Claim processing Edits - Prepayment, service specific and provider edits

Prepayment Edits 

Prepayment edits are designed by contractor staff and put in place to prevent payment for noncovered and/or incorrectly coded services and to select targeted claims for review prior to payment. MR edit development is the creation of logic (the edit) that is used during claim processing prior to payment that validates and/or compares data elements on the claim.

Service Specific Edits

These are edits that select claims containing specific services for review. They may compare two or more data elements present on the same claim (e.g., diagnosis to procedure code), or they may com- pare one or more data elements on a claim with data from the beneficiary ’ s history file (e.g., proce- dure code compared to history file to determine frequency in past 12 months).

Provider Specific Edits

These are edits that select claims from specific providers flagged for review. These providers are se- lected due to unusual practice patterns, knowledge of service area abuses, and/or utilization com- plaints received from beneficiaries or others. These edits may suspend all claims from a particular provider or focus on claims for selected services, place of service, etc. from a selected provider

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