CurrentPremera BluecrossPolicy cmi_127101

Claim Editing Policy

Defines Premera's claim editing process, categories of claim edits, and exceptions; applies to Premera Blue Cross and affiliated lines of business and products.

Policy Summary

PayerPremera Bluecross

PolicyClaim Editing Policy

Policy CodePolicy cmi_127101

Change TypeClarification and additions (exceptions)

Effective DateJun 12, 2025

Next Review Date

Key ActionClaims are edited against coding/billing standards; coding or billing errors may result in denial of payment.

SourceLink

POLICY UPDATE CHANGES

Modified policy to indicate facility claims are no longer an exception but are edited by CES.

Added an exception to the policy in the Exception section for Self-funded groups.

Policy title changed; Revised the Purpose statement, Definition, Policy statement and Exception sections to provide more details and clarity on claim editing.

Removed references to 'CES' to accommodate multiple internal claim clinical editors established in the claims processing system.

Multipleediting engines applied distinctly to claims

NCCI/MUEs/Globalcommon edits implemented

Premera & affiliateslines of business covered

MedSupp/PBM/BlueCard/Dentalclaim types excluded from editing

Through 06/12/25policy approval history

Claim Editing Criteria and Exceptions

Claim editing criteria and exceptions

The Plan applies claim editing across claims using industry standards and Plan Payment Policies, with specified exceptions.

Claims will be edited using multiple independent claim editors against industry coding and billing standards (e.g., AMA, CMS, specialty organizations) and Plan Payment Policies; resulting edits may lead to denial of payment.

Each claim editor maintains an independent set of edits and exceptions; not every claim will be subject to the same edits due to differences in editors, claim information, or provider/employer contract exceptions.

Editors may use a member's historical claims to perform editing only when those claims are in a completed/final status at the time of editing; claims in a pended or closed status are not used.

CMS Medically Unlikely Edits (MUEs) unit limitations are used as a base for unit-limit edits, with business-driven variations applied as needed.

Policy Summary

PayerPremera Bluecross

PolicyClaim Editing Policy

Policy CodePolicy cmi_127101

Change TypeClarification and additions (exceptions)

Effective DateJun 12, 2025

Next Review Date

Key ActionClaims are edited against coding/billing standards; coding or billing errors may result in denial of payment.

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.

Claim editing is not applied to Medicare Supplement claims.
Claim editing is not applied to pre-paid claims (for example, Pharmacy Benefit Manager (PBM) claims).
Claim editing is not applied to Blue Card Home claims.
Claim editing is not applied to Dental claims.

Exceptions to claim editing may be established by provider or employer group contract; self-funded group exceptions were added to the policy.

Violations of this policy by parties with written arrangements with the Plan may result in increased auditing and monitoring, contractual penalties, or termination of contract; disciplinary actions are at the Plan's discretion.

Coding Sources, Edit Sets, and MUEs

Coding sourcesmixed

CPT	Current Procedural Terminology procedure codes and guidelines used as base for edits
HCPCS	HCPCS procedure codes and guidelines used as base for edits
ICD-10-CM	Diagnosis coding guidelines
ICD-10-PCS	Inpatient procedure codes

Edit setsmixed

MUE	Medically Unlikely Edits unit limitations used as a base
NCCI	National Correct Coding Initiative edits

MUE unit limits

MUE sourceCMS Medically Unlikely Edits (MUEs) unit limitations are used as the base for MUE unit limits

Business variationsMUEs are applied with some variations due to business needs

Use of historical claimsEditors may use a member's historical claims for editing only if those claims are in completed/final status at time of editing

Excluded claim typesMUE application does not extend to Medicare Supplement, PBM (pre‑paid), Blue Card Home, and Dental claims

Multiple editorsMultiple independent claim editors apply MUEs and other edits separately, so unit limits may be enforced differently by each editor

Claim Editing Impact and Denial Risk

Denial Risk

Claims are edited against coding/billing standards; errors may result in denial

Claims submitted to the Plan are reviewed by multiple internal claim editors against industry coding and billing standards and Plan Payment Policies; if a claim encounters a coding or billing error based on these standards the claim may be denied for payment.

Each claim editor applies its own independent edits and exceptions; not every claim will be edited identically.
Denials may result when claims fail to meet correct coding principles established by AMA, CMS, or other industry specialty organizations.

Key Terms

Claim Editing (definition)

DefinitionClaim Editing is a step within the claim adjudication process where a claim is edited against correct coding principles (e.g., AMA, CMS, specialty organizations)

Purpose within adjudicationThe Plan utilizes multiple claim editors to analyze submitted claims against industry coding and billing standards and Plan Payment Policies

Effect of errorsWhen a claim encounters a coding or billing error based on correct coding principles, the claim may be subject to denial of payment

Editor independenceEach claim editor has an independent set of edits and exceptions and may not apply the same edits to every claim

Exceptions and contractsEdits applied may vary based on provider or employer group contract exceptions