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Professional Claim Editing

Provider Type

  • Physicians

For individual Medicare and Special Needs Plans

For individual Medicare and Special Needs Plans (SNP), Health Net has a contractual relationship with ClaimsXten to provide a technology solution for professional claim edit policy management. Using ClaimsXten's services, Health Net has the ability to apply advanced contextual processing for application of edit logic, also uses another editing vendor, HCI/PCI, to perform a secondary review after ClaimsXten.

The process is as follows:

  • Customizes and controls the selection of all edit policy.
  • Claims are transferred through various interfaces to Cotiviti every night.
  • ClaimsXten reviews each claim in the file and renders coding recommendations based on s edit policy.
  • After ClaimsXten review, if there are any unedited lines remaining, they are sent to HCI/PCI for a secondary review.
  • Once all reviews are complete edit recommendations from the vendors are then applied to the claims.

ClaimsXten and HCI/PCI also provide management support services, including edit policy advisory services. The vendor's Medical Policy teams conduct ongoing research into payment policy sources, including, but not limited to, the Centers for Medicare & Medicaid Services (CMS), the American Medical Association (AMA) and other specialty academies, to provide Health Net with the necessary information to make informed decisions when establishing edit policy.

For Medicare Employer Groups

For Medicare employer groups, Health Net has a contractual relationship with Cotiviti to provide a technology solution for professional claim edit policy management. Using Cotiviti's services, Health Net has the ability to apply advanced contextual processing for application of Health Net edit logic. Health Net also uses another editing vendor, Verscend, to perform a secondary review after Cotiviti.

The process is as follows:

  • Health Net customizes and controls the selection of all edit policy.
  • Claims are transferred through various interfaces to Cotiviti every night.
  • Cotiviti reviews each claim in the file and renders coding recommendations based on Health Net's edit policy.
  • After Cotiviti review, if there are any unedited lines remaining, they are sent to Verscend for a secondary review.
  • Once all reviews are complete edit recommendations from the vendors are then applied to the claims.

Cotiviti and Verscend also provide management support services, including edit policy advisory services. The vendor's Medical Policy teams conduct ongoing research into payment policy sources, including, but not limited to, CMS, AMA and other specialty academies, to provide Health Net with the necessary information to make informed decisions when establishing edit policy.

Last Updated: 10/30/2019