New Reimbursement Policy for Coding and Billing Accuracy effective January 13, 2025

November 22, 2024

Effective January 13, 2025, Cigna HealthcareTM will implement a new reimbursement policy, R46 Coding and Billing Accuracy, which outlines types of reported charges and billing errors that are not eligible for reimbursement. These include, but are not limited to, services billed without supporting documentation, services billed with insufficient supporting medical documentation, and services that do not adhere to correct coding and billing guidelines.

Complete and accurate medical documentation is necessary to support the payment integrity process and ensure proper reimbursement. Medical documentation may be requested to support appropriate reimbursement of reported charges.

The policy is effective for claims with dates of service on or after January 13, 2025. The table below identifies types of charges that are not reimbursable or may affect reimbursement. This list may not be inclusive.

Duplicate chargesIncorrect coding
Services with no or insufficient supporting medical documentationCharges unrelated or inconsistent with documented care
Misrepresentation of services performedClinically Inappropriate
Quantity, units, or charge errors (e.g., data entry errors)Wasted, broken, destroyed items or services
Services outside of claim date rangeInformational services
Services related to a documented primary service when the primary service is erroneously not reported and is otherwise not payableBilled charges that are not documented/ordered
Omission of documented diagnosis codesCloned records or documentation
Impossible/Excessive units of serviceIncorrect provider/group reported
Documented services are inconsistent with definition and/or description of code reportedUnlisted codes not supported
Modifiers not supported by medical documentationInvalid site of service
Non-covered servicesUnidentifiable services

For additional information, view the R46 Coding and Billing Accuracy reimbursement policy on the Cigna for Health Care Professionals portal (CignaforHCP.com).

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