Harvard Pilgrim Health Care Home
  Learn more.
  Sign up for HPHConnect.
Medical Management
For Your Patient
News Center
Network Matters
Newsletter Archives
Newsletter Registration
Office Support
Provider Manual
Medicare Advantage
Research & Teaching
Resources & Links
Print    Text Size

Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

January 2019

Coding Program Launching in January for Medicare Advantage

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.

Email this article to a colleague   

Network Matters Archives

Download printer-friendly version


HPHConnect for Providers Getting a New Look in 2019

2019 Quality Grant Applications Due by Feb. 15

HEDIS 2019 Coming Soon: Your Cooperation is Crucial

HPI to Administer BMC HealthNet Plan

Behavioral Health: Services for Improved Access


New Opioid Safety Edits for 2019 Medicare Advantage Plans

Medical Policy Update: Tumor Treating Fields

Reminder: Formulas and Enteral Nutrition Require Prior Authorization

Updates to Proton Beam Therapy Medical Policy

Lumoxiti Now Covered with Prior Authorization

TriVisc and Jivi Now Covered with Prior Authorization

Pharmacy and Therapeutics Committee Meeting Update


Coding Program Launching in January for Medicare Advantage


Robert Farias,
Senior Vice President, Corporate Network Strategy

Annmarie Dadoly,

Joseph O'Riordan,

Kristin Edmonston,
Production Coordinator