Payer Rejection: Smart Edit

Payer Rejection: Smart Edit

Medicare started the concept of SmartEdits. 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 - 277CA Smart Edits List (External link).

  • If you want to send the Claim without making any changes disregarding the SmartEdit warning, change the Claim Status to Ready for Submission/Resubmission. This claim is now Payer Accepted and will be adjudicated by the Payer and will be visible on the Payer portal.

 

UHC also utilizes SmartEdits, 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 SmartEdit.

  • Use this link for more information on UHC Smartedits: UHC Smartedits (external link).


Learn More

  1. Resubmit Claims

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