The Enhanced Claim Editor Program is a prepayment claims editing program to ensure compliance with AmeriHealth claim payment policies and industry standard coding principles and guidelines. As of February 1, 2021, the AmeriHealth Enhanced Claim Editor Program includes coding validation reviews as well as automated edits.
Automated Edits are systematic edits automatically applied based on coding rules.
Coding Validator reviews are denials based on a thorough review of the claim coding by a Registered Nurse who is also a Certified Professional Coder (CPC) against pertinent information billed on the claim and the claims in the member's history.
If your claim was affected by the Enhanced Claim Editor Program, the edit explanation will be displayed on your electronic remittance report (835) and/or paper Provider EOB or Facility Remittance. Unique alpha-numeric codes and messages have been created that begin with E8. When the claim line contains an E8 code/message, it means it was affected by the Enhanced Claim Editor Program.
Identifying a Coding Validator edit from an Automated Edit
A Coding Validator edit claim line will contain an E819X denial, all other E8XXX codes/messages are Automated Edits. You can also find the E8XXX codes/messages on the Claim Status Inquiry Detail screen on the NaviNet® web portal (NaviNet Open) and on the PEAR portal.* To view, hover your mouse over the service line and select
View Additional Detail. If you see an
E819X code/message the further detail in the Rationale and Description section will also state
“per Coding Validation review". This is an additional indication that the edit is related to Coding Validation and is not an Automated Edit. Only E8XXX codes/messages are part of the Enhanced Claim Editor Program. All other codes/messages are unrelated to the program.
Choosing the correct denial dispute process
Request for Coding Validator claim review
While you may use NaviNet Open or the PEAR portal* to view detailed information on a
Coding Validator E819X denial, clinical information needs to be submitted in order to dispute the denial. The clinical information should include all applicable medical records, notes, and tests along with a cover letter explaining the reason for the dispute.
To facilitate a review, submit the documents listed above via:
Claim Coding Validation
1901 Market Street
Philadelphia, PA 19103
Request for an Automated Edit claim review
For all other E8XXX edits related to
Automated Edits, providers should continue to use the Claim Investigation transaction via NaviNet Open or PEAR portal* to ask questions or request an adjustment. Please reference the enhanced claim editor in the Claim Investigation transaction and provide any additional information including reference claim numbers or corrections submitted to support your request for reconsideration for approval.
*If your organization has transitioned to use PEAR Practice Management on the Provider Engagement, Analytics & Reporting (PEAR) portal, you can use the Claim Search transaction to view this information. Additional information and self-service training materials are available in the PEAR Help Center.
For more information
For questions about the claim editing process, please review our Claim edit enhancements: Frequently asked questions (FAQ).
Note: The FAQ will be updated as more information becomes available.
If you still have questions after reviewing the FAQ, please send an email to email@example.com.
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