Effective October 1, 2020, The Health Plan (THP) will be implementing ClaimsXten, a claims editing tool developed by McKesson Information Solutions. ClaimsXten rules are clinically based and validated by a national panel of clinicians and medical experts.
THP previously implemented this software for professional claims and is now incorporating hospital claims.
The hospital claims edits will be applied across all THP product lines, which currently include Commercial, Medicare Advantage, Public Employees Insurance Agency (PEIA) and West Virginia Medicaid lines of business.
Some examples of ClaimsXTen edits include:
- Deleted code edits
- Gender edits
- Age edits
- Pre-operative visit, same day visit, post-operative visit bundling edits
- Frequency validation: once or multiple times per date edits
- Bilateral procedure edits
- Multiple code re-bundling, multiple surgery, and assistant surgeon edits
- Unbundling, incidental, mutually exclusive edits
- Medicare and Medicaid-related Correct Coding Initiative (CCI) logic
- Other Centers for Medicare and Medicaid Services (CMS) carrier directives
As a result of THP’s ClaimsXten claims editing software, hospital providers will receive less post-payment audits and recoveries.
Please contact THP at 1.800.624.6961 with questions.