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June 2019
Here’s helpful information about clinical editing appeals for Blue Cross PPO and Medicare Plus Blue claims
When we receive clinical editing appeals for PPO and Medicare Plus BlueSM PPO claims, we review the entire claim and all documentation provided. The goal of the review is to make sure that the documentation supports the services and procedures reported on the claim and that the claim follows correct coding and billing guidelines.
Occasionally, the documentation does not support the coding on the claim. When this happens, a recovery may occur on a code or service that wasn’t appealed. When this happens, you have a right to appeal the determination since it is a new edit or denial.
For more information, see your online provider manual.
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