Medicare AdvantageAdministrativeHigh impact
Enhanced claim editing effective July 1
UPMC Health Plan·Provider Announcement
Effective date
Jul 1, 2024
We identified it
Aug 7, 2026
Summary
UPMC Health Plan is implementing enhanced claim editing effective July 1, 2024, to expand automated edits that promote correct coding and billing practices. The plan will apply stricter edits based on AMA CPT guidelines, Medicare policies, and state Medicaid guidelines, which may result in increased claim denials. Billing teams should expect to see denial explanations on Explanations of Payment and electronic remittances based on these new comprehensive editing rules.
Action Required
By June 28, 2024: Billing team must prepare for enhanced claim denials by reviewing current claims submission patterns and identifying high-risk billing areas. (1) Review historical claim denials from UPMC Health Plan to identify patterns that may trigger new edits. (2) Audit current CPT coding practices against AMA guidelines, Medicare policies, and state Medicaid guidelines to identify potential coding compliance issues. (3) Brief all providers and clinical staff on coding accuracy requirements. (4) Monitor UPMC's resource portal at upmchp.us/claimsediting regularly (beginning immediately and continuing through July) for detailed editing specifications and supporting documentation. (5) Upon receiving denial explanations post-July 1, analyze denial patterns and adjust billing workflows accordingly. Failure to proactively address coding compliance will result in increased claim denials and delayed reimbursement.