Correct coding software has been developed to assist health plans in expediting claims processes and evaluates submissions for medical billing information and coding accuracy. MHP with the support and guidance of its medical directors has implemented consistent and objective correct coding software. MHP utilizes this software for professional and certain outpatient institutional claim submissions. The software is reviewed as periodic updates are released.
Claims adjudication procedures are reviewed regularly and modified as necessary to ensure claim processing accuracy. The software applies code auditing to medicine, anesthesiology, laboratory, pathology, radiology and surgery. The auditing rules applied, include but are not limited to: age conflicts, Correct Coding Initiative (CCI), duplicates, gender conflicts, improper use of modifiers, pre/post operative auditing, Intensity of Service (IOS) and bundling.
If the audit result is not as expected, providers may appeal the decision with the appropriate documentation for medical review and final payment determination.
The claims review software does not make determinations of medical necessity.