News
New Patient to Established Patient Denial
Date: 12/22/25
Thank you for your continued partnership with Ambetter from Meridian. As you know, we are committed to continuously evaluating and improving overall Payment Integrity solutions as required by State and Federal governing entities. We are writing today to inform you of changes to existing review criteria that will go into place on or after 2/2/26.
Description of Changes | Lines of Business |
|---|---|
New Patient to Established Patient Denial: This is a correct coding edit backed by CMS in denial of new patient CPT codes if the member is not a new patient. | Marketplace
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Claims system denial code remains ‘EXw4’ as the denial code seen on the claim.
Thank you for your continued participation and cooperation in our ongoing efforts to render quality health care to our members. We look forward to helping you provide the highest quality of care for our members.