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Two New ClaimsXten Rules to be Implemented in April 2020

Posted January 13, 2020

We will soon update our ClaimsXten software database to better align coding with the reimbursement of claim submissions.

Implementation Schedule

On April 20, 2020, we will update two new rules, as follows:

  • Bilateral Services for Professional Claims
  • Modifier to Procedure Validation Filter – Non-Payment Modifiers

Rule Details

Bilateral Services for Professional Claims

This rule identifies claim lines where the submitted procedure code was already billed with a modifier – 50 for the same date of service.

The same service performed bilaterally should not be billed twice when reimbursement guidelines require the code to be billed once with a bilateral modifier.

The rule denies the second submission.

Modifier to Procedure Validation Filter – Non-Payment Modifiers

For non-payment modifiers, this rule identifies claim lines with an invalid modifier to procedure code combination.

It recommends the denial of procedure codes when billed with any non-payment affecting modifier that is not likely or not appropriate for the procedure code billed.

When multiple modifiers are submitted on a line, all are evaluated and if at least one is found invalid with the procedure code, the line is recommended for denial.

For More Information

To help determine how coding combinations on a particular claim may be evaluated during claim adjudication, use Clear Claim ConnectionTM (C3). Refer to the Clear Claim Connection page for answers to frequently asked questions about ClaimsXten and details on how to gain access to C3.

Important note: C3 does not contain all claim edits and processes used by BCBSIL in adjudicating claims; and the results from the use of the C3 tool are not a guarantee of the final claim determination.

This material is for educational purposes only and is not intended to be a definitive source for coding claims. Health care providers are instructed to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials.  

ClaimsXten and Clear Claim Connection are trademarks of Change Healthcare, an independent company providing coding software to BCBSIL. Change Healthcare is solely responsible for the software and all the contents. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Change Healthcare. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.