Claim Editing Policies & Procedures
ClaimsXten™ is a rule-based software application that edits submitted claims for adherence to Cigna medical coverage policies, reimbursement policies, benefit plans, and industry-standard coding practices based mainly on Centers for Medicare & Medicaid Services (CMS) and American Medical Association (AMA) guidelines.
ClaimsXten facilitates accurate claim processing for medical and behavioral claims submitted on a CMS 1500 claim form and for certain claims submitted on a UB04 claim form. Code editing within ClaimsXten is based on assumptions about the most common clinical scenarios for services performed by a health care professional for the same patient, while the logic within ClaimsXten is based on a thorough review by doctors of current clinical practices, specialty society guidance, and industry-standard coding.
In some situations, Cigna's medical coverage or reimbursement policy may differ from industry-standard coding, such as a CMS-sourced code edit. When that happens, Cigna's posted policy will supersede the industry-standard edit.
ClaimsXten code editing rules for CMS 1500 and UB04 claim forms are detailed in the Code Edit Policy and Guidelines, which can be found on the Cigna for Health Care Professionals website. New code edits and National Correct Coding Initiative (NCCI) edits will be applied to Current Procedural Terminology (CPT®) and Health Care Procedure Coding System (HCPCS) codes introduced every January.
If you are not currently registered for the Cigna for Health Care Professionals website, you can complete the registration process and log on. Go to www.cignaforhcp.com and click on the Login/Register link
Viewing ClaimsXten Clear Claim Connection™
ClaimsXten Clear Claim Connection, Cigna's code edit disclosure tool powered by McKesson, allows users to enter CPT and HCPCS coding scenarios and to immediately view the audit result. Clinical edit rationales, as well as edit sourcing, are provided for any code that is not allowed in Clear Claim Connection.
Clear Claim Connection is accessible through the secure Cigna for Health Care Professionals website at www.cignaforhcp.com. Once logged on, you may review the Clear Claim Connection Frequently Asked Questions for more information.
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For additional information, call the Customer Service Center at 1.800.88 Cigna (882.4462).
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