Audience: Participating Providers, Hospitals and Facilities
Based on feedback from our participating providers, we are pleased to share advance notice of a new enhancement to claim processing. Later this year, we will move post payment audit recovery for Administrative Policy 31 – Related Services, to a prepayment clinical edit. This update pertains to all lines of business.
This update will allow for more accurate editing related to the code descriptors of a procedure, such as frequency limitations. We will provide additional information on this update prior to implementation.
A service that has already been reimbursed can cause a service on a subsequent claim to be disallowed, regardless of which service is considered primary. As a result, you may see a difference in how an edit is applied when services are on the same claim versus on different claims. To avoid out-of-sequence editing:
- Services performed on the same day should be submitted on the same claim
- Services performed on different days may continue to be submitted on separate claims, but must be received and processed in date of service order
- To dispute a clinical editing denial, a Clinical Editing Review Request form is no longer required. Simply correct your claim electronically on our website, Provider.UniveraHealthcare.com > Claims & Payments tab.
- Administrative and clinical editing policies are accessible on our website, Provider.UniveraHealthcare.com > Policies & Guidelines tab (Secure log in required).
If you have questions, please contact your Provider Relations representative.
Thank you for the quality care and service you provide to our valued members.Email this article