The Enhanced Claim Editor Program is a prepayment claims editing program to ensure compliance with the AmeriHealth claim payment policies and industry standard coding principles and guidelines. The AmeriHealth Enhanced Claim Editor Program includes coding validation reviews as well as automated edits as of February 1, 2021.
- 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. Most reviews focus on whether this information indicates appropriate billing of modifiers such as 59, XE, XS, XU, 79, etc.
- Automated Edits are systematic edits automatically applied based on industry standard correct coding rules.
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 find the E8XXX codes/messages within PEAR Practice Management by using the Claim Search transaction. From the Claim Details screen, if there is an E8XXX code, a Claim Editor link will appear. This link will show further detail in the rationale and description. 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.
Please refer to our previously published article to learn how to request a Coding Validator claim review or an Automated Edit claim review.
For more information
For questions about the claim editing process, please review our Enhanced Claim Editor Program: 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 ahclaimeditquestions@amerihealth.com.