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HIPAA Claim Edits and Smart Edits

Smart Edits

We’re speeding up claims payment processing with Smart Edits, UnitedHealthcare’s new claims editing tool that identifies claims with potential errors before they enter our claims processing system. Smart Edits go out within 24 hours of a claim submission, so you can review problematic claims in a matter of hours instead of getting claims denials days later.

If you receive a claim with a Smart Edit, you’ll have five calendar days to correct the claim before it’s automatically processed. Timely responses to Smart Edits are expected to help increase the rate of clean and complete claims, help improve the claims processing time, reduce claim denials, resubmissions and account receivables in your revenue cycle.

Smart Edits scan Electronic Data Interchange (EDI) claims and return electronic Smart Edit messages back to the submitting care provider’s office through a 277CA clearinghouse rejection report.

This is the same process we use to communicate about Health Insurance Portability and Accountability Act (HIPAA) edit rejections, which occurs before the claim enters UnitedHealthcare’s system for processing.

Care providers who submit claims to Payer ID 87726 should receive Smart Edits. Please see our Claims Payer List to find out what Payer ID number to use for claims submissions.

Smart Edits apply to commercial, Medicare and Medicaid claims. The “Active Smart Edit” list details the specific edits.

A Smart Edit message explains why the claim was returned and provides direction on how to update and resubmit the claim. The edits help prevent services billed from being denied once they are accepted by UnitedHealthcare.

An example of a Smart Edit message on your 277CA will pull relevant procedure codes and place of service codes from the claim in question. The message will appear as:

  • P4999mPI SmartEdit (mPI): Per the Medicare Physician Fee Schedule, Procedure Code [XXXXX] describes a physician interpretation for this service and is inappropriate in Place of Service [XX].

You have two options for responding to Smart Edits:

  1. Review, correct and modify the claim submission by responding to the edit message on the 277CA clearinghouse rejection report.
  2. Resubmit the claim with its original content, which allows the claim to bypass the Smart Edits and enter the UnitedHealthcare claims processing system.

Smart Edit Resources

HIPAA Claim Edits

UnitedHealthcare applies HIPAA edits to professional (837P) and institutional (837I) claims submitted electronically.

HIPAA claim edits apply to all plans and Payer ID numbers on our Claims Payer List, except:

  • Harvard Pilgrim (04271)
  • The Alliance (88461)
  • TRICARE West (99726)

We periodically update the claim edit list and note changes, additions or deletions by date in the legend at the bottom of the last page.

We validate and apply HIPAA claim edits before the claim is processed. This means rejections that may occur will appear at a clearinghouse level so you can identify and correct rejected information before we accept and process the claim.

EDI Claim Edits: A list of HIPAA edits applied by UnitedHealthcare, including edits specific to ICD-10 codes. Edits are subject to change so the list may not be all inclusive.

Questions?

Do you have questions about HIPAA Claim Edits or Smart Edits?

First, contact your EDI vendor or clearinghouse for help answering questions about HIPAA or Smart Edit claims.

If you need assistance from UnitedHealthcare, see our EDI Contacts page.