Additional iCAP edits begin this month

Beginning in May 2015, Wellmark will apply additional iCAP (Improving the Claims Adjudication Process) edits. Editing means Wellmark may deny or alter the claim line (e.g., reducing the number of units of service on a claim line from 5 to 3) based on the payment policy that is invoked on the claim line. Formerly iCAP editing was applied to the same claim type, (e.g., professional claims against professional claims or outpatient facility claims against outpatient facility claims). Starting this month, Wellmark will be looking across claim types. This initiative may result in claims payment adjustments (denial or adjustment that results in the recoupment of claims). It could also require providers to submit appropriate documentation to support the original claims submission or submit a corrected claim. Wellmark will closely review both the claims submission accuracy compared to the consistency of Wellmark’s payments across all claim types to identify inconsistencies across settings of care.