Using the Edits Checker tool

Enter professional or facility claim data into the Edits Checker tool to see any clinical edits and the associated rationale that may apply to a claim scenario. The tool can mirror how claims may process for:

  • Age
  • Gender
  • Unbundling and bundling
  • Frequency
  • Medicare LCD and NCD criteria
  • Inappropriate modifier use
  • Correct coding initiative errors
  • And more

Limitations / disclaimers

It’s important to note that a clean claim result in Edits Checker isn’t a guarantee of edit results and doesn’t guarantee payment.

Claim payment or denial depends on several variables (product, benefits, contractual agreements, etc.) as well as the coverage determinations included in Edits Checker.

Please also note that:

  • Edits Checker doesn’t include our medical policy requirements and coding.
  • A clean claim result indicates that clinical edits won’t apply to the claim scenario you entered. Any changes in the claim scenario may generate different results.
  • A clean claim result doesn’t replace an authorization or infer that the service will be authorized.

How to access Edits Checker

  1. Log into your prism account.
  2. Open the Resources menu.
  3. Click Edit Checker.

How to use Edits Checker

Enter your claim data

  • Use the same field formats you would use on a paper/electronic claim.
  • Do not use decimals/periods within the diagnosis codes.
  • Capitalize alpha characters for modifiers, procedure and diagnosis codes.
  • Format date fields as MM/DD/YYYY.
  • Separate multiple modifiers and/or diagnosis codes for a claim line with a comma only, no spaces.
  • Fill in as many fields as possible for the most accurate analysis. Leaving any fields blank may result in inaccurate results.

Review your claim analysis results

  • Line ID – Indicates whether the clinical edit flag status applies to the entire claim (as indicated by "CLAIM") or to a particular claim line (as indicated by the claim line ID)
  • Flag Description – Short description of the clinical edit
  • Flag Status – Indicates how the claim/line will process
  • Deny – indicates a clinical edit is applicable to the claim/line and will result in a denial
  • Review – indicates a clinical edit is applicable to the claim/line and will require manual review (e.g. unlisted codes)
  • Profile – indicates a clinical edit is applicable for tracking purposes; will not result in a claim/line denial or manual review
  • Clean line – indicates a clinical edit is not applicable to the claim/line
  • Disclosure – Rationale or source for the clinical edit