PH - Clinical Edits Effective Sepetember 15, 2022

July 27, 2022

From Priority Health: 

 

As posted on our website as a recent news item  earlier this month and in  Clinical Edits Listing webpage, we’ve defined each edit and outlined the coding procedures that will help ensure payment.

 

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 Sept. 15, 2022, the clinical edits outlined below will go into effect:

 

Claim type

Product

Clinical edit

Facility claims

All products

Device-Intensive Procedures Requiring Device HCPCS Code

Revenue Code Requires HCPCS

Resubmissions for Adjusted Claim Type of Bills and Change Reason Codes

Multiple Facility E/M Services on the Same Date

 

We adopted these edits based on Center for Medicare and Medicaid Services (CMS) guidelines.

 

How to ensure payment

In our recent news item and in Clinical Edits Listing webpage, we’ve defined each edit and outlined the coding procedures that will help ensure payment