Update to ClaimsXten Software

Date Issued: 8/19/2019

EmblemHealth will be updating our ClaimsXten software with new rules and modifications to existing rules. EmblemHealth will add the following new billing and reimbursement edits for all EmblemHealth benefit plans, both in- and out-of-network. EmblemHealth follows the policies of the Centers for Medicare & Medicaid Services (CMS), the American Medical Association, and its own medical policy regarding the correct coding of claims.

A complete list of edits, including updates and additions, is available here.

Rule Description
Obstetrics Services Identifies claim lines to determine if any global obstetric care codes (defined as containing antepartum, delivery and postpartum services, i.e. 59400, 59510, 59610 and 59618) were submitted with another global OB care code or a component code, such as the antepartum care, postpartum care or delivery only services, during the average length of time of the typical pregnancy: 280 or 322 days with postpartum services.
Ambulance Bundled Service Identifies claim lines with a procedure code for services that CMS considers inclusive to a valid ambulance HCPCS service or mileage code billed with an ambulance HCPCS code for the same member, same date of service, by the same provider and on Same Claim Only.
Ambulance Frequency Identifies ambulance claim lines when the frequency exceeds the maximum limits assigned to an ambulance HCPCS code reported for the same member on the same date of service.
Valid Ambulance Modifiers Identifies ambulance services that lack an appropriate origin-destination modifier or modifier QL, lacks an appropriate arrangement modifier (QM or QN) for facility-based claims and two claims lines billed for the same date that lack identical origin-destination or arrangement modifiers.
Valid Ambulance Services Identifies inappropriate ambulance services as defined by CMS, which typically requires two lines of coding (a line for the transport/service code and one line for the mileage code). In addition, this rule will identify ambulance services lacking an origin-destination modifier and facility-based claim lines lacking an appropriate required arrangement modifier.
DME – Own Identifies a claim line for a DME item that has been submitted with an ownership modifier (NU – New, NR – New when rented, UE – Used), when the same DME item has previously been paid with the same or different ownership modifier.
DME – Rent to Own Identifies claims lines submitted for the rental of a DME item in which the rental payment for the DME item exceeds the maximum number of rental payments as defined by CMS.
DME – Rent to Own History Identifies claim lines submitted for the rental of a DME item (Rental Modifier:  RR) when the same DME item shows a history of beneficiary ownership (Ownership modifiers: NU – New, NR – New when rented, UE – Used).  

In addition, the following existing rules will utilize federal tax identification number (TIN) and specialty matching logic as support.

Rule Description
Unbundling Rule Edits claim lines where a procedure is submitted with another procedure that is one of the following: a more comprehensive procedure, a procedure that results in overlap of services, or procedures that are medically impossible or improbable to be performed together on the same date of service.
Same Day Visit Edits claim lines with E&M codes billed on the same date of service as a procedure code within a global period.
CMS Correct Coding Initiative Edits claim lines for which the submitted procedure is not recommended for reimbursement when submitted with another procedure as defined by a code pair found in National Correct Coding Initiative (NCCI).