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Third-Party Claim and Code Review Program

 

Beginning June 1, 2022, you may see new claim edits. These are part of our Third-Party Claim and Code Review Program. These edits support our continuing effort to process claims accurately for our commercial, Medicare and Student Health members. You can view these edits on our Availity provider portal.*

 

We are also expanding our claim edits for E&M services to our Medicare line of business with this update. This expansion enhances our prepayment claims editing processes for coding policy rules related to correct coding of E&M of levels of care for our Medicare members. We already apply these rules to our commercial line of business. These edits evaluate the correct coding for level 4 and 5 E&M codes (CPT codes 99204, 99205, 99214, 99215, 99244, 99245, 99204 and 92014) using the American Medical Association (AMA) E&M criteria.

 

We will review claims billed with the following places of service: office, inpatient hospital, on campus — outpatient hospital, emergency room — hospital, off campus — outpatient hospital, and urgent care facility.

 

Based on the outcome of the review, we may adjust your payment if the claim detail doesn’t support the billed level of service. We will not change the procedure code you bill.

 

These changes will support our goal of consistency across all lines of business.

 

You can view any of these edits on our Availity® provider portal.

 

For coding changes, go to:

 

  • Aetna Payer Space
  • Resources
  • Expanded Claim Edits

 

Except for Student Health, you'll also have access to our code edit lookup tools. To find out if our new claim edits will apply to your claim, log in to our Availity provider portal. You'll need to know your Aetna® provider ID number (PIN) to access our code edit lookup tools.

 

We may request medical records for certain claims, such as high-dollar claims, implant claims and bundled services claims, to help confirm coding accuracy.

 

Note: This is subject to regulatory review and separate notification in Washington state.

 

*Availity is available only to U.S. providers and its territories.

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