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New Prepay Edits: Institutional Ambulance Claims

New Prepay Edit from Payment Integrity Department: Institutional Ambulance Claims

Our Prepay department was asked to take over an Encounters Department Script so it could become more of a permanent edit for WellCare and take responsibility for updating edits on a regular basis.

Currently Encounters has a script to ensure that Non-Emergent Ambulance Claims billed with A0426 or A0428 are correct. These claims must have the Required Revenue Code, Bill Type and have the QL modifier on same claim line, or if not, the Attending Physician’s NPI must be on the claim. In the past, CMS has changed the codes effecting this requirement and Scripting has decided to have Prepay build official edit to handle this.

While developing this edit, our vendor informed us that this would have to be a three part edit to accomplish the final task for A0426 or A0428.
The first edit will look at a claim line’s Revenue Code to ensure it is 450 when billing Ambulance Services. If not, the claim line will deny with CE431 and Description of: Invalid Revenue Code for ambulance services.

The second edit will look at a claim’s Bill Type to ensure only bill types 13x, 22x, 83x, and 85x are on the claim, if not the entire claim will deny with CE434 and Description of: Institutional Ambulance Claim Incorrect Bill Type.

The final edit will look at a claim’s line with either A0426 or A0428 to determine if a QL Modifier is on the same line. If not, it will look at the User Defined Field (UDF) 13 to see if the Attending’s Provider’s NPI was submitted on the claim. If modifier QL is on claim line with A0426 or A0428 the claim will pay. If there is no QL Modifier on claim line with A0426 or A0428, the edit will look for the UDF to see if it is populated and the claim will pay. If not, claim will deny with CE433 and Description of: Non-Emergent Transport Inst Claim Requirements Not Met.

Our Prepay Department has January 1, 2021 as Go-Live Date. If implemented on time, Encounters will stop their script for this and incorrect claims will be denied appropriately.

Thank you for your understanding and please contact Provider Relations if you have any questions or concerns.


Carl W. Costa RHIT, CDIP, CPC
Business Analyst III
Payment Integrity Department

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Last Updated On: 12/15/2021