Smart Edits is a claims optimization tool that identifies billing errors within a claim and allows care providers the opportunity to review and repair problematic claims. 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.
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.
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. How you respond to a Smart Edit depends on the type of Smart Edit that you receive.
Return Edits: These edits are sent when a claim you submitted may be delayed or denied, due to potential billing errors.
What do I do with return edits? You can resolve and resubmit the claim within five calendar days, before your claim is automatically processed as originally submitted.
Rejection Edits: These edits will be sent when a claim is automatically returned before adjudication and requires you to resubmit a claim.
What do I do with rejection edits? The appropriate action provided by the edit message must be made for the claim to enter our claims processing system. If no action is taken, the claim will not be processed.
Informational Edits and Banners: These are sent to provide you with additional information on upcoming reimbursement policy changes or other resources for more information.
What do I do with informational edits/banners? Please review the additional information provided to support our common goal of reducing claims errors.
Documentation edits: These edits will be sent if supporting documentation is needed to accurately process your claim. The more accurate the claim, the faster it can be approved and the quicker you’ll be paid for the services you deliver.
What do I do with Documentation Edits? You can submit your supporting documentation through Link within five calendar days. There will be a dedicated section for Smart Edits within the new Link experience.
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].
For more information on the type of Smart Edits you may receive, and what response is needed to accurately process your claim, visit the Smart Edits Frequently Asked Questions (FAQs) resource.