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Experience. Integrity. Advocacy.

MHS to Implement Physician Emergency Department Post Payment Review of Level 5 Services

MHS to Implement Physician Emergency Department Post Payment Review of Level 5 Services

Just two months after Anthem announced upcoming post-payment reviews of level 5 emergency department visits for their Medicare Advantage plans, Managed Health Services (MHS) has advised physicians they will also begin post-payment reviews of level 5 ED claims for their Hoosier Healthwise, Healthy Indiana Plan (HIP), and Hoosier Care Connect plans.

“Beginning in September 2019, MHS will partner with VARIS, LLC to implement a post payment review of physician ED claims to ensure adherence to correct coding guidelines,” the payer said in a recent announcement. “This program will examine those claims for all Indiana Health Coverage Programs billed with a CPT® 99285 but appear to have a lower level of services provided.”

According to MHS, claims will be selected for review based on the following:

  • CPT 99285, 
  • Diagnosis (though specific diagnoses were not specified), 
  • Member medical history from prior claims, and
  • Indiana ED historical billing patterns.

For claims that meet the criteria for additional level of review, VARIS, LLC, will contact providers to request medical records. VARIS will then complete a coding review, comparing the services provided and documented to the CMS 1995/1997 Documentation Guidelines for E/M Services. 

If VARIS finds that the claim has been coded and paid inappropriately based on the medical record review, a notice will be sent within 45 days. Physicians will then have the opportunity to appeal the finding for further review. If the medical records review supports the original E/M level, no notice will be sent and no adjustments will be made to the claim.

For more information, check out the post-payment review announcement on the MHS website or contact MHS Provider Relations at 1-877-647-4848.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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