ClaimsXten Solution is a clinically based claims-editing software solution that advances claims-auditing capabilities and resolves limitations in the current ClaimCheck software. ClaimsXten Solution offers clinical coding logic and rules-based claims management with the capability of implementing customized Benefit Funds’ policies, as well as the ability to read historical claims data. The customization provides consistency in managing the complexities of benefit plans, provider contracts and reimbursement policies. ClaimsXten Solution will adjudicate claims in a manner that is more efficient and aligns with industry standards.

Physicians, other healthcare professionals, outpatient hospitals, ambulatory surgical centers, and ancillary providers billing paper and electronic claims to the Benefit Funds will have their claims evaluated and processed according to the ClaimsXten Solution code-auditing software rules and clinical rationale

The implementation of ClaimsXten Solution editing will not impact the reimbursement rates outlined in provider contracts. However, edits may impact how a claim or claim line is processed. Most of the edits being implemented are already applied to current claims with the current ClaimCheck software, such as National Correct Coding Initiative (NCCI) and American Medical Association (AMA) Procedure Manual guidelines.

The Centers for Medicare & Medicaid Services (CMS) developed the NCCI to promote national correct coding methodologies and to control improper coding and incorrect payments for medical services. The coding policies are based on coding conventions defined in the AMA’s Current Procedural Terminology (CPT) Manual, national and local Medicare policies and edits, coding guidelines developed by national societies, standard medical and surgical practice, and current coding practice. According to the NCCI Policy Manual, NCCI includes the following three types of edits:

1. NCCI Procedure-to-Procedure Edits prevent inappropriate payment of services that should not be reported together. If a provider reports the two codes of an edit pair for the same member on the same date of service, the column one code is eligible for payment, but the column two code is denied, unless a clinically appropriate NCCI associated modifier is also reported.
2. Medically Unlikely Edits (MUEs) prevent payment for an inappropriate number/quantity of the same service on a single day. An MUE for a Healthcare Common Procedure Coding System (HCPCS)/CPT code is the maximum number of units of service under most circumstances reportable by the same provider for the same member on the same date of service.
3. Add-on Code Edits consist of a listing of HCPCS and CPT add-on codes with their respective primary codes. An add-on code is eligible for payment if, and only if, one of its primary codes is also eligible for payment.

No. Providers should bill in accordance with industry standard billing, which includes using current CMS National Uniform Claim Committee (NUCC) CMS Form 1500 or UB-04 CMS-1450 (UB-04) Form, or the electronic equivalent, whichever is appropriate, with applicable coding including, but not limited to, ICD-10 Current Procedural Terminology, CPT codes, HCPCS coding, appropriate modifier(s) and/or Revenue Code. Note: If the service or procedure is missing the appropriate modifier or was reported with the incorrect modifier, an edit will be applied.

When new edits are implemented, we will notify you through the Provider Connections electronic newsletter, the Benefit Funds website and/or the Provider Portal. ClaimsXten Solution will continue to be updated on a quarterly or as-needed basis, as new CPT/HCPCS and NCCI edits and other CMS data are issued.

Yes. ClaimsXten Solution will continue to identify services that have been previously submitted in conjunction with the current claim being evaluated. This may result in historical claims adjustments or appropriate offset from the current claim.

These are identifiable by the explanation codes on your Explanation of Payment, as well as within NaviNet. A brief description of the edit rationale will be provided with the explanation code.

If you disagree with an applied edit, you will need to submit an inquiry within 180 days of the date of the initial claim denial or adverse benefit determination. Reconsideration inquiries must include an explanation of the reason for the reconsideration request and supporting documentation, such as medical records or industry reference sources (NCCI table, AMA CPT/HCPCs, CMS Medicare Learning Network, etc.). You may submit your reconsideration request in writing by using the Medical Claim Reconsideration Request form. You may mail, fax or email the form to:

Mail: 1199SEIU Benefit Funds, Medical Claims Reconsideration, P.O. Box 717, New York, NY 10108-0717 Fax: (646) 473-7088 Email: MedicalRecon@1199Funds.org

The edits within ClaimsXten Solution are composed of CPT/HCPCS with valid modifiers, CMS, AMA Coding Manual and Correct Coding Initiative coding and billing practices. In the interim, resources such as the NCCI tables available on the CMS website can be used to identify code pairs and the proper application of modifiers. For additional information regarding ClaimsXten Solution, email Providers@1199Funds.org. You should receive a response within 24 hours.