Edits Checker User Guide now available

03-17-2017

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.

Edits Checker shows up in your provider tools list, on the left of your logged-in Priority Health provider account landing page.

New! 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.

Basic instructions for using 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

Disclaimer explanation

A claim scenario processing as clean in Edits Checker does not guarantee payment.

A clean result in Edits Checker simply indicates that clinical edits will not apply to the claim scenario that has been entered in Edits Checker. Any changes in the claim scenario may result in different results.

A claim submitted to Priority Health will process and pay/deny depending on several variables (product, benefits, contractual agreements, etc.).