Harvard Pilgrim Health Care has engaged Change Healthcare to support complete and accurate claims coding and to help reduce the burden of external medical record audits. Beginning this month for our Medicare Advantage plans, Harvard Pilgrim will use Change Healthcare’s Dx Gap Advisor in which providers review claims coding, where historical information supports a strong probability that a review will result in greater diagnosis coding accuracy.
For this program, claims will be screened using Dx Gap Advisor when they are received into the clearinghouse, before submission to Harvard Pilgrim, to identify any claims that do not include certain expected diagnoses based on previously submitted information — such as diagnoses documented in historical claims data or chronic conditions.
If claims require additional review, the submitter will receive a message indicating that further review is required to validate that the claims diagnosis codes are complete and accurate. Change Healthcare will also provide information about the patient’s prior diagnoses to make chart review more efficient.
The provider and coding staff may revise or add diagnoses or could determine that no changes are necessary. After the review is conducted, the provider must resubmit the claim within timely filing deadlines — regardless of whether any changes were made. If the claim is not resubmitted, it will not be processed and reimbursed appropriately.
If you have questions concerning a claim status message received at the point of claim submission, please contact Change Healthcare Customer Service at 844-592-7009 (option 3) or visit this google drive video for more information about the program.