Availity Advanced Claims Editor For Health Plans
Advanced Claims Editor

ACE allows providers to clean claims before adjudication

Availity’s Advanced Claims Editing (ACE) is a comprehensive solution that reviews and edits claims against five categories: HIPAA, payer-specific administrative, duplicate claims, and member and provider eligibility. By stopping claims before they reach adjudication, health plans and providers can reduce administrative costs associated with managing claim denials.

ACE resides within Availity’s ARIES platform, so health plans don’t have to change their adjudication process or add new infrastructure to receive cleaner claims. Providers submit claims via 837, and before the claims enter the health plan gateway they go through a sequential series of edits:

  1. HIPAA: Compliance edits that focus on claims data formatting and required fields. Claims are rejected and sent back to the provider and will not pass through the gateway until the edit condition is resolved.
  2. Payer-specific: Administrative edits payers request to address specific situations. Claims are rejected and sent back to the provider and will not pass through the gateway until the edit condition is resolved.
  3. Duplicates: Edits that evaluate submitted claims over a specific time period. Claims are rejected and sent back to the provider and will not pass through the gateway until the edit condition is resolved.
  4. Member and provider: Real-time queries that validate the member or provider information in the submitted claim against the most current payer-provided file. Claims are rejected and sent back to the provider and will not pass through the gateway until the edit condition is resolved.
  5. Clinical: Clinical edits that evaluate claims at the line level based upon the clinical components of a claim such as diagnosis, procedure, modifier, place of service, as well as member and provider demographics. Evaluation is based upon the current submission as well as data history from previously submitted claims. Claims are routed back via a “soft return” and providers can either correcting the claim or resubmit as originally coded.

Features

  • Best-in-industry knowledgebase accumulates commercial, Medicare, and Medicaid claims processing guidelines from more than 80 sources.
  • Customizable rules engine comprised of hundreds of edits configured to address claims processing factors stored in the knowledgebase.
  • Claim scrubbing based on edits defined by the health plan.
  • Messaging to providers based upon what is interpreted as incorrect or incomplete data.
  • Claims history allows health plans to see all claims that come through the Availity Platform.

Benefits

  • Operational savings from reduced rework associated with pended, denied, or contested claims.
  • Improved provider satisfaction by streamlining claims processing and reducing tasks required to manage denials and inquiries.
  • Claim payment savings by avoiding overpayments caused by duplicate claims, duplicate lines, or overstated levels of care.
  • Improved risk and analysis through customized reports and business insight.
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