Understanding ClaimsXten

ClaimsXten^TM was implemented in March of 2019 and is a robust code-auditing software designed to ensure health insurance claims are coded properly. The software relies on clinically supported rules and logic influenced by national medical societies, current coding practices and the National Correct Coding Initiative (NCCI).

ClaimsXten contains rules, each of which consists of the logic necessary to execute a specific payment policy or guideline. Each rule has an associated set of clinical data that, when applied, results in an edit. The edit is a recommendation to deny, review, modify or allow a specific claim line.

Please be mindful that ClaimsXten does not only follow the Centers for Medicare & Medicaid Services (CMS) coding guidance.  BlueCross BlueShield of South Carolina aligns with CMS, when possible, but there are times in which the alignment isn’t necessary or warranted. Do note the following:

• CMS applies edits that BlueCross BlueShield of South Carolina does not.
• CMS is a regional governmental payer and BlueCross BlueShield of South Carolina is a local private payer.
• NCCI is editing for CMS as a payer for claims that are paid by CMS.

To ensure claims follow the correct coding guidelines of ClaimsXten, providers are encouraged to:

• Review their current coding practices.
• Consult with their business partners who code and bill on their behalf to ensure proper coding is being used.
• Ensure all appropriate staff are up to date on correct coding guidelines.
• Identify any potential impacts and make the necessary changes.

If you have any questions on this bulletin, please contact Provider Education using the Provider Education Contact Form on www.BlueChoiceSC.com.