Code Edits

Clear Claim Connection, a web-based code auditing reference tool created by McKesson Health Solutions, enables providers and their office staff to review PEHP’s claim auditing rules and the clinical rationale inherent in our claims editing software. This tool has been designed to make claims payment policies, related rules, clinical edit clarifications, and source information easily accessible. To locate this tool:

• Use Provider Login button on top of the page to access PEHP for Providers secured application
  If you have not previously signed an Electronic Trading Partner Agreement (ETPA) and don’t have a login to our secured website, you can download the entire document for execution. The executed ETPA can then be faxed to your Provider Relations Representative.
• Select Clear Claim Connection (agreement to the terms & conditions is required).
• Enter in Claim Entry Information. This is not claim specific; however, you must provide the patient’s birth date. This tool accepts up to four modifiers and 10 procedure codes.
• Click Review Claim Audit Results.

Clear Claim Connection will indicate if we allow or disallow codes being billed.

If the code is disallowed, you can see PEHP’s rationale by selecting the code and clicking on Review Clinical Edit Clarification. If you disagree with the rationale, you may submit a written appeal.

There are many advantages of using Clear Claim Connection:

• Reduces administrative costs
• Fewer “front line calls”
• Less Provider Appeals
• Reduces reprocessing of claims
• Easy tool for providers to use
• Provides an immediate response to provider inquiries related to the evaluation of code combinations during the processing of claims
• Enables providers to pre-screen a claim or review the rationale for a claim denial
• Is available 24 hours a day, 7 days a week
• Used by internal personnel for consistent communications with provider