Submit accurate documentation and valid coding; respond to claim review requests

Providers must submit accurate documentation of services performed and submit claims using valid, industry-standard code sets and combinations. Claims are subject to code edit protocols and review; upon request, providers should supply any additional documentation the Plan requests.

• Use HIPAA-approved code sets and follow Uniform Billing, AMA CPT, HCPCS, ICD-10-CM/PCS, NDC, and CMS coding guidance.
• Claims may be reviewed against benefit terms, provider contract language, medical and reimbursement policies, and coding software logic.
• Be prepared to provide additional documentation upon request to support medical necessity and coding.

Account for reimbursement edits and added/updated codes from policy history

Review the Policy History for recent reimbursement edits and newly added procedure codes; reimbursements, allowed frequencies, and non-reimbursable tests have been updated in the policy history entries.

• Note newly added procedure codes in policy history (examples added: 86200, 86340, 86341, 0446U, 0447U, 0521U, 0522U).
• Recognize that reimbursement information was revised for allowed testing frequencies (e.g., RF/anti-CCP frequency clarifications, ANA frequency guidance) and that multiple proprietary biomarker panels were added to the non-reimbursable list.
• Policy history entries include dates and descriptions of these edits—providers should consult the policy history when submitting claims for affected tests.