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  • Claims > Claims Review Software

    EmblemHealth uses multiple types of commercially available claims review software to support the correct coding of claims that result in fair, widely recognized and transparent payment policies.

    To avoid any payment adjustments, we recommend you carefully document each service provided, according to CMS guidelines: Documentation Guidelines for Evaluation and Management. Complete medical record documentation is the foundation of every patient's health record and can significantly affect claims coding and adjudication. Accurate coding translates clinical documentation into uniform diagnostic and procedural data sets and provides the evidence that the services billed were rendered to the patient.

    In addition to the above, EmblemHealth utilizes the services of several organizations for claim editing services as indicated below:

    Cotiviti, Inc.

    The Cotiviti, Inc. Payment Policy Management software provides EmblemHealth with correct coding and payment policy for EmblemHealth to administer and pay claims in a manner consistent with relevant policy sources. Policy sources include, but are not limited to, the requirements of CMS, AMA and other specialty academies' policies and procedures. Examples of claims editing software rule recommendations include, but are not limited to: A) Implementation of industry standard and vendor recommended updates; B) Systematic revisions to ensure correct administration of EmblemHealth benefit plans; C) Correction of diagnoses and procedure inconsistencies, procedure and setting inconsistencies and incorrect/coding of multiple services.

    McKesson Health Solutions ClaimsXten

    ClaimsXten is an ICD-9- and ICD-10-compliant software solution that assesses claims information, including CPT/HCPCS procedure codes, to detect coding irregularities and conflicts or errors, and makes recommendations for correction for both professional and facility claims1. ClaimsXten coding rules come preconfigured in Knowledge Packs and are based on a compilation of guidance from AMA and CPT publications, CMS, specialty societies, and McKesson’s clinical physician teams. The auditing logic evaluates modifiers in a correct, hierarchical fashion when multiple modifiers are reported per claim line. All rules, codes, edits sources and edit clarification are updated quarterly. Preconfigured ClaimsXten clinical rules may be revised by Senior EmblemHealth Medical Directors to align with EmblemHealth clinical policies.

    Montefiore CMO Claims Review Software

    Montefiore CMO (the management services organization for Montefiore IPA) uses a series of claims rules that encompass CMS National Correct Coding Initiative edits, specialty edits, commercial edits and unique, code-specific edits. For Montefiore CMO claims inquiries, contact 1-877-447-6888.

    TriZetto® QNXT (version

    QNXT is a comprehensive payer solution developed by TriZetto to administer all lines of medical business and efficiently manage all relationships between HIP, members and practitioners. QNXT manages complex reimbursement capabilities, flexible benefit plan design functions and complex contract modeling capabilities.

    HealthCare Partners Claims Review Software (HCPIPA)

    HCPIPA claims review follow EmblemHealth, Current Procedural Terminology (CPT), American Medical Association (AMA) and ASA claims processing guidelines and apply CMS coding initiative guidelines. For HCPIPA claims inquiries, contact 1-800-877-7587 or use the EZ-Net system on the HCPIPA website at A valid username and password are required.

    EZCAP (version 4.6)

    EZCAP collects and stores provider profiles, health plan benefit and member eligibility data, specialist treatment authorizations, procedure and diagnosis codes, case management and customer service information. EZCAP also stores and processes professional and facility claims and calculates member months and capitation payments.

    Palladian Muscular Skeletal Health Claims Review Software

    Palladian currently uses Health Solutions Plus (HSP). This software is a modular system providing claims payment, member eligibility, provider credentialing, repricing and internal and external reporting.

    QicLink System (version

    The QicLink System is a suite of applications providing claims payment, member eligibility and utilization management, provider credentialing, repricing and internal and external reporting services. Claims and authorizations are subject to member eligibility and practitioner contractual agreements before being paid or authorized. This system also integrates with other software programs such as ProviderNet, PUMA and DataPiction.

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    Glossary terms found on this page:

    The process by which a claim is paid or denied based on eligibility and contract determination.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    Services that have been approved for payment based on a review of EmblemHealth's policies.

    A health insurance product offered by a health plan company that is defined by the benefit contract and represents a set of covered services. Also called a health benefit plan.

    A program that assists the patient in determining the most appropriate and cost-effective treatment plan, including coordinating and monitoring the care with the ultimate goal of achieving the optimum health care outcome.

    An itemized statement of health care services and their costs provided by a hospital, physician's office or other health care facility. Claims are submitted to the insurer or managed care plan by either the plan member or the provider for payment of the costs incurred.

    The government agency responsible for administering the Medicare and Medicaid programs.

    A legal agreement between an individual member or an employer group and a health plan that describes the benefits and limitations of the coverage.

    A determination of whether or not a person meets the requirements to participate in the plan and receive coverage under the plan.

    A health care benefit arrangement that is similar to a preferred provider organization in administration, structure and operation but does not cover out-of-network care. Also called an Exclusive Provider Organization.

    A hospital, ambulatory surgical facility, birthing center, dialysis center, rehabilitation facility, skilled nursing facility or other provider certified under New York Public Health Law. A hospice is a facility. An institutional provider of mental health substance abuse treatment operating under New York Mental Hygiene Law and/or approved by the Office of Alcoholism and Substance Abuse Services is a facility.

    The group of individuals who provide person-centered care coordination and care management to participants in a FIDA plan. Each participant will have an interdisciplinary team (IDT). Each IDT will be comprised, first and foremost, of the participant and/or his or her designee, and the participant’s designated care manager, primary care physician, behavioral health professional, home care aide, and other providers either as requested by the participant or his or her designee or as recommended by the care manager or primary care physician and approved by the participant and/or his or her designee. The IDT facilitates timely and thorough coordination between a FIDA plan and the IDT, primary care physician and other providers. The IDT makes coverage determinations. Accordingly, the IDT’s decisions serve as service authorizations, may not be modified by a FIDA plan outside of the IDT, and are appealable by the participant, their providers and their representatives. IDT service planning, coverage determinations, care coordination and care management are delineated in the participant’s person-centered service plan and are based on the assessed needs and articulated preferences of the participant.

    An organization comprised of individual physicians or physicians in group practices that contracts with the managed care organization on behalf of its member physicians to provide health care services. Also called an Independent Practice Association.

    Acronym for Medicare Advantage. An alternative to the traditional Medicare program in which private plans run by health insurance companies provide health care benefits that eligible beneficiaries would otherwise receive directly from the Medicare program.

    A doctor of medicine or doctor of osteopathic medicine who is duly licensed to practice medicine and is an employee of, or party to a contract with, a utilization management organization, and has responsibility for clinical oversight of the utilization management organization's utilization management, credentialing, quality management and other clinical functions.

    A nationwide insurance program for the disabled and people age 65 and over, created by the 1965 amendments to the Social Security Act and operated under the provisions of the Act. It consists of two separate but coordinated programs, Part A and Part B.

    An individual and each of his or her eligible dependents, including Medicare beneficiaries who are enrolled or participate in a benefit program and who are entitled to receive covered services from the practitioner pursuant to such benefit program and the terms of the practitioner's agreement.

    The group of physicians, hospital, and other medical care providers that a specific plan has contracted with to deliver medical services to its members.

    A health plan that offers benefits in-network and out-of-network. In-network services are available to enrollees at lower out-of-pocket cost than the services of non-network providers. In addition, PPO enrollees may self-refer to any network provider at any time. Also called a Preferred Provider Organization.

    A medical practitioner or covered facility recognized by EmblemHealth for reimbursement purposes. A provider may be any of the following, subject to the conditions listed in this paragraph:

    • Doctor of medicine
    • Doctor of osteopathy
    • Dentist
    • Chiropractor
    • Doctor of podiatric medicine
    • Physical therapist
    • Nurse midwife
    • Certified and registered psychologist
    • Certified and qualified social worker
    • Optometrist
    • Nurse anesthetist
    • Speech-language pathologist
    • Audiologist
    • Clinical laboratory
    • Screening center
    • General hospital
    • Any other type of practitioner or facility specifically listed in the member's Certificate of Insurance as a practitioner or facility recognized by EmblemHealth for reimbursement purposes

    A provider must be licensed or certified to render the covered service. The covered service must be within the scope of the Provider's license or certification.

    A review to determine whether covered services that have been provided or are proposed to be provided to a member, whether undertaken prior to, concurrent with or subsequent to the delivery of such services are medically necessary. Also called Coordinated Care.


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