Aetna recently announced that effective September 1, 2025, its Claim and Code Review Program (CCRP) will expand to include additional claim coding edits for all commercial, Medicare, and Student Health claims. While the announcement lacks specifics about the expanded processes that Aetna will implement, Aetna does say that high-dollar, implant, anesthesia, and bundled services claims will be subject to additional review "to help confirm coding accuracy." The announcement directs providers to visit the Availity platform, specifically the Resources section of the Aetna Payer Spaces webpage, for more detailed information on the new code editing processes.
Providers should promptly review the expanded claim edits that Aetna intends to implement on September 1 and monitor remittance documents for appropriate reimbursement. In the past, Aetna has used updates to the CCRP as a way to implement a wide range of processes that unilaterally reduce reimbursement, including a pre-payment coding review process to downcode physician and hospital emergency department evaluation and management (ED E/M) claims. Aetna's failure to adequately disclose the details of the ED E/M coding review process drew a formal objection from the California Medical Association.
Aetna's use of claim edits aimed at reducing reimbursement under the guise of coding accuracy reflects a broader industry trend. Providers nationwide are experiencing an uptick in health plans denying payments by improperly asserting that providers are not coding their claims correctly. Many health plans are downcoding claims using undisclosed software algorithms, often without first requesting and reviewing clinical documentation to verify whether the billed services are justified. Health plans justify their code edits by pointing to vague announcements—such as this one by Aetna—as providing sufficient notice of the expanding claim editing procedures.
Providers may have grounds to challenge Aetna's September implementation of additional CCRP processes, as well as other health plans' ongoing updates to their claim editing procedures.
[View source.]
