Claims Processing Edits

Over the next several months, HMSA will be phasing in a new claims processing system that will use OPTUM as the primary source of code edits. Most of HMSA’s payment policies will not change significantly; however, in some cases, it will become increasingly important that providers change the manner in which they file claims. For example, use of modifiers, as appropriate, will be required under the new system, while under the current system some services are paid without the use of modifiers.

During the transition from the current system to new, some claims will process using HMSA's current system's existing edits and others will process using the new claims processing system with OPTUM edits. Because HMSA is transitioning to the new system, it does not plan to incorporate the policy changes into the old system. As a result providers may notice small variations in processed claims, depending on whether the old system or the new system was used for processing.

The web documents linked below reflect the claims filing guidelines required under the new system. The guidelines should be used for filing all private business claims. Use of the guidelines will facilitate claims processed under the new system and should not negatively affect claims processed under the current system. Providers should implement the updated guidelines as soon as possible.

Notes:

• The code edit changes described in the guidelines below will not override HMSA's existing medical policies.
• CPT code descriptions in the guidelines below have been truncated for economy of space. Please refer to the current CPT manual for the full description of a particular code or code pair.

Office Visits Billed with Other Services

Outpatient Consultations Billed with Other Services

Preventive Service Visits Billed with Other Services

Hospital-Based Visits Billed with Other Services

Immunization Administration Billed with Other Services

Injections and Intravenous Infusion Billed with Other Services

Surgical Services from the 10000 Series of CPT Billed with Other Services

Surgical Services from the 20000 Series of CPT Billed with Other Services

Surgical Services from the 30000 Series of CPT Billed with Other Services

Surgical Services from the 40000 Series of CPT Billed with Other Services

Surgical Services from the 50000 Series of CPT Billed with Other Services

Surgical Services from the 60000 Series of CPT Billed with Other Services

Services from the Radiology Section of CPT Billed with Other Services

Services from the Medicine Section of CPT Billed with Other Services

Revision History