Third-Party Claim and Code Review Program

Starting from June 1, 2021, Aetna will change some claim edits as part of the Aetna Third-Party Claim and Code Review Program. For New Jersey providers, edits will be activated for billing modifiers 58, 78, and 79. To find out more, read along!

Beginning June 1, 2021, Aetna will change some claim edits. These are part of the Aetna Third-Party Claim and Code Review Program.

Medical records may be requested for certain claims, such as high-dollar claims, implant claims, and bundled services claims, to help confirm coding accuracy. For procedures considered incidental to another procedure or service, Aetna may not allow modifier 59 to allow the incidental service.

NJ providers: edits activated for billing modifiers 58, 78 and 79

As of June 1, 2021, Aetna will activate edits for billing modifiers 58, 78, and 79 in New Jersey for fully insured and self-insured membership claims. Medical records may be requested to support billed services with modifiers:

• 25, 59, and X series: effective December 1, 2020
• 58, 78, and 79: effective June 1, 2021

Aetna will review the service, service history, changes in condition, diagnostic tests, and the medical chart to determine if these services require separate payment.

Source: https://www.aetna.com/content/dam/aetna/pdfs/olu/officelink-updates-march-2021-olu.pdf