Medicare AdvantagePrior AuthHigh impact
22-653 Stay Up to Date with Claims Edits for National Coverage Determination Coding
Health Net·Cardiology, Endocrinology, Radiology +5 more·Prior Authorization
Effective date
Oct 26, 2022
We identified it
Jun 20, 2026
Summary
Wellcare By Health Net is implementing new prepay claims edits for National Coverage Determination (NCD) coding effective October 26, 2022, to align with CMS guidelines. These edits will review diagnosis-to-procedure code combinations for specific services including bone density studies, cardiac devices, diabetes screening, and various preventive screenings before payment.
Action Required
Immediately: Billing team must update claims editing systems to ensure proper diagnosis-to-procedure code combinations for all listed NCD codes. Verify that billing staff understand CMS requirements for correct place of service, bill type, and diagnosis relationships for these specific procedures. Review and update billing software rules to prevent claim denials due to incorrect code combinations. Contact Provider Services at 800-929-9224 within 60 days with questions.