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Claims Auditing

The purpose of the claims auditing process is to ensure that all claims are submitted according to CPT IV Coding Guidelines, the American Medical Association, current health care trends and Centers for Medicare and Medicaid Services (CMS) guidelines. Adjudication of claims will be completed applying these guidelines.

Because our customers’ health care partners play an important role in our business, we want to provide you with background on the ClaimCheck® claims auditing system. We use standardized coding guidelines to ensure that we consistently and efficiently adjudicate claims applying national coding standards.

American Family Mutual Insurance Company applies a set of basic premises to claims auditing. We:

  • Will not add code lines to a claim.
  • Will not automatically “down code” Evaluation and Management codes.
  • Will not process charges with inappropriate CPT code or coding combination submissions.
  • Will provide information to customers and providers through customer service calls.
  • Will perform reconsideration and appeals on resubmitted claims or when additional information is provided for a denied claim.
  • Will provide the coding guideline source to support claims payment decisions.

We'll screen claims to ensure they are billed appropriately and if not, they will be denied. When we're unable to process a claim as submitted, a detailed explanation of benefits will be sent to the provider and customer. In some instances, the provider will be asked to resubmit a claim with the corrected coding or with additional information.

Our customer service representatives received extensive training on the claims auditing system and are available by telephone. They will be able to field questions and provide information to customers and providers on reconsideration procedures. Specially trained nurses will assist with reconsideration of claims, and a Medical Director will be available for consultation, when needed.

Each year, our claim auditing system will be updated to include the most current CPT and ICD-9 codes. In addition to this annual update, we will make other enhancements during the policy year to improve our claims processing efforts.

See specific edit information