Please refer to the tables below for claims edits that will go into effect on Nov. 1, 2020. These edits will apply to both commercial and Medicare Advantage plans.
| Ambulance rules |
|---|
ClaimsXten rule
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ClaimsXten rule description
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| AMB_BUNDLED_SVC |
- This rule recommends the denial of any claim lines with a procedure code other than a valid ambulance HCPCS service or mileage code reported along with a valid ambulance HCPCS procedure code for the same beneficiary, same date of service, by the same provider and on Same Claim Only.
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AMB_FREQUENCY
|
- This rule recommends the denial of an ambulance claim line when the frequency exceeds than allowed limits for a valid ambulance HCPCS service code reported for the same member on the same date of service from.
- This rule will evaluate unique ambulance trip frequency, based on an Ambulance Transport code submitted on the same DOS, Same Member, Same PROVIDER ID, same Origin/Destination MODIFIER and on the same claim ID ONLY.
|
| AMB_MOD_PROC_VALID |
- This rule recommends the denial of ambulance services for the following reasons:
- Claim lacks an appropriate origin-destination modifier or modifier QL.
- Institutional (facility-based) claim lacks an appropriate arrangement modifier (QM or QN).
- Two claim lines for the same date of service lack identical origin-destination and arrangement modifiers.
- For unique Ambulance trip auditing, this will evaluate Ambulance Transport and mileage codes submitted on the Same Claim ID Only and by the same Provider ID, for same member and on same Date of Service.
|
| VALID_AMB_SVC |
- This rule recommends the denial of inappropriate ambulance services for supplier and provider claims, as defined by CMS. Generally, two lines of coding (i.e. mileage code and transport/service code) are required in most ambulance billing scenarios.
- This rule also recommends the denial of claim lines, which lack the presence of an ambulance origin-destination modifier and institutional claim lines which lack appropriate arrangement modifiers as required.
- For unique Ambulance trip auditing, this will evaluate Ambulance Transport and mileage codes submitted on the Same Claim ID Only and by the same Provider ID, for same member and on same Date of Service.
|
| Durable medical equipment rules |
|---|
ClaimsXten rule
|
ClaimsXten rule description
|
| DME_OWN_MADV |
- Denies a current claim line for a DME item that has been submitted with an ownership modifier, when the same DME item has been previously paid in history with another or the same ownership modifier.
- Ownership modifiers are -NU (New), -NR (New when rented), and -UE (Used). They indicate that the DME is paid for in one lump sum (paid for in total, in one payment).
- The rule looks for the DME item and the presence of ownership modifiers -NU, -NR, or -UE on the current claim and the support claim line.
|
| DME_RENT_HX_OWN_MADV |
- Denies claim lines submitted for the rental of a DME item when the same DME item is beneficiary owned in history.
- It is unexpected that a previously owned DME would be rented. A previously submitted paid claim for the same DME indicates that it was beneficiary owned and it is likely that one lump-sum payment or a rental with subsequent purchase has already been made for the DME.
- The current claim line looks for the presence of rental modifier -RR. The support claim lines look for the presence of ownership modifiers -NU, -UE, and -NR.
- Modifier Descriptions:
- RR – Rental
- NU – New Equipment (Indicates Ownership)
- NR – New when Rented, subsequently purchased (Indicates Ownership)
- UE – Used (Indicates Ownership)
|
| DME_RENT_OWN_MADV |
- Denies claim lines submitted for the rental of a DME item in which the rental payment for the DME item exceeds the maximum number of rental payments as defined by CMS.
- Each DME item has a number of rental payments permitted as defined by the DME fee schedule payment guidelines. The rule looks for the presence of rental modifier -RR on both the current and support claim lines.
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| Obstetrical rule |
|---|
ClaimsXten rule
|
ClaimsXten rule description
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| OB_PACKAGE_RULE |
- This rule audits potential overpayments for obstetric care. It will evaluate claim lines to determine if any global obstetric care codes (defined as containing antepartum, delivery and postpartum services, i.e. 59400, 59510, 59610 and 59618) were submitted with another global OB care code or a component code such as the antepartum care, postpartum care, or delivery only services, during the average length of time of the typical pregnancy (and postpartum period as applicable) 280 and 322 days respectively.
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