New clinical edits are going into effect

We value the care you provide our members and strive to reimburse you accurately and fairly for that care. Thoughtful implementation of clinical edits supports this goal, while allowing us to process your claims more efficiently.

During the third quarter of this year, we’ll implement the new clinical edits outlined below:

Professional claims 

All products

Online Digital E/M or Assessment Group Frequency

Online digital evaluation and management (E/M) services may be reported only once in a 7-day period by the same provider per CPT coding guidelines. Online digital evaluation and management (E/M) services reported more than once in a 7-day period by the same provider will be denied.

Ambulance Required Modifiers for Ambulance Service HCPCS Code Rule

Ambulance origin and destination modifiers should be appended to ambulance services. Ambulance codes that are missing origin and destination modifiers will be denied. Exception – an ambulance service will not be denied for missing origin and destination modifiers if modifier QL is appended to indicate the patient was pronounced dead after the ambulance was called.

Facility claims

All products 

Ambulance Required Modifiers for Ambulance Service HCPCS Code Rule

Ambulance origin and destination modifiers should be appended to ambulance services. A modifier indicating whether the service was provided under arrangement or directly should also be appended. Ambulance codes that are missing origin and destination modifiers and/or a modifier to indicate whether the service was provided under arrangement or directly will be denied. Please refer to the Ambulance services page in the Provider Manual for exceptions and further information.