March 26, 2025
Effective June 1, 2025, we will enhance our claims editing and review process for our Turquoise Care Medicaid members to help ensure accurate coding of services and that services are properly reimbursed.
What this means for you: The enhancements require you to continue to follow generally accepted claim payment policies. With your help, the enhanced claims review process will help our members get the right care at the right time and in the right setting. This change should not increase response times.
Note: Inaccurately coded claims will result in denied or delayed payment.
About the guidelines: We will continue to follow claim payment policies that are global in scope, simple to understand and come from recognized sources, including:
- ICD-10 coding guidelines
- The Healthcare Common Procedure Coding System
- Current Procedural Terminology (CPT®) codes as documented by the American Medical Association
- Correct Coding Initiatives
- Post-Operative Period Guidelines as outlined by the Centers for Medicare and Medicaid Services
Using these guidelines will help ensure a more accurate review of all claims.
What’s changing for Diagnosis Code Guidelines: Use of correct ICD-10 codes will be verified. Use of ICD-10 clinical modification diagnosis coding guidelines, including reporting of inappropriate code pairs, as well as correct coding of secondary, manifestation, sequelae, chemotherapy administration, external causes and factors influencing health status diagnoses. These guidelines are contained in the ICD-10-CM Diagnosis Codes Manual.
More Information: Watch News and Updates for future updates.
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