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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