CurrentArizona Complete HealthPolicy CC.PP.011

Payment Policy: Code Editing Overview

This payment policy governs the Health Plan's code editing process for facility and professional claims, describing software and clinical validation used to detect and correct coding errors prior to payment and applicability to members governed by the Health Plan.

Policy Summary

PayerArizona Complete Health

PolicyPayment Policy: Code Editing Overview

Policy CodePolicy CC.PP.011

Change TypeNo material clinical or coverage changes

Effective Date01/01/2013

Next Review Date

Key ActionThe software may recommend Deny, Pend for clinical review/validation, or Replace and Pay; decisions and reconsideration/appeal instructions are documented on provider EOP.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

facility & professionalScope of application

vendor & internalCode editing tools

Deny/Pend/ReplaceAdjudication actions

CMS NCCI + othersPrimary edit sources

through 11/13/2025Revision history

Code Editing and Review Criteria

Code editing and review criteria

Claims are evaluated against correct coding guidelines and multiple edit sources; clinical review may be used for exceptions.

Claims are processed through internal and vendor-sourced HIPAA-compliant code editing software that detects, corrects, and documents coding errors prior to payment by analyzing CPT, HCPCS, ICD-10-CM, modifiers, and place-of-service codes against correct coding guidelines (a 'rule').

Edit sources include

CMS National Correct Coding Initiative (NCCI) edits including column 1/column 2, medically unlikely edits (MUE), mutually exclusive and OCE edits.
Public domain specialty society guidance, CMS Claims Processing Manual, CMS Medicaid NCCI Policy Manual, state provider manuals/fee schedules/updates, AMA resources, and other CMS coding resources (HCPCS Coding Manual, National Physician Fee Schedule, MLN Matters).

Policy Summary

PayerArizona Complete Health

PolicyPayment Policy: Code Editing Overview

Policy CodePolicy CC.PP.011

Change TypeNo material clinical or coverage changes

Effective Date01/01/2013

Next Review Date

Key ActionThe software may recommend Deny, Pend for clinical review/validation, or Replace and Pay; decisions and reconsideration/appeal instructions are documented on provider EOP.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Adjudication Recommendations and Provider Notification

Note

Adjudication recommendations and provider notification

As claims reach the code-editing stage, the software may recommend one of three adjudication actions — Deny, Pend (for clinical review/validation), or Replace and Pay. Each recommended decision and the instructions for reconsideration or appeal are documented on the provider's Explanation of Payment (EOP).

Deny — Code editing rule recommends denial of a service line; the appropriate explanation code and reconsideration/appeal instructions are documented on the provider EOP.
Pend — Service line is recommended to pend for clinical review and/or validation; the review may result in pay or deny and the decision and appeal instructions are documented on the provider EOP.
Replace and Pay — Software denies the original billed service line and adds a new paid line reflecting the recommended code; the provider's original billing remains unchanged.

Key Definitions

Edit — definition and context

TermEdit

DefinitionA software recommendation applied to a claim when it does not adhere to a coding rule

ScopeApplied when code editing software audits a claim against correct coding guidelines and multiple code sources (CPT, HCPCS, ICD-10-CM, modifiers, place of service)

PurposeDetects, corrects, and documents coding errors on provider claims prior to payment

When clinical validation is usedClinical review by nursing, physician, and/or coding experts may be used for exceptions that software cannot fully evaluate

Replace and Pay — definition

ActionReplace and Pay

DefinitionAn action where the software denies the original billed service line and adds a new line that is paid without altering the provider's original billing

Claim effectOriginal service line remains unchanged on the claim; a new service line reflecting the software's recommendation is added and paid

ExampleIf an incorrect CPT code is billed for a member's age, the software denies the original line and adds a paid line with the correct CPT code

OpenPayer

Payment Policy: Code Editing Overview

Code Editing and Review Criteria

Code Sets and Edit Sources

Adjudication Recommendations and Provider Notification

Key Definitions

CPT	Current Procedural Terminology codes are analyzed
HCPCS	Healthcare Common Procedure Coding System codes are analyzed
ICD-10-CM	Diagnosis codes are analyzed
NCCI	National Correct Coding Initiative edits (including MUE, column1/2, mutually exclusive)