What is a Smart Edit?

Smart Edits scan electronic claims and return electronic Smart Edit messages back to the provider's clearinghouse within the 277CA response.

Per United Healthcare, if a claim response is received with a Smart Edit, providers will have five calendar days to correct the claim before it is automatically processed. Timely responses to Smart Edits are expected to help increase the rate of clean and complete claims, help improve the claims processing time, reduce claim denials, resubmissions and account receivables in your revenue cycle. A Smart Edit message explains why the claim was returned and provides direction on how to update and resubmit the claim. The edits help prevent services billed from being denied once they are accepted by UnitedHealthcare.

An example of a Smart Edit message on the 277CA carrier response will pull relevant procedure codes and place of service codes from the claim in question. The message will appear as:  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].

Providers who submit to payer ID 87726 should receive Smart Edits. Go to the link below for carrier listing. A column with Smart Edits will provide if these edits pertain to the individual payer.

https://www.uhcprovider.com/content/provider/en/viewer.html?file=%2Fcontent%2Fdam%2Fpro vider%2Fdocs%2Fpublic%2Fresources%2Fedi%2FPayer-List-UHC-Affiliates-StrategicAlliances.pdf

Palmetto GBA has also launched Advanced Communication Engine (ACE) Smart Edits as well. For a list of Palmetto GBA Smart Edit, please go to the link below:

https://www.palmettogba.com/Palmetto/Providers.Nsf/files/EDI_277CA_Smart_Edits.pdf/$File/EDI_27 7CA_Smart_Edits.pdf

After reviewing the Smart Edit, it is elected to not to change the claims, users are able to Ready the claim within Practice Insight to be resubmitted to the payer for adjudication without refiling the claim.