We pay providers directly in accordance with the federal No Surprises Act. This federal mandate ends surprise medical bills by holding the patient harmless for care in:
- Emergency services regardless of network status
Non-emergency situations when services are performed by out-of-network (OON) providers at in-network facilities
The act also requires insurance companies to pay OON providers directly.
Professional claims from providers who have acquired a Notice of Surprise Billing and Consent by the member to allow you to bill balances outside of member cost-share must submit their electronic claim(s) by populating the PWK segment with a value of “CK” to indicate that you acquired a signed notice and consent from the member. If this information is not reflected in the EDI portion of the claim, your claim(s) will be processed according to the Federal No Surprise Act using the Qualified Payment Amount and balances must be written-off.
Note: Washington state law does not allow providers to acquire notice and consent from members on fully insured groups or self-funded groups that have opted into the Washington state mandate.
The administrative policies and guidelines that we use to review and pay claims are important and integral to the relationship we share with our participating providers. When establishing our policies, we attempt to adopt widely accepted community policies and standards when they are available and supportable. In keeping with this, we use CMS' NCCI edit data with our claims processing system. In addition, we have identified correct coding edits to supplement NCCI.
Correct coding edits identify component service codes that are inappropriately reported as separate and distinct services from the comprehensive code. In comprehensive and component codes edits, the comprehensive code will be reimbursed to contract benefits and the component code will be considered included in the comprehensive code.
Our Correct Code Editor (CCE) houses the correct coding edits and is updated quarterly (January, April, July and October.) Coding changes occurring in the updates are effective for dates of service on or after the installation date and no claims will be adjusted retrospectively.
All lines of business will use CCE. NCCI logic will apply first, then supplemental CCE edit logic will apply when a claim is being adjudicated. Feedback may be submitted by contacting us.
If you have a specific question or concern regarding a specific claim, please follow the provider billing dispute and medical necessity procedure determination appeal process.
Correct Coding Solutions, LLC, develops and refines NCCI, coordinates the receipt of comments, the prioritization of issues, the review and research of previous actions and the discussion with CMS about the concerns. Correct Coding Solutions accepts written comments via mail or fax at:
National Correct Coding Initiative
Correct Coding Solutions, LLC
P.O. Box 907
Carmel, IN 46082-0907
Fax: (317) 571-1745