Claims Edit: Coming Soon in 4th Quarter
Posted on September 28, 2022
As a reminder, Health New England is undertaking an initiative to ensure our claims payment and pricing systems align with CMS rules. The Centers for Medicare & Medicaid Services (CMS) has a process for Medicare coverage determination. This includes National Coverage Determinations (NCDs), which are determined through an evidence-based process. In the absence of a national coverage policy, we may cover a service at the discretion of the Medicare contractor using Local Coverage Determinations (LCD).
In the 4th quarter of 2022, the following edits will be implemented:
Same Day Visit – (professional services) – Identifies Procedure Codes billed by the same provider on the same date of service as a code with a global period.
Global Component – (professional and outpatient facility) – This rule identifies claim lines with procedure codes that have components (professional and/or technical). The rule also detects when duplicate submissions occurred for the total global procedure or its components across different providers.
The following scenarios are audited:
- Global vs. Global
- Global vs. Professional
- Global vs. Technical
- Professional vs. Global
- Technical vs. Global
- Professional vs. Professional
- Technical vs. Technical
CMS Status Indicators – (professional services) – Claim lines containing procedure codes with a status indicator defined by CMS on the Medicare Physician Fee Schedule (MPFSDB).
For additional questions, please call your Provider Relations Representative at (800) 842-4464, extension 5000, or send an email to providerrelations@hne.com.
