Medicare AdvantageAdministrativeMedium impact
Mutual News Q3 2022 Newsletter
Medical Mutual of Ohio·Mutual News Newsletter
Effective date
Oct 1, 2022
We identified it
Jun 20, 2026
Summary
Medical Mutual is implementing a new Diagnosis Gap Advisor system starting October 2022 that will send real-time messages via EDI 277CA transactions when claims for Medicare Advantage and ACA marketplace members don't include all known chronic conditions from the patient's history. Providers must review and resubmit ALL claims that receive these messages, whether changes are made or not.
Action Required
Starting October 2022: Billing team must establish workflow to monitor for 277CA EDI transactions from Medical Mutual's Diagnosis Gap Advisor system. When received, staff must review the medical record and resubmit the claim using the original claim ID - even if no diagnosis changes are needed. All claims flagged by this system require resubmission regardless of whether coding changes are made.