Enhanced Edits on Paper and Electronic Claims

Posted 3 July 2012 by asanders & filed under Provider News.

Managed Health Services (MHS) is planning to enhance the edits on paper and electronic claims. These edits will be introduced on a phase-in basis from June through July. These edits will align our claims system more closely with State required claim standards. Claims hitting against these edits will result in rejections and/or denials.

The following are the edits that will be introduced. Please note that these are required depending upon “claim type and location of service” provided, so these may or may not apply to claims submitted by your office.

Edit description

• Diagnosis, CPT, HCPCS ICD-9 code, modifier, revenue code missing when required or invalid
• Physician administered drugs billed with HCPCS codes, must always be accompanied by the corresponding National Drug Code (NDC)
• Admit type/source/discharge hour, admission date, admission hour, patient status, bill type missing or invalid
• Place of service missing (location code) or invalid
• Present on Admission Indicator (POA) missing when required or invalid

Having all fields accurate and complete on your claims will allow prompt adjudication and payment, and will eliminate resubmissions.

Thank you for serving MHS members. We value our relationship with you, and we continually strive to improve our processes. If you have questions about the edits described, please call Provider Services at (877) 647-4848.