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HealthSCOPE Benefits Advanced Clinical Editing

In an effort to better streamline electronic claims processing, beginning June 1, 2016, HealthSCOPE Benefits is implementing an Advanced Clinical Editing (ACE) system. Each pre-adjudicated claim submitted to us will be automatically evaluated by the ACE system. This system scans claim information to detect potential errors. Claims identified as having a definite or potential Edit error will be returned to the submitter along with a 277CA report. This report will contain a clear message explaining the error so that you can quickly and easily identify the problem and resolve it; then resubmit the claim for quick and reliable electronic processing.

The report is based on the Medicare 277CA Healthcare Claim Acknowledgement report. Claims listed on this report are not submitted to our claims adjudication system until they are returned to HealthSCOPE Benefits from the submitter. Upon return, they will enter the adjudication system, whether they have been corrected or not.

When you receive a returned claim with its accompanying explanation for return, it is your choice to correct and resubmit, or resubmit without corrections. Keep in mind, however, that returning these claims without requested corrections may result in denial of the claim or a request for additional information. Also note, if you are currently using a clearinghouse or billing service to submit your claims, please share this information with them.

Under the new process, the required timeframe to adjudicate a claim that may be required by (1) any applicable preferred provider organization or direct agreement(s); (2) plan document term(s); or (3) state/federal law, regulation, or rule will not commence until the claim has entered the adjudication system.