CurrentEmblemHealthPolicy N/A

Pre/Post Claims Payment Reviews

Governs EmblemHealth's routine review of claims (pre- and post-payment) for coding, billing accuracy, appropriateness, and supporting documentation; affects contracted and submitting healthcare providers and claims processing staff.

Policy Summary

PayerEmblemHealth

PolicyPre/Post Claims Payment Reviews

Policy CodePolicy N/A

Change TypeAdministrative transfer / initial creation

Effective DateAug 1, 2021

Next Review DateN/A

Key ActionRespond promptly and completely to records requests; additional or amended records will not be accepted once review is complete.

SourceLink

POLICY UPDATE CHANGES

Transferred policy content to individual company-branded template with no changes to policy title or number.

New Policy created in 4/2021 as the initial document.

pre- and post-paymenttypes of claims reviews performed

all claimsclaims scope (includes facility, lab, professional)

documentation requiredproviders may be asked for itemized bills and medical records

no late recordsadditional or amended records not accepted after review completes

Claims Review Criteria

EmblemHealth may adjust claims based on documentation and applicable coverage/reimbursement policies, benefit plans, and medical necessity.

EmblemHealth (or our designees) routinely evaluate claims for coding, billing accuracy, and appropriateness; reviews may apply to all claims including facility, laboratory, and professional services.

Examples that may prompt adjustment or denial include

Selection of incorrect codes (e.g., DRG/APC validation, CPT, ICD-10, HCPCS).
Excessive charges, unit errors, duplicate or redundant charges.
Billing for items or services not provided or not supported by the documentation submitted.

Policy Summary

PayerEmblemHealth

PolicyPre/Post Claims Payment Reviews

Policy CodePolicy N/A

Change TypeAdministrative transfer / initial creation

Effective DateAug 1, 2021

Next Review DateN/A

Key ActionRespond promptly and completely to records requests; additional or amended records will not be accepted once review is complete.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Code Selection, Validation, and Documentation

Code selection and validationmixed

DRG/APC, CPT, ICD-10, HCPCS

Examples of code sets reviewed for selection errors

Documentation sufficiency — Insufficient documentation may lead to adjustment or denial.

ThresholdInsufficient documentation in the medical record submitted to support the charges billed may lead to adjustment or denial.

Provider responsibilityProviders must submit complete records when requested; records received in response are considered the complete documentation for the review.

Late recordsAdditional or amended records will not be accepted once the audit review is complete; records received after conclusion are considered not to have existed at time of claim submission.

Records Requests, Adjudication, and Appeals

Documentation Required

Records Request and Submission

EmblemHealth (or our designees) may request supporting claim payment information to evaluate coding, billing accuracy, and appropriateness. Examples of requested documentation include itemized bills, operative and procedure reports, implant logs, histories and physicals, office notes, laboratory and radiology reports, and other relevant medical records. When records are submitted in response to a records request, those items are considered the complete documentation for the billed services; documents received after the review is complete are treated as if they did not exist at the time of claim submission. It is the billing provider's responsibility to ensure responses to records requests are prompt and complete. Note: additional or amended records will not be accepted once the audit review is complete. The Treatment, Payment and Health Care Operations (TPO) exception under HIPAA (45 CFR 164.506) permits release of PHI between covered entities for payment purposes.

Examples of items that may be requested: itemized bills, operative/procedure reports, implant logs, histories & physicals, office notes, lab and radiology reports
Records received in response to a request are considered the complete documentation; late submissions will not be accepted once review is complete
Billing provider must ensure responses are both prompt and complete
TPO exception (45 CFR 164.506) allows release of PHI for claim payment without additional authorization

Note

Adjudication, Findings, and Appeals

If EmblemHealth or our designees determine a coding or payment adjustment is warranted after review, the provider will receive claim adjudication, an Explanation of Remittance (EOR), and/or a findings letter detailing the results. Providers have the right to dispute or appeal review results per the provider manual. Appeals should include a written explanation describing how the originally submitted records support the billed items and quantities and must explain how billed units were calculated based on physician orders and medical records. Additional records that were not part of the original review cannot be considered in the appeal. Pre-payment reviews may address overutilization and other practices that result in unnecessary costs; post-payment reviews may identify miscoding, duplicate billing, insufficient documentation, lack of medical necessity, items not separately payable, or other improper payments.

Provider will receive claim adjudication, EOR, and/or findings letter if adjustments made
Providers may dispute results as outlined in the provider manual
Documentation for appeals must include a written explanation tying submitted records to items/quantities billed and a clear calculation of billed units based on physician orders and medical records
Note: Additional records not submitted for the original review are not eligible for consideration on appeal
Common review findings: wrong code selection, unit/duplicate errors, insufficient documentation, lack of medical necessity, items included in other charges, experimental/investigational items, excessive charges

Key Definitions

Pre-Payment reviews

PurposePre-Payment reviews look for overutilization of services or practices that directly or indirectly result in unnecessary costs to the healthcare industry, including Medicare and Medicaid.

ScopeReviews may apply to all claims including facility, laboratory, and professional services.

Actions soughtMay prompt requests for supporting claim payment information such as itemized bills, operative/procedure reports, implant logs, histories and physicals, office notes, lab and radiology reports.

TPO exception (HIPAA)

DefinitionThe Treatment, Payment and Health Care Operations (TPO) exception under HIPAA allows release of medical records containing PHI between covered entities without additional authorization for the payment of healthcare claims.

Regulatory citeReferenced under the HIPAA Privacy Rule: 45 CFR 164.506.

Use in reviewsEmblemHealth and/or designees may rely on the TPO exception to obtain PHI needed to evaluate and adjudicate claims without separate patient authorization.