Availity’s Advanced Claims Editing (ACE) helps stop bad claims
Your health plan has enough claims to process without adding ones that don’t belong to your organization. But that’s what happens when claims with invalid member or provider IDs enter your adjudication system. Internal resources can spend significant time working these before the error is discovered, which means higher staffing and administrative costs.
How do you stop them? Many smaller and regional health plans rely on provider-side editing tools to catch these claims, but even the best provider solutions aren’t equipped to handle the speed at which member and provider data changes. That’s why health plans need a payer-side solution to stop the flow of bad claims.
Health plans that use Availity’s Intelligent Gateway for EDI processing have access to a powerful tool that can prevent these invalid claims from entering the health plan’s gateway. Advanced Claims Editing (ACE) is a comprehensive solution embedded within the Intelligent Gateway that checks claims against five families of edits: HIPAA, payer-specific, duplicate, member and provider ID, and clinical edits.
When providers submit an 837 file, ACE performs a sequential edit check against the following categories:
- HIPAA: Claims are checked for formatting and required fields. A claim that fails returns to the provider to be fixed before it can pass through the gateway.
- Payer-Specific: Claims are checked against a set of administrative edits unique for a given health plan. A claim that fails returns to the provider to be fixed before it can pass through the gateway.
- Duplicate: Claims are checked against past submissions to ensure they are not duplicates. A claim that fails returns to the provider to be fixed before it can pass through the gateway.
- Member and Providers: Claims are checked against the most recent member and provider files provided by the health plan. A claim that fails returns to the provider to be fixed before it can pass through the gateway.
- Clinical: Claims are checked against an extensive knowledgebase that accumulates commercial, Medicare, and Medicaid claims processing guidelines from more than 80 sources. The edits take place 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. A claim that fails is returned to the provider, but the provider can bypass the edit and submit the claim as is if they feel that the coding is correct.