Effective August 3, Community First Health Plans will enhance the existing claims processing program to improve the overall accuracy of claim processing in partnership with Cotiviti. We want to share this information in advance, so you are prepared for the upcoming changes.
To support accurate claims submission and reduce denials, Providers are encouraged to review the following notices, which outline specific coding and coverage requirements impacted by clinical editing:
Laboratory Modifiers 59 and 91: Correct Use and Coding Guidance – Clarifies the appropriate use of laboratory services and documentation requirements.
Medical Nutrition Therapy (MNT) Services: Coding and Billing Guidance – Details covered diagnoses, frequency limitations, and billing rules for MNT services.
Lung Cancer Screening with Low-Dose Computed Tomography (LDCT): Coverage and Billing Guidance – Outlines diagnosis, age, and frequency requirements for LDCT screening services.
Implant Billing and Reimbursement Guidelines for Inpatient and Outpatient Services – Explains billing, coding, and documentation requirements for devices that meet the FDA definition of an implant.
Wheeled Mobility Systems: QRP Seating Assessment and Billing Guidance – Provides billing requirements for Qualified Rehabilitation Provider (QRP) participation in seating assessments and final fittings for wheeled mobility systems.
Modifier 25: Correct Use and Coding Guidance for Preventive and Acute Care Services – Clarifies appropriate billing and documentation requirements when reporting a significant, separately identifiable E/M service on the same date as a preventive visit.
Modifier 26: Correct Use and Coding Guidance for Diagnostic Services (Professional Component) – Explains proper reporting of the professional component of diagnostic services and appropriate use of Modifier 26.
These notices and other coding guidance resources are also available on the Community First Provider Portal.
The goals of this endeavor are to implement, to the extent possible, claim payment policies that are broad in scope, simple to understand and that come from regulatory guidance. We believe that this will enable you and your billing staff to more readily understand our payment of claims given the widespread use of these policies.
We focused our payment policies on nationally accepted means of claims payment, which include:
- American Medical Association (AMA) CPT® coding guidelines
- National and regional Medicare policies
- National specialty academy guidelines
- State Medicaid guidelines, as applicable
Community First’s payment policies focus on areas including, but not limited to, the following:
- AMA CPT® procedure code definitions and guidelines
- National Correct Coding Initiative (NCCI)
- Modifier usage
- ICD‑10‑CM diagnosis code guidelines
- Global Surgery periods
- Evaluation and Management (E/M) guidelines
- Add‑on code usage
- Professional, technical, and global billing rules
- Diagnosis‑to‑procedure
- Place of service requirements
- Age‑appropriate services
- CMS National and Local Coverage Determinations (NCDs and LCDs)
- Revenue code validation
After the implementation, you may receive claims denials or payment changes based on these enhanced claim editing concepts on your Explanation of Benefits or electronic remittances. For additional information on the specifics of your claim submission payment decisions, or to file a grievance or appeal, please contact Provider Services at 210-358-6030 or use our online directory to contact your Provider Relations representative directly.
Action:
Providers are encouraged to share this information with their staff. If you have any questions about this notice, please email Provider Relations at ProviderRelations@cfhp.com or call 210-358-6030. You can also contact your Provider Relations Representative directly.
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- Sign up for the Community First Provider eNewsletter
- Log into the Community First Provider Portal
- Go to CommunityFirstHealthPlans.com/Provider-News