New clinical edit and medical policy introduced for pain management

Ensuring your patients, our members, receive the right care at the right price is central to our partnership with you and all providers in our network. Clinical edits help us achieve this goal by identifying coding errors, non-standard utilization patterns and more.

On Jul. 25, 2022, a new clinical edit will go into effect which will deny anesthesia and moderate sedation services when not deemed medically necessary. This edit will apply to claims for our commercial members and for any provider for a patient 18 years of age or older.

How to ensure payment

Anesthesia and moderate sedation must be billed with a concurrent surgical code or appropriate modifier (i.e.: KX to indicate the medical policy criteria are met) to be considered medically necessary and eligible for payment. Claims that don’t meet these criteria will be rejected to member liability.

Learn more about clinical edits