UCare – Reinstatement of Previously Suspended Medicare Claims Processing Edits

Effective for Medicare claims processed after Jan. 1, 2021, UCare will be reinstating certain claims processing edits that were temporarily suspended in July 2020.

• UCare will reinstate edits that were temporarily suspended from July 2020 – December 2020 for Medicare members claims for Part B medical, drug and durable medical equipment (DME) services.

• The reinstated edits will impact any claims processed after Jan. 1, 2021. These edits are driven by process date, not date of service.

• This includes new claims, reprocessed claims, replacement claims, adjusted claims and/or void/reinstated claims.

• During the edit suspension period (July 2020 – December 2020), UCare paid claims for covered services for our Medicare members without applying certain edits.

• Effective Jan. 1, 2021, claims for covered services that may have previously paid during the suspension may now result in denials of claims with the reinstatement of these claims edits.

• UCare expects all providers to continue to bill covered services following Medicare guidelines and that medical necessity criteria are met for all services delivered and billed.

• UCare will not proactively reprocess/recoup claims processed during this suspension period; however, UCare reserves the right to retroactively audit services for medical necessity and recoup payment for those services that did not meet criteria.

Source: https://docs.ucare.org/filer_public/files/bulletin_2020_nov23_cesreinstate.pdf