Ingenix Claims Editing System (iCES) - Exceptions - Premera Blue ...

Professional Services ClaimsCoding Corporate PolicyTitleNumberCurrentEffective DateOriginalEffective DateReplacesCrossReferenceClaims Editing System (CES) - ExceptionsCP.PP.373.v1.406/09/1409/27/07N/ANonePurposeScopePolicyViolations ofPolicyTo define the claim categories identified as not being subject to the professional ClaimsEditing System (CES).Applies to PREMERA and its subsidiaries and affiliates (“Premera” or the “Company)with the exception of Medicare Advantage.The following claim types/claim categories are not sent through the CES clinical editor:• Medicare Supplement• Pre-paid claims (Medco)• Facility claims• Blue Card Home Claims• Dental claimsHowever all claims in a completed status contained in the members history are utilized toconduct editing on those claims sent to the CES clinical editor. Those claims containedin a member’s history that are in a "pended" or "closed" status are not utilized to conductediting on those claims sent to the CES clinical editor. Such claim examples include:• Claims which contain a “PROXY member number” (i.e. Blue Cross HostClaims) and• “FEP” historical claims in a “closed status”.Violations of this policy by any party that enters into a written arrangement with the Planmay result in increased auditing and monitoring, performance guarantee and othercontractual penalties and/or termination of the contract. Disciplinary actions will beappropriate to the seriousness of the violation.Violations of this policy may be grounds for disciplinary action. The level of discipline isat the discretion of the Company, and may include any of the following: (1) verbalwarning; (2) written warning; (3) suspension; (4) termination; and (5) restitution.ExceptionProcessLaws,Regulations &StandardsControlsContactNoneNoneConfiguration is tested and systems are compliant at time of testing.Any questions regarding the contents of this policy or its application should be directedto an HCDS director or regional contracting manager, or an HCE director or manager.1Confidential & Proprietary – For Internal Use Only.Please refer to the Corporate Policies iWeb site for the most recent version of this policy.

ApprovalDates06/09/14; 06/17/13; 06/20/12; 12/12/11; 08/01/11Policy OwnerReviewPrint NameSignatureSenior Vice President, Health Care Delivery SystemsRich MaturiElectronic approval on fileDate 06/08/14ApprovalPrint NameSignaturePresidentJeff RoeElectronic approval on fileDate 06/09/142