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HIPAA Claim Edits and Smart Edits

Smart Edits

Let’s speed up claims processing, together.

Smart Edits is a claims optimization tool that identifies potential billing errors within a claim and allows care providers the opportunity to review and repair before the claim is processed. Smart Edits are sent within 24 hours of a claim submission, so you can review identified claims in a matter of hours instead of potential claims denials days later.

If you receive a Smart Edits message, you’ll have five calendar days to correct the claim before it’s automatically processed as originally submitted. When claims are submitted accurately and in compliance with the latest policies and regulations, it results in less re-work, quicker approvals and faster payments.

Get More Claims Approved the First Time

Catch and fix claim errors before claims are processed, resulting in shorter wait time.

Enhance Existing Claims Workflow

Smart Edits are delivered via electronic data interchange (EDI) process workflow so no software is required.

Speed Up Claims Processing

Fixing claims upstream leads to fewer denied claims and payment delays.

Let’s simplify claims processing. If you have any questions, contact EDI Support at 800-842-1109 or email SupportEDI@uhc.com.

Smart Edit Resources

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Inappropriate Primary Diagnosis Code (IPDDN) is a common claims error. Learn what the IPDDN edit means, how to resolve it and avoiding the same mistake in the future.

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The Smart Edits tool detects and flags errors within 24 hours of submitting a claim, prompting a Smart Edits message on your 277CA clearinghouse rejection report. The claims process will be paused for five calendar days, allowing you to resolve and resubmit the claim before it is processed. You can repair the claim by responding to the Smart Edits message. The more accurate the claim, the faster it can be approved and the quicker you’ll be paid for the services you deliver.

As an additional benefit, you’ll also receive informational edits to communicate upcoming changes to reimbursement policies, notices for administrative requirements and other communications specific to the claims submitted. Informational edits won’t pause the claims process, and no action is needed from you.

Please see our Claims Payer List to find out what Payer ID number to use for claims submissions.

A message on your 277CA clearinghouse rejection report will explain why the claim was flagged and provide direction on how to resolve and resubmit the claim. The message will always begin with P4999, followed by the edit mnemonic, which is a short combination of letters that identifies a unique edit.

Smart Edits are designed to identify the specific error that triggered the edit. An example Smart Edit message is:

  • 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 that was identified 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 enter the UnitedHealthcare claims processing system. The resubmitted claim will carry the new date of submission, not the date of the original submission.

If you choose to take no action on the Smart Edit, the claim will be processed after five business days as originally filed.

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.


Insurance coverage provided by or through UnitedHealthcare Insurance Company or its affiliates. Health plan coverage provided by UnitedHealthcare of Arizona, Inc., UHC of California DBA UnitedHealthcare of California, UnitedHealthcare of Colorado, Inc., UnitedHealthcare of the Mid-Atlantic, Inc., MAMSI Life and Health Insurance Company, UnitedHealthcare of New York, Inc., UnitedHealthcare Insurance Co. of New York, UnitedHealthcare of Oklahoma, Inc., UnitedHealthcare of Oregon, Inc., UnitedHealthcare of Pennsylvania, Inc., UnitedHealthcare of Texas, Inc., UnitedHealthcare Benefits of Texas, Inc., UnitedHealthcare of Utah, Inc., UnitedHealthcare of Washington, Inc., Optimum Choice, Inc., Oxford Health Insurance, Inc., Oxford Health Plans (NJ), Inc., Oxford Health Plans (CT), Inc., All Savers Insurance Company or other affiliates. Administrative services provided by OptumHealth Care Solutions LLC, OptumRx, Oxford Health Plans LLC, United HealthCare Services, Inc. or other affiliates. Behavioral health products provided by U.S. Behavioral Health Plan, California (USBHPC), United Behavioral Health (UBH) or its affiliates.