ADJ Clinical Edit

Nature of Issue: Process Improvement: Edits denying for Med Necessity evidence even if service had already been authorized.

Date Identified: 3/15/2024

Dates of Service Impacted: 1/1/2023 to Current

Product Line Impacted: MMP and Medicaid

Summary of Issue: Optimizing provider experience for services that require and have obtained approved authorization to prevent redundant medical necessity evidence requirement after edits

New Claim Submission Issue Resolution Date: TBD

Prior Claim Correction Issue Resolution Date: TBD

Any action required by the provider if applicable: Escalate any denials to your Provider Representative for overturn and review.