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May 2018: Further Updates on Smart Edits in the EDI Worfklow

In the April 2018 Network Bulletin, we shared with you that UnitedHealthcare has a new capability in the EDI workflow, known as Smart Edits, which autodetects claims with potential errors and delivers feedback within 24 hours of submission. This capability is now available for a limited number of commercial professional claims submitted to Payer ID 87726. For a list of health plans by payer ID, please see the Claims Payer List for UnitedHealthcare, Affiliates and Strategic Alliances.

Smart Edits will continue to roll out to the rest of our plans during the second half of 2018. View the list of active Smart Edits.

If you have a claim returned with a Smart Edit, you’ll have five calendar days to correct the claim before it’s automatically processed. This five-day limit helps ensure timely processing of claims. Interacting with Smart Edits helps you submit accurate, complete claims more quickly, reducing potential claims denials or rework.

UnitedHealthcare’s Smart Edits Solution identifies claims with potential errors in the pre-adjudication workflow so that you don’t have to wait for days to receive claims denials. It’s expected to increase the rate of clean and complete claims submissions, improve the claims cycle time, and reduce claims denial and post-adjudication rework volume.

Smart Edit messages explain why the claim was returned and provide direction on how to correct the claim for re-submission. Re-submit the claim electronically with the modifications suggested by Smart Edit notifications to minimize potential denials or rework.

Smart Edit messages delivered via the 277CA report are usually mapped by your software vendor so that edit messages appear on the same claim status reports you receive for HIPAA edit rejections. Smart Edits currently apply to UnitedHealthcare commercial, professional claims for Payer ID 87726. If you aren’t receiving edit messages for these plans on your clearinghouse rejection reports, please contact your software vendor. UnitedHealthcare is working with providers and vendors to help ensure that messages are accessible. Please refer to our Vendor List to see if your vendor supports Smart Edit messages. Regardless of what software vendor you use, you can always find Smart Edit messages in your raw EDI transaction data.

For Smart Edits to correctly categorize claims and act accordingly, you’ll need to include your group number on your claim submissions. The group number can be identified on an insurance card as shown on the following sample card:

Example medical card showing a highlighted box around the group number and pharmacy information. Example medical card showing a highlighted box around the group number and pharmacy information.

If you’re experiencing issues with Smart Edits, visit our website for further information. If issues persist, please contact EDI Support online at EDI Transaction Support Form, by email at SupportEDI@uhc.com or call 800-842-1109.