Claims Editing System (CES) Go-Live May 17
| Date: | May 15, 2024 |
| From: | Health Plan |
| To: | Health Plan of San Joaquin/Mountain Valley Health Plan (Health Plan) Providers and Facilities |
| Type: | Informational |
| Subject: | Claims Editing System (CES) Go-Live May 17 |
| Business: | Medi-Cal Managed Care |
Reminder: Health Plan is implementing new institutional claims editing processes.
We are enhancing our existing, internally developed claims editing processes, which we use to administer reimbursement policy and claim editing rules, by passing institutional claims through the Optum Claims Editing System® (CES).
CES will go live on Friday, May 17, 2024.
CES uses the following sources for its edits:
- National Correct Coding Initiative (NCCI) edits, including Medically Unlikely Edits (MUEs)
- Federal Register (the Daily Journal of the US Government that contains agency rules, proposed rules, and public notices) Medicaid publications
- Medi-Cal State regulations
What do you need to do?
Because many other carriers with whom you work already use Optum’s CES, we do not anticipate this implementation will disrupt how you work with Health Plan. CES will replace our legacy edits and automatically review and catch errors, omissions, and questionable coding. The result will be streamlined claims, reduced reimbursement errors and improved payment integrity. All edits are transparent, and you will be able to look up specific claims and see both the edits and the sourced citations.
The following are examples of types of institutional edits that will be reviewed through CES beginning May 17:
| Outpatient Edit Examples | Inpatient Edit Examples |
| Data validity edits
· Invalid diagnosis codes · Diagnosis code requires additional digits · Diagnosis to age or gender conflict · E-code as reason for visit · Invalid CPT/HCPCS code · CPT/HCPCS to gender conflict · Invalid modifier, service date, age, gender, units, revenue code |
· Invalid diagnosis code
· Diagnosis code requires 3rd or 4th digit · Invalid procedure code · Secondary diagnosis duplicates the principal diagnosis · Diagnosis/procedure conflicts with patient age or gender · Invalid principal diagnosis o Manifestation o Non-specific o V-codes o E-code · Invalid age, gender, discharge status
|
| Medical necessity edits
· No supporting diagnosis · Not medically necessary for this age or gender · Missing appropriate secondary diagnosis · Missing appropriate associated procedures |
|
| Coding issues
· Inappropriate coding of bilateral services · Evaluation & management (E&M) with surgery without modifier 25 · Claim contains only incidental services · Terminated procedure with units > 1 · Multiple E&M services with same revenue code on same date · Revenue center requires CPT/HCPCS · Implantable device without surgery · Duplicate claim checks |
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG
