Let’s speed up claims processing, together.
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.
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) so no software required.
Speed Up Claims Processing
Fixing claims upstream leads to fewer denied claims and payment delays.
Featured Interactive Guide: Types of Smart Edits
- Smart Edits 101
- Types of Smart Edits
- Always Therapy Smart Edit (MODAT)
- Professional/Technical Component Based on Place of Service
- Clinical Laboratory Improvement Amendments (CLIA)
- Custom Therapy Procedure to Modifier (CTPM)
- Inappropriate Primary Diagnosis Code (IPDDN)
- Missing Taxonomy Code (Texas Medicaid Only)
- National Drug Code (NDC)
- Replacement Code Denial (RCPDN)
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.
New Rejection Edits: Starting August 2020, Rejection Edits will be sent when a claim is automatically returned before the claim is processed 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.
Coming soon in 2020, there will be a new type of Smart Edits called 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.
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].
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.
The status codes found on your 277CA are a way for you to identify the different types of Smart Edits. Each type of Smart Edit has a unique status code to help you organize your workflow.
- A3:21 will indicate a Return Edit
- A7:21 will indicate a Rejection Edit
- A3:54 will indicate a duplicate claim rejection
- A1:19 will indicate an Informational Edit
- R1:294 will indicate a Documentation Edit
Do you have questions about Smart Edits?
First, contact your EDI vendor or clearinghouse for help answering questions about Smart Edit claims.
If you need assistance from UnitedHealthcare, see our EDI Contacts page.