May 26, 2026
On or after Sept. 1, 2026, we’ll expand prepayment review of some inpatient and outpatient claims for commercial members with a threshold of $50,000 or more. These expanded reviews will enhance our claims editing process to better align provider coding with industry standards for accurate billing and proper reimbursement
What this means for you: The enhancements require you to continue to follow generally accepted claim payment policies. Claims that do not follow this guidance may be delayed or denied for payment.
Please note that this enhancement should not impact response times.
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The information provided does not constitute coding or legal advice. Physicians and other health care providers should use their own medical judgment based upon all available information and the condition of the patient in determining the appropriate course of treatment, and to submit claims using the most appropriate code(s) based upon the medical record documentation, coding guidelines and reference materials.