Reminder: New Claims Processes

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Date: March 13, 2024
From: Health Plan of San Joaquin/Mountain Valley Health Plan(“Health Plan”) Claims Department
To: Health Plan Providers
Type: Informational
Subject: Reminder: New Claims Processes
Business: Medi-Cal Managed Care

Health Plan is implementing two new claims management processes on April 1, 2024, to support automated application of correct coding principles.

Claims Pre-Payment Processing Changes
Beginning April 1, 2024, Health Plan is partnering with Optum to assist with pre-payment claims workflow review. Please continue submitting claims for Health Plan members as you do today. You may receive co-branded materials from Optum and Health Plan requesting medical records and other documentation to assist in any necessary claim pre-payment reviews. We thank you in advance for your prompt attention and response to these requests.

Claims Editing Processing Changes
In addition, on April 1, Health Plan is implementing new institutional claims editing processes. We are enhancing our existing, internally developed claims editing processes, which we use to administer reimbursement policy and claim edit rules, by passing institutional claims through the Optum Claims Edit System® (CES).

CES uses the following sources for its edits:

  • National Correct Coding Initiative (NCCI) edits, including Medically Unlikely Edits (MUEs)
  • Federal Register (the Daily Journal of the US Government that contains agency rules, proposed rules, and public notices) Medicaid publications
  • Medi-Cal State regulations

What do you need to do?
Because many other carriers with whom you work already use Optum’s CES, we do not anticipate this implementation will disrupt how you work with Health Plan. CES will replace our legacy edits and automatically review and catch errors, omissions, and questionable coding. The result will be streamlined claims, reduced reimbursement errors and improved payment integrity. All edits are transparent, and you will be able to look up specific claims and see both the edits and the sourced citations.

The following are examples of types of institutional edits that will be reviewed through CES beginning April 1:

*Incentive amounts for NCQA HEDIS rate improvement


Outpatient Edit Examples Inpatient Edit Examples
Data validity edits

  • Invalid diagnosis codes
  • Diagnosis code requires additional digits
  • Diagnosis to age or gender conflict
  • E-code as reason for visit
  • Invalid CPT/HCPCS code
  • CPT/HCPCS to gender conflict
  • Invalid modifier, service date, age, gender, units, revenue code
  • Invalid diagnosis code
  • Diagnosis code requires 3rd or 4th digit
  • Invalid procedure code
  • Secondary diagnosis
  • Diagnosis/procedure conflicts with patient age or gender
  • Invalid principal diagnosis
    o Manifestation
    o Non-specific
    o V-codes
    o E-code
  • Invalid age, gender, discharge status
Medical necessity edits

  • No supporting diagnosis
  • Not medically necessary for this age or gender
  • Missing appropriate secondary diagnosis
  • Missing appropriate associated procedures
Coding issues

  • Inappropriate coding of bilateral services
  • Evaluation & management (E&M) with surgery without modifier 25
  • Claim contains only incidental services
  • Terminated procedure with units > 1
  • Multiple E&M services with same revenue code on same date
  • Revenue center requires CPT/HCPCS
  • Implantable device without surgery
  • Duplicate claim checks

Virtual Look and LearnIf you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG

Posted on March 11th, 2024