We're reviewing the implementation of four clinical edits

Ensuring you're reimbursed fairly and accurately for the services you provide our members is of the utmost importance to us. Thoughtful implementation of clinical edits supports this goal, while allowing us to process your claims more efficiently. We're constantly monitoring our edits to make sure they're working as they should.

Through this review, we've decided to pause the four edits listed below to make sure they're following our medical policies as they should.

There's no need to resubmit any claims denied due to these edits. We'll automatically reprocess them for payment as appropriate.

Clinical edits to be paused on Oct. 25, 2022

The following clinical edits will be paused while our Payment Integrity team assesses any necessary modifications:

  • Deny any code billed by a DME provider when the code isn’t a DME code
  • Deny professional radiology services when billed by a provider other than an anesthesiologist, cardiologist, multi-specialist, neurologist, physical medicine specialist, radiologist, or radiation oncologist in the inpatient or outpatient hospital setting

Clinical edits will be modified on Oct. 25, 2022

We've identified the modifications needed for the following edits to align with our medical policies.

  • Deny chemotherapy administration when the primary or principal diagnosis isn’t an encounter for antineoplastic chemotherapy or antineoplastic immunotherapy.
    This edit will be modified to look at the claim line rather than the claim header for all lines of business.
  • Deny A4305, A4306 (Disposable drug delivery system), or A9274 (External ambulatory insulin delivery system, disposable) when billed as a noncovered item.
    This edit will be modified so that it's turned off for Commercial and Medicaid. It will remain on for Medicare.