As part of our continued commitment to supporting providers and ensuring compliance with State and CMS requirements, we are implementing important system changes aligned with the Dual Special Needs Plan (D-SNP) offering, effective January 1, 2026.
We are working to implement Pre-Payment Edits associated with the D-SNP product. These updates will enhance claim accuracy, strengthen policy compliance, and streamline payment processing.
Temporary Process: Post Payment Edits
While implementation work continues, Pre-Payment Edits are expected to go live in early 2026. Until that time, select claims may be subject to Post-Payment Edits rather than pre-payment validations, unless otherwise stated in your provider agreement.
This approach allows payments to continue without disruption while maintaining oversight through post-payment review. When the edits are activated, any claims paid incorrectly according to policy may be subject to recoupment under standard procedures.
Provider Responsibilities and Next Steps
We appreciate your partnership during this transition and ask that you please review the following reminders:
- Providers remain responsible for submitting complete, accurate, and timely billing information to ensure correct payment. Continue to submit claims per the existing guidelines outlined in your provider manual.
- Payment Integrity teams may issue additional reminders or updates as we approach go-live.
- If you have any questions or concerns, please reach out to the Provider Relations team.
We value your continued collaboration and partnership as we implement these improvements to ensure accuracy, efficiency, and compliance with claims processing.
