Coding and Cost Analysis Unit and pre-payment claim editing
Geisinger Health Plan’s Coding and Cost Analysis Unit (CCAU), along with contracted vendor partners, apply pre‑payment claim edits to support accurate coding, regulatory compliance, and identification of high‑dollar or high‑risk claims. Various types of claim edits may occur to make sure claims are submitted accurately and in alignment with coding guidelines. Types of claim edits our CCAU and partners may apply include the following:
Lifetime event limits
Claims may be denied when a service exceeds a member’s plan‑specific lifetime benefit limit.
Organ transplant validation
Verifies whether a member has a previous instance of the same transplant. Edits may apply when a transplant service appears duplicative.
Global surgical edits
Determines whether a service falls within the pre‑operative or post‑operative global period of a major or minor surgery previously billed by and paid to the same provider.
Unbundling and incidental services
Services that should be bundled, or that are considered incidental to another procedure, may be subject to denial or adjustment to maintain correct coding.
Medically unlikely edits (MUEs)
Edits may apply when billed units exceed the maximum allowable units for a service, such as:
- Skin substitute codes A2022, A2008, Q4101–Q4332
- Laboratory tests subject to daily unit limits
- Drug dosage units exceeding CMS‑defined maximums
Have a question about your claims?
Call 844-GHP-PROV (844-447-7768).
Have other questions? See who to call to get the right answer quickly.
Claims reconsideration process
Visit Availity.com and click on Geisinger Health Plan under Payer Spaces to use the Claims Appeals (CRRF) function.
No internet?
Use the paper CRRF to avoid unnecessary delays in processing. The CRRF and necessary accompanying documentation must be submitted within 60 days from the date of the Explanation of Payment (EOP). Any request submitted without required supportive documentation or submitted more than 60 days from the date of the EOP will have the original denial upheld.
