Q&A: Reviewing claims edit data

Q: What type of claims edit data should we capturing and reviewing as part of denials management?

A: Most bill submission systems produce reports on claims that hit a payer or regulatory edit before submission, as well as data on claims that were submitted to the payer but rejected by either the clearinghouse or the payer. These are technical denials/rejections and include demographic errors and insurance identification errors. Other causes of claim rejections or denials include unit of service errors or Current Procedural Terminology® (CPT)/Healthcare Common Procedure Coding System (HCPCS) errors. Medicare claims in particular should be monitored for denials due to Local Coverage Determination or National Coverage Determination errors as well as medically unlikely edits (MUE). MUEs were developed to reduce the paid claims error rate for Medicare Part B claims and represent the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service

For more information, see The Essential Guide to Healthcare Payer Contracting.