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Claim Edit Sources and Frequency

The following are results from the National Health Insurer Report Card (NHIRC) years 2008-2013 that address claim edit sources and frequency.

**Metric 8 - Source of payer disclosed claim edits1
Description:  On what percentage of claim lines is the source of the disclosed claim edit applied by the payer based on one or more of the following: CPT, NCCI, CMS Publication 100-04, ASA Relative Value Guide or payer-specific edits?

  Aetna Anthem Cigna HCSC Humana Regence UHC Medicare
CPT 3.20% 25.20% 27.60% 9.10% 4.90% 93.90% 4.90% 8.90%
ASA 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%
NCCI 4.90% 7.80% 7.90% 14.00% 4.40% 2.20% 6.60% 9.10%
CMS 19.90% 37.70% 54.00% 51.20% 24.70% 3.80% 47.60% 35.10%
Payer-specific 72.00% 29.40% 10.50% 25.70% 66.00% 0.20% 40.90% 46.80%

Metric 8A - Total number of available claim edits2
Description:  What are the total number of available claim edits in each rule source (CPT, NCCI, CMS, ASA and disclosed payer-specific) by payer?

  Aetna Anthem Cigna HCSC Humana Regence UHC Medicare
CPT  404,518  404,820  404,533  404,820  404,820  404,839  404,819  404,820
ASA  1,070  1,070  1,070  1,070  1,070  1,070  1,070  1,070
NCCI 1,135,126 1,135,197 1,135,197 1,135,197 1,135,197 1,135,197 1,135,197 1,135,197
CMS 110,215 112,091 110,639 110,548 110,548 110,548 103,466 110,548
Payer-specific 142,329 157,337 81,183  80,453 86,404 85,187 148,920 3,009,536

Metric 9 - Percentage of total claim lines reduced to $0 by disclosed claim edits2
Description: On what percentage of total claim lines does the payer apply a claim edit, which the payer has disclosed on its website or in other provider communications that reduces the payment (allowed amount) of the claim line to $0?

Metric 9


Metric 10 - Percentage of total claim lines reduced to $0 by undisclosed claim edits2,3
Description: On what percentage of claim lines does the payer apply a claim edit, which the payer has not disclosed on its website or in other provider communications that reduces the payment (allowed amount) of the claim line to $0?

Metric 10

Metric 10A - Percentage of total claim lines reduced to $0 by disclosed and undisclosed claim edits
Description: On what percentage of total claim lines does the payer apply a disclosed or undisclosed claim edit (the sum of metrics 9 and 10) that reduces the payment (allowed amount) of the claim line to $0?

Metric 10a

 

1This metric is not intended to infer a payer's compliance with a claim edit source.  This metric only identifies claim edit matches to publicly available and recognized sources based on the following claim edit match hierarchy: CPT, NCCI, CMS Publication 100-04 and ASA Relative Value Guide.

2Increased transparency by payers in edit rules resulted in a general improvement in disclosed edits in Metric 9 and a decrease in the number of undisclosed edits in Metric 10.

3To be considered a "disclosed edit" for the purposes of the NHIRC, the complete scope of an edit rule must be disclosed. More detailed information on this can be found in the document "2013 National Health Insurer Report Card: Statement of methodology, inlcuding the step-by-step guidance."

** = May not total 100% due to rounding error  
HCSC = Health Care Services Corporation
UHC = UnitedHealthcare