Clinical Edits Module for XEServer Overview

Claims denials is a significant challenge for many healthcare organizations today. However, recent research reveals that a vast majority of these denials are actually avoidable. Typically, claims denials are caused by missing information such as

  • wrong plan codes,
  • duplicate submissions (when a claim for the same service/beneficiary/provider has already been submitted),
  • or prior adjudication (when benefits for a service have been included in another service or procedure).

Annually, payers get millions of denied claim status inquiries by phone, fax, and email that take up time and money spent on investigation and troubleshooting. To eliminate avoidable denials, claims should be cleared for payments up front to both healthplans and consumers. To accomplish this, Edifecs offers a hybrid approach of smart front-end edits.

What we offer

When you use Clinical Edits Module for XEServer, you improve the claim processing system, dramatically cut off administrative burdens, and significantly reduce denial rates and still meet the prompt pay laws of 30 days. This solution combines clinical edits and HIPAA validation into a single process that eliminates dependency on costly third-party service providers. Clinical Edits Module allows you to analyze claims and identify billing and coding inaccuracies by cross-referencing claims history and claims data. The module also helps identify claims with missing information and helps send automated responses to providers in a data-ingestible and understandable form. This improves payment accuracy, increases visibility, and enhances provider relationships.

With Clinical Edits Module for XEServer, you can:

  • Validate data and severity error impact assessments through pre-production tests,
  • Identify the common clinical edits that produce repeat errors,
  • Upload lists of common clinical edits into the server to prevent repeat errors,
  • Gain actionable insights with error status reports tied to each claim,
  • Configure the clinical edits process to specific transactions or to the claim status code,
  • Share claim error reports directly with your provider network.

Solution benefits

Clinical Edits Module for XEServer brings you the following benefits:

  • Improved first-pass rates that help you to save costs on manual processes for pended claims or denial/appeal processes,
  • Maintenance of operational control through insourcing,
  • Ability to receive prompt and usable provider feedback,
  • Improved payment accuracy and timeliness,
  • Leveraging of the framework for future optimizations.

Note To get a Clinical Edits Module license, contact Edifecs Sales at sales@edifecs.com.