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

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