Enhancing Claims Processing Accuracy with ClaimsXten™

As of June 2021, Healthfirst launched ClaimsXten (CXT), an industry-leading claims-editing software that adjudicates claims more efficiently and in a manner that aligns with industry standards. CXT reviews:

• National and Local Coverage Determinations
• Medically Unlikely Edits (MUE) — Practitioner and Outpatient Hospital Limits
• National Correct Coding Initiative (NCCI) for Practitioners and Outpatient Hospitals 
• Multiple Procedure Pay Percent Reductions
• Add-on Code Without Base Code 
• Component Billing Across Providers
• Unbundling Code Pairs 
• Appropriate Use and Payment for Modifiers 
• Alignment with New York State Payment Policies

Additionally, providers can access an online reference tool called Clear Claim Connection™ (C3) to model their Healthfirst claims submissions.

C3 is an online reference tool designed to display coding combinations according to Healthfirst claim-editing logic. Providers can use the C3 tool to:

• View the appropriate coding and supporting edit clarifications with references to national coding standards and guidelines.
• Determine the appropriate code or code combination representing the service for accurate billing purposes.
• Access the edit clarifications on a denied claim after a Remittance Advice (RA) statement has been received.

Please note: The C3 tool does not contain all claim edits and rules that Healthfirst uses in the claims adjudication process. In addition, results from the C3 tool should not be considered a guarantee of accurate member eligibility status at the time service was rendered and therefore may not be reflective of the actual Healthfirst live claims-processing results.

Frequently Asked Questions

Updated September 2024

Q1. Who can use ClaimsXten?

A1. Physicians, other healthcare professionals, outpatient hospitals, and ancillary providers billing paper and electronic claims to Healthfirst can use ClaimsXten. These claims will be evaluated and processed according to the CXT select code-auditing software rules and clinical rationale.

Q2. Will there be changes to how providers submit claims?

A2. No. Providers don’t need to make any changes to how claims are coded and submitted.

Q3. Will CXT require providers to submit additional information?

A3. No. Providers don’t need to submit additional information to Healthfirst.

Q4. Will CXT have the ability to read historical claims data?

A4. Yes. CXT will identify services that have been previously submitted in conjunction with the current claim being evaluated. This may result in historical claims adjustments.

Q5. Can these CXT recommendations result in overpayment recovery?

A5. Yes. A new claim submission can result in the recoupment of a previously paid claim without an overpayment recovery letter being sent.

Q6. Why did my claim get a CXT denial even though the C3 tool did not identify a coding recommendation?

A6. The C3 tool does not consider previously submitted services. If all services for a date of service is not inputted into the tool, you may receive conflicting recommendations.

Q7. How will this affect reimbursement rates?

A7. This will not impact reimbursement rates. However, CXT may impact how a claim or claim line is processed.

Q8. What if I disagree with a claim edit?

A8. If you are not satisfied with a claim determination made by Healthfirst, you must submit a written request for review and reconsideration. Please refer to section 17.6 of the Healthfirst Provider Manual for additional information.

Questions?

If you have any questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am–5:30pm.

Coverage is provided by Healthfirst Health Plan, Inc., Healthfirst PHSP, Inc., and/or Healthfirst Insurance Company, Inc. (together, “Healthfirst”)