Claims Edits Information

In May 2013, Blue Cross and Blue Shield of Nebraska (BCBSNE) began using a new software program to examine medical claims for consistency and accuracy in billing processes. The goal of this program, employed by other health care payers, is to improve the efficiency and accuracy of our claims processing system.  

The claims review software uses nationally accepted and sourced guidelines, including Current Procedural Terminology (CPT) regulations as documented by the American Medical Association (AMA), Correct Coding Initiatives (CCI) and Post-Operative Period Guidelines as outlined by the Centers for Medicare and Medicaid Services (CMS).

Program components include: 

 

  • National CCI (as defined by CMS)

    • Comprehensive
    • Mutually Exclusive
    • New Visit Principles
    • Add-On Principles 
    • Medically Unlikely Principles 
    • Multiple Unit Principles
    • Global Surgery 






    Based on the frequency of guideline source updates, these edits are subject to change and additional guidelines will be added without prior notice.  

    With the implementation of this program, claims submitted with inappropriate coding will be returned or denied.  Providers will be notified via a return letter or remittance advice, which will include a reason code for the claim return or denial.  Any returned claims must be corrected prior to resubmission. 

    To help you understand the codes, we encourage you to refer to the following resources:

    Medically Unlikely Edits (MUE) – Provides access to frequently asked questions on MUEs, along with updated MUE information.

    National Correct Coding Initiative (NCCI) Edits – Provides guidance on the NCCI policy manual for Medicare Services.

    Medicare Claim Review Programs (MR, NCCI Edits, MUEs, CERT, and Recovery Audit Program) – Provides a summary of NCCI and MUE edits and additional information on Medicare claim review programs.

    The National Correct Coding Initiative (NCCI) – FAQs regarding NCCI edits for Iowa, Kansas, Missouri and Nebraska providers. 

    To check for the most current status on recently submitted claims, go to NaviNet

    For escalated claims questions, please call (800) 635-0579.

      

    Note: When claims are returned or denied due to the claims edits, submitting an appeal or a reconsideration is not necessary. Please resubmit the corrected claim electronically. Please note the policy below.

    Requirement for Electronic Claim Submitters

    Effective August 1, 2013, electronic claim submitters MUST file their corrected (replacement) claims electronically.  Corrected claims submitted on paper by a provider who has electronic claim filing capabilities will be returned with instructions to submit the corrected claim electronically.

     

    If your corrected claim will include attachments, your corrected paper claim must be filed to Blue Cross and Blue Shield of Nebraska, attached to a Reconsideration Request Form, as you have done in the past.

     

    If you have any questions regarding how to submit a replacement claim electronically, please refer to the HIPAA ANSI X12N 837P or HIPAA ANSI X12N837I implementation guide for detailed instructions.

     

     

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