Medicare - Administrative Procedures
ConnectiCare evaluates medical billing information and coding for accuracy and appropriateness. This practice is designed to detect coding patterns such as unbundling, integral procedures, and mutually exclusive procedures.
In addition, ConnectiCare’s claims payment system will adjudicate claims based on CMS (Centers for Medicare & Medicaid Services) and NCCI (National Correct Coding Initiative) edits. ConnectiCare considers coding edits that are based on industry sources, including but not limited to CPT guidelines from the American Medical Association, specialty organizations, and CMS. In coding scenarios where there are conflicts between sources, ConnectiCare will apply edits that ConnectiCare determines are most appropriate.
For questions about why a particular claim was denied based on a coding edit, refer to your remittance, or, contact Provider Services at 1-877-224-8230.