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Cross Claim Edits Will Be Performed Across 1500 and 1450 forms
Effective May 30th, 2017, Aetna will have the capability to look across claim types during claims adjudication. This will allow Aetna to correctly adjudicate claims where conflicts may exist between professional (CMS-1500) claims and institutional (CMS-1450) claims.
For example:
- A procedure is reported by a physician in a place of service indicating a physician's office while the same procedure is also reported by an ambulatory surgical center on a facility claim. This conflict would be identified so that the provider receives the appropriate reimbursement.
- A home infusion service is reported from a member indicating the service took place in a patient's home on a CMS-1500 but a CMS-1450 claim indicates that the member was an inpatient during that period of time. This conflict would be identified so that the home infusion provider receives appropriate reimbursement.
Implementing this new payment policy capability to evaluate services across claim types will enable Aetna to more accurately and appropriately adjudicate services.
Please contact us at
1-855-364-0974 from 8:00 AM to 5:00, Monday through Friday, with any questions or concerns you may have.
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