National Correct Coding Initiative (NCCI) Retrospective Claims Editing

The National Correct Coding Initiative (NCCI) edits are effective for claims received on or after April 1, 2011, for service dates beginning 10/1/2010. Compliance with the edits may be determined prospectively (pre-payment editing that results in a claim denial) or retrospectively (post-payment editing that results in a refund request). Nebraska Medicaid applied retrospective claims editing during the month of October 2012 for claims received between April 1, 2011 and November 1, 2011. When a claim receives an NCCI edit retrospectively, a refund of the payment is requested. Providers must respond to NCCI refund requests within 30 days of the date of the remittance advice or RFNDRPT report. Providers may request that a modifier be appended to the procedure code or the units of service be changed, pay the refund, or request an appeal.