Prepayment clinical validation review process

Category: Medicaid

Effective with dates of service on or after September 5, 2019, Empire BlueCross BlueShield HealthPlus will update our audit process for claims with modifiers used to bypass claim edits. Modifier reviews will be conducted through a prepayment clinical validation review process. Claims with modifiers such as -25, -59, -57, LT/RT and other anatomical modifiers will be part of this review process.

 

In accordance with published reimbursement policies that document proper usage and submission of modifiers, the clinical validation review process will evaluate the proper use of these modifiers in conjunction with the edits they are bypassing (such as NCCI). Clinical analysts who are registered nurses and certified coders will review claims pended for validation, along with any related services, to determine whether it is appropriate for the modifier to bypass the edit.

 

If you believe a claim reimbursement decision should be reviewed, please follow the normal provider claims payment dispute process and include medical records that support the usage of the modifier applied when submitting claims for consideration.

 

For more information, contact your Provider Relations representative or call Provider Services at 1-800-450-8753.

 

NYE-NU-0133-19

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