As a reminder, effective February 1, 2021, the AmeriHealth Enhanced Claim Editor Program includes coding validation reviews in addition to automated edits. 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.
- Automated Edits are systematic edits automatically applied based on industry standard correct 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. Most reviews focus on whether this information indicates appropriate billing of modifiers such as 59, XE, XS, XU, 79, etc.
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 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. 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
After viewing detailed information on a Coding Validator E819X denial, clinical information needs to be submitted 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:
Request for an Automated Edit claim review
For all other E8XXX edits related to Automated Edits, providers should submit a Claim Investigation through the Claim Search transaction in PEAR Practice Management* to ask questions or request an adjustment. Please provide additional information, including reference claim numbers or corrections submitted to support your request, for reconsideration for approval.
*Additional information and self-service training materials for
the Provider Engagement, Analytics & Reporting (PEAR) portal
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. The FAQ will be updated as more information becomes available.
If you have questions after reviewing the FAQ, please send an email to ahclaimeditquestions@amerihealth.com.
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