News

Reminder: New and Improved Front End Paper Claim Processing

Date: 04/02/13

Peach State Health Plan is planning to enhance the edits in our claims processing system to more closely align with HIPAA standards and Georgia billing requirements. Until now, several edits have been considered ‘soft’, meaning that a claim could pass through the claims system even if the edits were not met. When these claims are turned to ‘hard’ edits, billing errors will result in upfront claim rejects or a denial of the claim or claim lines in our processing system.

The following are a few examples of the edits that will be turned to ‘hard’ edits effective July 5, 2012.

  • Edit descriptions
  • Attending provider name/ NPI missing or invalid
  • Operating provider name/ NPI missing or invalid
  • Admit type/source/date/hour missing or invalid
  • Discharge date/hour/status missing or invalid
  • Diagnosis missing or invalid
  • Modifier missing or invalid
  • ICD9 procedure missing or invalid
  • Bill type missing or invalid
  • Revenue code missing or invalid
  • Place of service missing or invalid
  • Accident information missing
  • EPSDT indicators missing or invalid
  • SSN invalid
  • Dates missing or invalid
  • Required Signature and date missing or invalid
  • Invalid/negative charge amount
  • City, State or Zip Code missing or invalid
  • Service unit invalid
  • Institutional Service lines exceeding 97 per claim submission

Having all fields accurate and complete on your claims will allow prompt adjudication and payment, and will eliminate resubmissions.

Thank you for being a provider to the members of Peach State Health Plan. We value our relationship with you, and we continually strive to improve our processes. If you have questions about the edits described in this letter, please call Provider Services at 1-866-874-0633.