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MHS to Implement Physician Emergency Department Post Payment Review

Date: 08/01/19

Managed Health Services (MHS) provides health coverage for member enrolled in Hoosier Healthwise, the Healthy Indiana Plan (HIP) and Hoosier Care Connect. Beginning in September 2019, MHS will partner with VARIS, LLC to implement a post payment review of physician ED claims to ensure adherence to correct coding guidelines. This program will examine those claims for all Indiana Health Coverage Programs billed with a CPT® 99285 (highest levels of payment) but appear to have a lower level of services provided. 

Claims billed with CPT® 99285 will be selected for review by utilizing several factors including but not limited to diagnosis billed, member medical history from prior claims and Indiana ED historical billing patterns. For claims that meet criteria for requiring an additional level of review, medical records will be requested by our review vendor, VARIS, LLC. Physicians will be requested to send in medical records, and VARIS, LLC will complete a coding review, comparing the services actually provided to the CMS 1995/1997 Documentation Guidelines for E & M Services. The physician will be notified if there is an audit finding within 45 days of the medical records being received by VARIS, LLC.

If the claim is found to be coded (and paid) inappropriately based on medical record review, the physician will have the opportunity to agree with the finding and have the reimbursement adjusted to the appropriate E&M level or appeal the finding for further review. If the medical records support the original level of billing, no notice will be sent and no adjustments will be made to the claim.

For additional information, please contact MHS Provider Relations at 1-877-647-4848. Thank you for being our partner in care.

CPT® is a registered trademark of the American Medical Association (AMA). All rights reserved.

Last Updated: 08/01/2019