Boost Efficiency, Accuracy, and Flexibility with Advanced Custom Edits

Managing complex healthcare claims requires a flexible editing system that adapts to the unique needs of your health plan. Traditional claims editing tools often fall short, leaving you vulnerable to errors and inefficiencies. That’s why HealthEdge Source™ (Source) developed Advanced Custom Edits (ACE), a new feature that allows users to create and manage custom edits directly within the Source interface.

Our solution goes beyond pre-defined edits by analyzing the member’s claim history, allowing you to identify potential irregularities with a high level of accuracy. This opens doors to a whole new level of control and adaptability you can access in-house. With ACE, you can tailor editing rules to address specific scenarios and business needs with ease.

Building on the foundation of our existing custom editing feature, Advanced Custom Edits empower your health plan to take editing a step further. You will have complete control over defining the edit itself, including name, ID, disposition, message, and provider type. In addition, it introduces a powerful new capability: evaluating data from historical member claims.

Think of it as adding a magnifying glass to your claims editing process. By incorporating claim history data (identified by beneficiary ID), ACE significantly expands the reach of your editing rules. This allows your team to analyze a broader range of claims data, resulting in more precise and comprehensive claim evaluation.

Advanced Custom Edits function through three key components:

1. Current Claim Conditions: Define the criteria that must be met on the current claim to trigger the edit.
2. History Claim Conditions (available with claim history license): Leverage historical member claim data to refine your edit’s focus and identify potential issues.
3. Relational Criterial (available with claim history license): Set up comparisons between current and historical data to pinpoint claims that meet your edit’s criteria.

When you activate an Advanced Custom Edit, these three components work together to identify claims that meet all the defined conditions and allow the edit parameters to determine whether to take action. This multi-layered approach empowers your health plan to achieve unmatched accuracy and control over your claim editing approach.

Plus, your team doesn’t have to worry about learning a new claims editing system. ACE seamlessly integrates with the familiar functionalities you already know and love. If your team needs to create a new edit quickly, they can copy and modify an existing edit. Your team can also leverage existing code collections within your edit conditions to ensure consistency and save you valuable time.

Have you already made changes and want to keep track of them? The Change Log keeps a record for easy reference. In addition, you can easily include your Advanced Custom Edits during configuration import and export for efficient workflow management.

With access to HealthEdge Source, your team can leverage tools like validation, payment integrity, and cost containment edits to improve control over your claims review process. But with Advanced Custom Edits, you can also:

• Reduce improper payments and ensure claims are paid correctly the first time by leveraging historical data for a more comprehensive evaluation.
• Streamline manual reviews and eliminate bottlenecks with more precise editing rules, freeing up valuable staff time.
• Boost your efficiency, accuracy, and flexibility with custom edits that leverage member claim history.
• Take control of your own edits without relying on external vendors.

Advanced Custom Edits is the ultimate solution for claim editing. It allows you to leverage the power of member claim history and customize your editing rules to meet your specific needs. Reduce errors, streamline workflows, and optimize your health plan’s operations.

HealthEdge Source is committed to continuous innovation. With Advanced Custom Edits, we are empowering health plans like yours to achieve a new level of control and efficiency in claim editing. Stay tuned for exciting upcoming features like edit exceptions, message mapping, and enhanced relational functionalities.

Are you looking for more information about how your health plan can take full advantage of retroactive claims configurations?

Watch our on-demand webinar at your convenience: “Optimizing Retroactive Configuration Changes.”