Wiki UHC Smart Edit Rejections (uMOD25)

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ShaunaWilliams

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UHC Smart Edit rejections uMOD25 - Claims with E/M and procedure codes (with mod 25 appended to E/M code) are rejecting in our clearinghouse. Claims refiled to bypass the smart edit are rejecting as duplicates. UHC's provider portal will show claims as rejected then some will end up processing after a 10 day or so delay. I am awaiting UHC EDI dept's response but has anyone else had this issue or found a resolution?
 
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Our billing company just informed me this is happening to us also and say the claims are being returned to us as rejections. These are established patients with new problems and the physician went out of his way to document why it was above and beyond the injection, but the claims are not being allowed through. Any ideas what we can do?
 
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Hello! I recently attended a UHC bootcamp and they discussed this very topic. Basically, they said it is to help Providers sending in claims that could have a "potential" denial for bundling. So they have initiated a "rejection edit" to allow Providers to review the coding before actually submitting the claim. If your coding is accurate, you must wait 24hrs to resubmit the claim (as is) or it will reject as a duplicate. We get these rejections almost every day and have never had a problem with resubmitting them and we have never received a denial after the claim has processed. It's just a real pain and UHC knows it. Hope that helps!
 
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