Our new clinical editing system OptumInsight iCES Our new clinical editing system

Goodbye PACE…Hello iCES! iCES will edit claims effective January 22nd, 2012 Will edit based on processing date, not date of service Medicare claims will process more in line with straight Medicare Will apply LCD/NCD/Medical policies in addition to coding edits

Edits Checker Tool for providers Providers will access the tool after logging in to Priority Health Providers can enter claim data for either professional or facility claims to view how the claim will process in regards to clinical editing

Edits Checker Provider should be aware that a claim processing as clean in the Edit Checker does not guarantee payment A clean result in the Edit Checker simply indicates that the claim will not hit a clinical edit A claim will still process and pay depending on several variables (product, benefits, contractual agreements, etc.)

Edits Checker The provider should fill in as many fields as possible in order to get the most accurate analysis. For instance, if the provider neglects to fill out the Date of Birth field, a claim line that would deny in Facets due to a age edit will not be represented in Edit Checker.

Input outpatient facility claim info and click the Submit button

Analysis results

Input inpatient facility claim info and click the Submit button

Analysis results

Provider Claim Inquiry After providers log into their Priority Health account, they can use the Claim Number Search tab or the Patient Search tab to find claims that have hit clinical edits.

Provider Claim Inquiry The CE icon will indicate that the claim has hit a clinical edit.

Provider Claim Inquiry There is a new Clinical Edit column. For lines that have hit a clinical edit, the provider can click on the See Edits link to view the edit rationale.

Provider Claim Inquiry The edit rationale will open in a new window and will provide any links for additional information.

Questions?