Claims Editing – November 2020
Posted on November 4, 2020
As you know, 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, a service may be covered at the discretion of the Medicare contractor using Local Coverage Determinations (LCD). Carriers have been expected to follow the CMS editing rules to adjudicate claims since this process was implemented in 2003.
Health New England is undertaking an initiative to ensure our claims payment and pricing systems align with CMS rules.
While we have historically notified you on a quarterly basis regarding updates to edit rules, the updates are now taking place monthly, and include more edit rules than we have had in the past. This means you could begin seeing variances in payments if you are not billing according to CMS guidelines.
For more information, please reference the sites below or call your Provider Relations Representative at (800) 842-4464, ext. 5000.
• CMS National and Local Coverage Determinations Indexes
• NGSMedicare.com > In the “Continue as Guest” Box, select Part B Provider and your state
