August 6, 2025

We are writing today to notify you that we will be conducting a retrospective review of claims that were originally processed without applying correct coding edits. 

The review will include all claims within the timeframes permitted in your provider contract, and may result in payment retractions.

As a reminder, claim editing ensures the accuracy and completeness of claims, identifying potential coding errors and rule infractions. The edits follow nationally recognized billing guidelines from several entities, including:

• Centers for Medicare and Medicaid Services (CMS)
• Regional carrier LCDs and Articles
• National Correct Coding Initiative (NCCI)
• American Medical Association (AMA)
• Healthcare Common Procedure Coding System (HCPCS)
• Internal Classification of Diseases Clinical Modification (ICD-10-CM)
• Professional medical society guidance, such as the National Comprehensive Cancer Network (NCCN), the American Society of Anesthesiology (ASA) manual, and specialty organizations like ACOG and ACR
• Food and Drug Administration (FDA)

If you have any questions, please contact the Provider Services Helpline at 1-888-991-9023.

Thank you for being a valued provider for members in one or more of our health plans: Health Partners Plans Medicaid, Health Partners Plans CHIP, Jefferson Health Plans Medicare Advantage, and/or Jefferson Health Plans Individual and Family Plans.