What If Tool does not apply member benefits, eligibility, provider contracting or reimbursement information and is not a guarantee of payment.

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