Edits applied by EmblemHealth; provider recourse

EmblemHealth applies coding edits using internal and third‑party vendors and may deny or recoup claim payment when coding/billing guidelines are not followed; providers may request an explanation of how specific edits were handled.

• Edits are applied to professional and outpatient facility claims (including ambulance, DMEPOS, drugs).
• Upon request, EmblemHealth will provide an explanation of how it handles specific coding issues; failure to follow guidelines may result in denial or recoupment.

Disposable breast milk bags — 200/month limit

Disposable breast milk bags (HCPCS K1005, A4287) are limited to 200 per calendar month; claim lines for these codes will be denied when that monthly limit is exceeded.

Modifier 50 — line quantity adjusted to 1 for bilateral codes

When a procedure is submitted with modifier 50 and the line quantity is greater than 1, the system will modify the line quantity to 1 for specified bilateral procedures per CMS bilateral indicators.

• Applies only to specific bilateral procedure codes identified from CMS conditional/independent bilateral lists.
• CMS bilateral indicators determine whether modifier 50, LT/RT, or per-side reporting is appropriate.

Q4 lab packaging and STV/T/N packaged HCPCS — deny when billed with non‑lab services

Laboratory services with CMS conditional packaging (Status indicator Q4) will deny when billed with any non‑laboratory service on hospital outpatient bill types 0130‑013Z; HCPCS codes packaged (Status N/STV/T) will deny when billed by an outpatient hospital in packaged scenarios.

Denials when billing conditions not met (examples)

Items, services and procedures designated Not Payable will be denied when required billing conditions are not met — examples include transportation of portable x‑ray (R0070/R0075) when corresponding radiology service is not billed, and chiropractic manipulation (98940‑98942) billed without required diagnosis or modifier AT.

Preventive/screening services — frequency and POS restrictions

Certain preventive and screening services (e.g., G0438/G0439 annual wellness visits; HIV screening G0432/G0433/G0435/G0475) are not payable under specified frequency or place‑of‑service rules and will be denied when those restrictions are not met.

Diagnosis laterality conflicts — denial risk

If a billed diagnosis indicates laterality that conflicts with the procedure or modifier reported (e.g., RT/LT vs a code/modifier indicating the opposite), the service is not payable and may deny.

Co‑surgeon services require modifier 62 and documentation

Procedures designated for co‑surgeons require modifier 62 and supporting documentation; claims for co‑surgeon services billed without modifier 62 or with conflicting claim data may be denied.

Clinical trial modifiers Q0/Q1 — will deny

All clinical trial procedure lines billed with modifier Q0 or Q1 will deny; providers must use the correct encounter coding rather than Q0/Q1 to avoid denial.

Single‑dose vial wastage — submit administered + JW waste line

When reporting wastage from single‑dose drug containers, submit two complete claim lines per CMS guidance: one line for administered units (no JW) and a separate line for wasted units with modifier JW; alternatively, use JZ on the administered line when no wastage.

Single‑dose container drug wastage — JW/JZ reporting required

For drugs from single‑dose containers, submit a complete administered drug line (no JW) and a separate wasted‑units line with modifier JW; single‑dose container drug claims will deny if not billed with JW or JZ as applicable.

Duplicate code/service billing — denial logic

Duplicate drug codes or duplicate services (same code and same units) billed by any provider for the same date of service are not payable and will deny.

DME/dressing modifier requirements (EY, A1‑A9, GY)

Items billed with modifier EY (no physician order) will not be paid; surgical dressing codes billed without required A1‑A9 or GY modifiers are not payable, and non‑surgical dressing codes appended with surgical dressing modifiers are not payable.

DME HCPCS lists — specified L‑codes not payable

Durable medical equipment HCPCS lists include non‑payable L‑series codes (e.g., L1810‑L1860 knee orthoses) and numerous other L‑codes that are not payable per the DME/Supplies policy.

Hemodialysis — limited to ≤3 sessions/week in specified POS

Hemodialysis CPT codes 90935 and 90937 are not payable when billed more than three times weekly in specified places of service (e.g., POS 11, 12, 16, 19, 22, 65).

E/M with preventive services — lower‑RVU E/M denied unless modifier 25

When preventive and problem‑oriented E/M services are billed on the same date, the lower‑RVU E/M is not payable; modifier 25 must be appended to the additional/problem‑oriented E/M (with supporting documentation) for it to be payable.

Unit limits — observation and critical care (one unit per DOS)

Observation, neonatal and pediatric critical care codes and specified observation/critical care services are limited to one unit per date of service by any provider; multiple units on the same DOS will not be payable.

NY Medicaid — Category II CPT codes required on global obstetric claims

For NY Medicaid global obstetric claims, the corresponding Category II CPT codes (0500F, 0502F, 0503F) must be included; claims submitted without the required Category II codes will be denied.

COVID‑19 specimen collection (G2023/G2024) — integral to testing; not separately reimbursed

COVID‑19 specimen collection codes G2023 and G2024 are considered integral to COVID testing and are not separately reimbursable when a COVID test is rendered.

MUE appeals — submit clinical documentation when MAI=2 or MAI=3

When CMS MUE limits are enforced with MAI=2 or MAI=3, providers may submit clinical documentation as part of an appeal to support reimbursement for additional units; MAI rules define whether modifier overrides are allowed.

• MAI=1: single claim‑line denial for exceeding MUE.
• MAI=2: date‑of‑service edit; no modifier override considered.
• MAI=3: clinical benchmark edit; modifier 59 will not override; clinical documentation may be appealed.

Home infusion modifier SJ — requires prior SH on same DOS

Intravenous home infusion codes billed with modifier SJ (third or more concurrently administered infusion therapy) are not payable unless a prior SH modifier (second concurrently administered infusion therapy) was billed on the same date of service.

Therapy revenue codes require GP/GO/GN modifiers

Claim lines billed with therapy revenue codes (042X, 043X, 044X) must include the appropriate therapy modifier: GP for Physical Therapy, GO for Occupational Therapy, or GN for Speech‑Language Pathology; lines without the correct modifier will be denied.

E/M separate payment requires modifier 25 with documentation

E/M services billed with procedures are not separately payable unless modifier 25 is appended with documentation; consultation codes and certain E/Ms follow modifier 25 rules to be separately payable.

NCCI Column one/Column two edits (COVID‑19 temporary guidance noted)

Temporary during COVID‑19, NCCI Column two procedure codes are not payable when billed with associated Column one procedure codes per NCCI guidance; standard NCCI column one/column two edits apply.

New patient code — denied if same provider had paid new‑patient within 3 years

New patient codes are not payable when the same provider has billed and been paid for a new patient within the prior three years; providers should validate prior new‑patient billing history before submitting.

Pay‑percent recommendations when preventive + other E/M billed same date

When a well visit (preventive) and other E/M codes are billed on the same date by the same provider, EmblemHealth applies pay‑percent recommendations by RVU rank: Rank 1 = 100%, Rank 2 = 50%, Ranks 3–5 = 0%.

DME rental vs purchase modifier conflict — denies conflicting same‑date billing

DME codes billed with rental modifiers (BR, RR, KI, KJ, KR, LL) and DME purchase modifiers (BP, NU, UE) are not payable if the same code was previously billed the same date with either rental or purchase modifiers (rental vs purchase conflict).

Drug administration must be billed with administration code on same claim/DOS

Claims for drug administration must include the appropriate administration code on the same claim and date of service; if the administration code is missing on the same claim/DOS, the claim will be denied.

E/M codes — place‑of‑service restrictions and E/M add‑on limits

Evaluation and management add‑on codes and many E/M services have place‑of‑service restrictions; E/M add‑ons are not payable with ED visits by emergency medicine in POS 23 (or disallowed POS) and other E/M codes are payable only in specified POS values.

PC/TC/26/TC and global component billing — ensure correct component reporting

Report professional (26) and technical (TC) components correctly: modifier 26/TC and PC/TC status '4' (global‑only) services have strict rules — billing incorrect component or billing global‑only codes in the wrong setting will result in denial or limited payment.

Global‑only (PC/TC=4) codes — bill correct component in appropriate setting

When PC/TC status is '4' (Global Only), do not bill the global code in the wrong setting; only the appropriate component (professional or technical) is payable in facility vs professional contexts — report the correct code/component and modifier.

Telehealth modifiers (GQ, G0, 95) — use only with approved codes/POS

Use telehealth modifiers only as allowed: do not append GQ, G0 or 95 inappropriately; modifier 95 is payable only with approved codes and place‑of‑service considerations (POS 02 for some GQ scenarios).

Intraoperative neurophysiology — integral to primary procedure; don’t report separately

Do not report intraoperative neurophysiology monitoring separately when performed by the operating surgeon or anesthesiologist — these services are included in the primary surgical procedure and only reimbursed when performed as a diagnostic service.

Unbundled pairs and examples — do not report separately

Do not report surgical preparation codes (15002‑15005) with wound management/debridement; E/M services and other listed pairs (e.g., 76140 with E/M, 77427 with E/M) are considered unbundled pairs and are not separately payable.

Aspiration during laryngoscopy/bronchoscopy — integral; not separately payable

Aspiration of saliva/foreign matter during laryngoscopy/bronchoscopy (e.g., CPT 31515) is integral to the procedure and is not reimbursed separately when performed by the operating provider.