Clinical edits

"Clinical edits" refers to the evaluation of billed codes in relationship to each other for the purpose of identifying unbundled procedures, surgical coding errors, invalid data relationships, patterns of utilization that deviate from practice standards, and diagnoses or procedures that may be invalid for the age and/or gender of the patient. Priority Health uses clinical editing software to perform its clinical edits.

  • Clinical edits are applied to all claims submitted by facilities or professionals, in and out of network, for all Priority Health medical plans, including Medicaid and Medicare, self-funded and fully funded.
  • The clinical edit database Priority Health uses is provided to us by software vendor OPTUM®.
  • For more about how clinical edits are determined, see Priority Health clinical edits policy information, below.

See the edit rationale that was applied to your claims

When you use the Claims Inquiry tool to review your claims, you can see the clinical edit denial reason and review the rationale behind any clinical edits applied to your claims.
Go to Claims Inquiry now.

Medicare local coverage determinations (LCDs)

LCDs are different for members under Medicare Part C vs. Original Medicare.

Asking for an exception

Priority Health will consider requests for individual claim exceptions to clinical edits. A multi-departmental, interdisciplinary oversight committee makes decisions on whether or not to customize edits based on evidence provided in the claim documentation.

To ask that we review a clinical edit denial, submit a Provider Level I Appeal form with supporting documentation such as operative, procedural, or office notes.
Go to the Provider Level I Appeal form (PDF) 

Priority Health clinical edits policy

Clinical editing decisions are based on a combination of Medicare edits such as Medically Unlikely Edits (MUE) or National Correct Coding Initiative (NCCI edits), CMS guidelines, CPT guidelines, ICD-10 guidelines, standard clinical practices and recommendations from medical societies. CMS and NCCI guidelines will take precedence in editing when discrepancies or conflicts exist with recommendations from medical societies.

Providers often assume that if there is no NCCI edit for the code combination they have submitted, then Priority Health should pay both codes. However, the claim may generate a clinical edit from any of the other sources of our clinical edit database.

  • Review of code usage in billing for medical services is a standard industry practice that supports fair reimbursement for medical services and supplies, accurate data collection, and identification of billing and coding errors.
  • Integrating clinical editing with claims adjudication ensures greater consistency in applying coding rules, greater efficiency, and more timely claims processing.
  • Priority Health has developed internal clinical editing processes that balance business needs against the integrity of the application database. This process entails automated application of edits to claims and limited review by certified medical coders.