Healthcare Claims Processing: Validation & Authorization Rules

Posted on Aug 7, 2025 in Graphic Arts

Claims Validation Procedures

  • Member Validation: ME1014 – Member ID & Member Date of Birth.
  • Provider Validation: PR1011 – Tax ID.
  • Claim Validation: CL1032/CL1033 – DOS, POS, Modifiers, Service Codes, Charge Amount, DX Codes.
  • Plan Validation: CL10323/CL1033 – (SHP – CC – QHP – NSD & MSO).

Authorization Processes

Validate and search for valid authorizations in CCMS, CL1011, Evicore (Radiology), or TruCare for Exchange Plans.

Authorization Validation Criteria

Authorization Tab Details

  • Event Status: Approval, Pending, or Denial.
  • Bubble Comments: (e.g., Negotiated Rate).
  • Closed Reason: (Do not consider authorization if “Void”).
  • Decision Date.
  • Start Date & End Dates.
  • Provider Details: (Provider Tax ID, Name, Network Status: In-Network or Out-of-Network).

Line Item Tab Details

  • Service Codes.
  • Bubble Comments.
  • Units: CL1011.

Authorization Not Required (Exceptions)

  • Anesthesia Providers (Except: Exchange Plan).
  • Dialysis Codes: 90935, 90937, 90999.
  • Behavioral Mental Health: POS 23, In-Network.
  • Emergency Room & Urgent Care: POS 20 & POS 23 (Both In-Network/Out-of-Network).
  • COB Claims.
  • DME – Hearing Exams & Hearing Aids (In-Network).
  • Transitional Care Codes (Hold Code TD, TR, !1, or !2).

Hold Code 42 Procedures

  • No Fee Schedule.
  • Charges $0.00 or $0.01 (V&E).
  • Check CCMS for a negotiated rate; apply the negotiated rate.
  • Use the Toolkit: Choose the “Hold Code 42” button, enter DOS Year, POS, and Charge Amount. The Toolkit will generate the allowed amount; use this amount in the Allowed Amount field.
  • Service Codes 99201-99205, 99211-99215, T1013, 90863: Do not apply Hold Code TZ.
  • For all other service codes, apply Hold Code TZ.
  • Update notes in the CL1083 screen.
  • Revenue Codes 022, 023, & 024 for all POS: Apply Hold Code A9.
  • Only Revenue Code, no CPT: Apply Hold Code A9.

If 1 service line is billed with only a Revenue Code, apply Hold Code B4.

Hold Code 42 Exceptions

  • APC Priced (Hold Codes PK, 2G, 5F).
  • APG Priced (Hold Codes PJ, &/ QM).
  • Ambulatory Surgery (POS 24): Hold Code TL.
  • Inpatient Claims (POS 21).
  • SNF Claims (Revenue Codes 191-194 or 100, 101, 120, etc.).
  • Dialysis Claims (POS 65).
  • Negotiated Rate is listed in CCMS.
  • IN or XN C-Codes: Apply Hold Code BT.

COB Review Procedures

  • EDI Claims: Other insurance information or other amounts populated.
  • Professional Claims: Hold Codes QY, 10, 22, 16.
  • Paper Claims: Claim image must include an EOB.
  • Hold Codes QY & D1: Verify and adjudicate the claim.

PCP Review

  • Review Priority Code – ME1013.

Priority Code = 1: Other insurance is primary (EOB required).

Priority Code = 2: Health First is primary.

  • Hold Code QY – VL: If bubble states Medicare is primary, deny with Hold Code HZ.
  • Apply provider paid amount in the COB field.
  • Apply Hold Code DF (if primary carrier’s allowed amount equals HF allowed amount) & Hold Code 16.
  • Behavioral Health, Non-Emergent Codes (A0428, A0425, etc.): Apply 100% of co-pay or co-insurance.
  • SNF Claims: Apply 100% of co-pay or co-insurance. Apply Hold Code 16 on all lines.

COB Exceptions

  • Authorization not required.
  • Different Modifier – Image between EOB: Apply Hold Code HZ.
  • Hold Codes QY & D1: Verify and adjudicate the claim.

SNF Service Codes

100, 101, 190, 120, 123, 124, 160, 169, 183, 185, 199, 191, 192, 193, 194.

  • 022: Apply Hold Code DB.
  • Other Charges (e.g., 250, 350, 450): Apply Hold Code AA.
  • No Fee Schedule:
    • Review CCMS bubble comments. If a negotiated rate is listed, pay the negotiated rate.
    • If no negotiated rate, use the benchmark rate sheet to apply the allowed amount.