HIPAA Claim Edits and Smart Edits

Smart Edits: Let’s speed up claims processing, together.

Smart Edits is a claims optimization tool that identifies potential billing errors within a claim and allows care providers the opportunity to review and repair before the claim is processed. Smart Edits are sent within 24 hours of a claim submission, so you can review identified claims in a matter of hours instead of potential claims denials days later.

If you receive a Smart Edits message, you’ll have five calendar days to correct the claim before it’s automatically processed as originally submitted. When claims are submitted accurately and in compliance with the latest policies and regulations, it results in less re-work, quicker approvals and faster payments.

Get More Claims Approved the First Time

Catch and fix claim errors before claims are processed, resulting in shorter wait time.

Enhance Existing Claims Workflow

Smart Edits are delivered via electronic data interchange (EDI) so no software required.

Speed Up Claims Processing

Fixing claims upstream leads to fewer denied claims and payment delays.


Featured Interactive Guide: CLIA Overview

This guide will cover the foundation of CLIA and an overview of the three Smart Edits that can help you meet CLIA requirements.

Let’s simplify claims processing. If you have any questions, contact EDI Support at 800-842-1109 or email SupportEDI@uhc.com.

Smart Edit Resources

The Smart Edits tool detects and flags errors within 24 hours of submitting a claim, prompting a Smart Edits message on your 277CA clearinghouse rejection report. The claims process will be paused for five calendar days, allowing you to resolve and resubmit the claim before it is processed. You can repair the claim by responding to the Smart Edits message.

Coming soon in 2020, there will be a new type of Smart Edits called documentation edits. These edits will be sent if supporting documentation is needed to accurately process your claim. The more accurate the claim, the faster it can be approved and the quicker you’ll be paid for the services you deliver.

As an additional benefit, you’ll also receive informational edits to communicate upcoming changes to reimbursement policies, notices for administrative requirements and other communications specific to the claims submitted. Informational edits won’t pause the claims process, and no action is needed from you.

Please see our Claims Payer List to find out what Payer ID number to use for claims submissions.

A message on your 277CA clearinghouse rejection report will explain why the claim was flagged and provide direction on how to resolve and resubmit the claim. The message will always begin with P4999, followed by the edit mnemonic, which is a short combination of letters that identifies a unique edit.

Smart Edits are designed to identify the specific error that triggered the edit. An example Smart Edit message is:

  • P4999mPI SmartEdit (mPI): Per the Medicare Physician Fee Schedule, Procedure Code [XXXXX] describes a physician interpretation for this service and is inappropriate in Place of Service [XX].

The Smart Edit will define what specific action is needed from you in order to correct and resubmit the claim.

You have two options for responding to Smart Edits:

  1. Review, correct and modify the claim that was identified by responding to the edit message on the 277CA clearinghouse rejection report. If supporting documentation is needed to accurately process your claim, the Smart Edit message will provide you with further instructions.
  2. Resubmit the claim with its original content, which allows the claim to enter the UnitedHealthcare claims processing system. The resubmitted claim will carry the new date of submission, not the date of the original submission.

If you choose to take no action on the Smart Edit, the claim will be processed after five business days as originally filed.

For more information on the type of Smart Edits you may receive, and what response is needed to accurately process your claim, visit the Smart Edits Frequently Asked Questions (FAQs) resource.

The status codes found on your 277CA are a way for you to identify the different types of Smart Edits. Each type of Smart Edit has a unique status code to help you organize your workflow. 

  1. A3:21 will indicate a Return Edit
  2. A1:19 will indicate an Informational Edit or Informational Banner
  3. R1:294 will indicate a Documentation Edit

HIPAA Claim Edits

UnitedHealthcare applies HIPAA edits to professional (837P) and institutional (837I) claims submitted electronically.

HIPAA claim edits apply to all plans and Payer ID numbers on our Claims Payer List, except:

  • Harvard Pilgrim (04271)
  • The Alliance (88461)

We periodically update the claim edit list and note changes, additions or deletions by date in the legend at the bottom of the last page.

We validate and apply HIPAA claim edits before the claim is processed. This means rejections that may occur will appear at a clearinghouse level so you can identify and correct rejected information before we accept and process the claim.

EDI Claim Edits: A list of HIPAA edits applied by UnitedHealthcare. Edits are subject to change so the list may not be all-inclusive.


Do you have questions about HIPAA Claim Edits or Smart Edits?

First, contact your EDI vendor or clearinghouse for help answering questions about HIPAA or Smart Edit claims.

If you need assistance from UnitedHealthcare, see our EDI Contacts page.