Using the Edits Checker tool

The Edits Checker tool lets any provider enter professional or facility claim data to view clinical edits and the associated rationale that may be applicable to a claim scenario. It'll show any local coverage determinations, national coverage determinations, correct coding initiative errors, and more.

To access Edits Checker

You must be logged in to your online account.

Request an account

Participating providers will have access automatically once they're logged in.

Non-participating providers must request access to Edits Checker.

Limitations

Priority Health medical policy requirements and coding are not included in Edits Checker.

Claims will process and pay/deny depending on several variables (product, benefits, contractual agreements, etc.) as well as the coverage determinations included in Edits Checker.

Where to find Edits Checker

Edits Checker shows up as a card on your logged-in Priority Health Provider Center home page, and in the Tools list at the bottom of every Provider Center and Provider Manual page.

User Guide for Edits Checker

We've created an Edits Checker User Guide you can keep handy for the first couple of times you try the tool.

How to use Edits Checker

  • Use the same field formats you would use on a paper/electronic claim.
  • Do not use decimals/periods within the diagnosis codes.
  • Capitalize alpha characters for modifiers, procedure and diagnosis codes.
  • Format date fields as MM/DD/YYYY.
  • Separate multiple modifiers and/or diagnosis codes for a claim line with a comma only, no spaces.
  • Fill in as many fields as possible for the most accurate analysis. Leaving any fields blank may result in inaccurate results.

Claim analysis results

  • Line ID – Indicates whether the clinical edit flag status applies to the entire claim (as indicated by "CLAIM") or to a particular claim line (as indicated by the claim line ID)
  • Flag Description – Short description of the clinical edit
  • Flag Status – Indicates how the claim/line will process
  • Deny – indicates a clinical edit is applicable to the claim/line and will result in a denial
  • Review – indicates a clinical edit is applicable to the claim/line and will require manual review (e.g. unlisted codes)
  • Profile – indicates a clinical edit is applicable for tracking purposes; will not result in a claim/line denial or manual review
  • Clean line – indicates a clinical edit is not applicable to the claim/line
  • Disclosure – Rationale or source for the clinical edit

Disclaimers

A clean claim result indicates that clinical edits will not apply to the claim scenario you entered. Any changes in the claim scenario may generate different results.

A clean claim result does not replace an authorization or infer that the service will be authorized.

A clean claim result does not guarantee payment.