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MA PAP236

Outpatient Code Edits and Remittance Advice Codes


Provider Administrative Policy

Section
Provider Information
Policy Date
August 2010
Status/Date
Revised/October 2011
Provider Type(s)
All Providers  

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.

Policy

Outpatient Code Edits and Remittance Advice Codes

There are currently 83 different edits housed in the Outpatient Code Editor (OCE).  All of the Medicare Advantage outpatient facility claims are run through the OCE edits.  Blue Cross of Idaho has mapped very specific explanation codes to each of the 83 edits showing exactly which edit occurred on your claim and listing the OCE edit that triggered.  These detail explanations will show on your paper remittance advice viewable on the web, but do not specifically translate to the electronic 835 file which must contain only HIPAA compliant transactions.

An OCE edit can cause your claim to deny on the line level, deny on the claim level or suspend in the claims processing system.  Often times, an edit on just one line item will cause a claim to hit a ‘Return to Provider' (RTP) status.  In this event, you will see a more specific remit message code on the line item that is hitting the edit, although all line items on the claim will show a $0.00 allowance.

For a complete listing of current OCE edits, you can visit the CMS website and view the quarterly updates. http://www.cms.gov/OutpatientCodeEdit/02_OCEQtrReleaseSpecs.asp#TopOfPage


Policy History

Date Action Reason
October 2011 Revised Language revision

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