Payer Rejection: Smart Edit

Payer Rejection: Smart Edit

Medicare started the concept of Smart Edits. The Claim rejects at the Clearinghouse level with an alert explaining that the Claim may be denied when processed.

  • Some claims are rejected by a Smart Edit and do not enter the claims processing system. These claims must be corrected and resubmitted.

  • To be processed by Medicare, the claim must be resubmitted.

  • Other Smart Edits are informational only and will still be passed to the claims processing system for payment consideration.

  • The following link directs you to Palmetto GBA Advance Clinical Editing (P-ACE) Smart Edits

  • If you want to send the Claim without making any changes disregarding the Smart Edit warning, change the Claim Status to Ready for Submission/Resubmission.

    • The Claim response will now be Payer Accepted.

    • It will be adjudicated by the Payer and visible on the Payer portal.

 

UHC also utilizes Smart Edits, but their behavior is different from Medicare and likely more common.

  • If no Claim is resubmitted with changes, UHC will release the Claim for processing after 5 days.

  • If no changes need to be made, no additional Claim is required

  • If you want to make changes to the Claim based on the advice of the SmartEdit, make the changes, and send a new Claim which may be subject to a different Smart Edit.

UHC Smart Edit Example

-A7-;Rejected for Invalid Information;Missing or invalid information. Usage- At least one other status code is required to identify the missing or invalid information.;-P4999REJINFO SMARTEDIT (REJINFO) [PATTERN 53845] INFORMATIONAL - THIS CLAIM HAS BEEN REJECTED AND WILL NOT BE PROCESSED. SEE UHCPROVIDER.COM/SMARTEDITS. REPAIRED CLAIMS SHOULD BE SENT WITH THE ORIGINAL FREQUENCY CODE, NOT A REPLACEMENT OR VOIDED INDICATOR-;-A7-;Rejected for Invalid Information;Missing or invalid information. Usage- At least one other status code is required to identify the missing or invalid information.;-P4999LBI SMARTEDIT (LBI) REJECT - PER LCD OR NCD GUIDELINES, PROCEDURE CODE 99406 HAS NOT MET THE ASSOCIATED DIAGNOSIS CODE RELATIONSHIP CRITERIA FOR CMS ID(S) 210.4.1.-;-Payer Claim Control Number - FLN 940252306498700 ICN FF83454140-; [PE]

  1. The green highlighted items represent the Smart Edit Code that can be used in the lookup on UHC's Smart Edit page: Smart Edits Lookup
  1. The yellow highlighted items provide the status of the Claim and a reason why the Claim was rejected.

Learn More

  1. Resubmit Claims

    • Related Articles

    • Rejection: Missing or Invalid Information

      Missing or Invalid Information Rejections Because these Rejection messages are from the Payer, Support may be are unable to discern the reason for a rejection. It is recommended that you reach out to the Payer for more information. Rejection for NDC ...

    • Payer Rejection Articles

      Payer Rejections Payer Rejections Overview Acknowledgement/Receipt Payer Rejection: A6 -A1-;Acknowledgment/Receipt Adjudication Date Payer Rejected: INVALID ADJ PAYMENT DATE Claim Filing Indicator (CFI) Payer Rejection: INVALID FILING INDICATOR CODE ...

    • Payer Rejection: Reason Not Clear

      Payer Rejection: Reason Not Clear Payer Rejection prefixes: EP: Third-Party Clearinghouse AP: Payer Contact the Payer Payer Rejections can be more difficult to read as they often do not comply with standard responses. For Payer rejections that you ...

    • Rejected Claims on the Encounter by Status Panel

      Three Categories of Rejections These Rejections are found in the Encounter by Status Panel on the Claims Management Dashboard or Home Dashboard if pinned. Local Edit Errors (LE) The Local Edit Errors are System delivered rules to catch specific ...

    • Encounters by Status Panel Overview

      Access the Encounters by Status panel on the Claims screen or the Home Dashboard if pinned. This panel is used for short-term Claims management. The Filters can be used to search for a specific Insurance, Facility, and Billing Provider and to Include ...