Claim Edits (Optum CES automated claim editing and mappings)
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Defines Sanford Health Plan's automated claim editing approach using the Optum Claims Editing System (CES) and the specific CES edits applied to professional and institutional claims; affects participating and non-participating providers submitting claims to Sanford Health Plan.
No material clinical or coverage changes in this revision.
Claim Edit Coverage Rules
Claim edit criteria and mappings
Sanford applies automated edits to claims; these edits determine accept/adjust/deny outcomes and map to CES and 835 reason codes.
Examples of rule-triggered outcomes
- Device-dependent procedures reported without required device codes or ambulance mileage may trigger edits that deny or adjust the claim.
- Diagnosis inconsistent with patient age is flagged by CES (e.g., CES9) and mapped to CO reason codes for correction or denial.
- Duplicate procedure or frequency edits may adjust or deny claims when duplicate reporting or frequency limits are exceeded.
Principal diagnosis-related edits
Mappings where missing/incomplete/invalid principal diagnosis (CES15 / CO-16) lead to various denials or restrictions:
Specific mapped outcomes
- Certain ICMf values map CES15 to CES49/CO-4 resulting in denial for missing/invalid modifier.
- Some ICMf values map CES15 to EXPER/CO-55 resulting in denial as experimental/investigational (not covered).
- Other ICMf values map CES15 to 119B/CO-119 for benefit maximum or frequency exceeded denials (e.g., typical daily or monthly frequency limits).
Discharge information edits
Discharge and provider data element validations:
Surgical and provider relationship edits triggered by discharge data
- Team or assistant surgeon rules may be enforced (CES55 / CO-54; EX27), including denial of multiple assistant surgeries or assistant/co-surgeon not allowed for the procedure.
- Missing discharge details can flag bundled procedure outcomes (CES44 / CO-234) or trigger Medicaid add-on primary-procedure flags (CES38 / CO-B15).
Bundling and NDC-related edits
Bundle and place-of-service or interpretation related edits:
Modifier GK/GZ and related outcomes
- Modifiers GK or GZ map to multiple outcomes including 'not billable to the member' (NOPAT / CO-45), physician interpretation only policy (CES31 / CO-96), and add-on reported without primary (CES1 / CO-107).
- Use of GK/GZ can also trigger location/specialist restrictions, team-surgeon prohibitions, and bundled/not-separately-payable mappings (CES29 -> CES44 / CO-234).
Denial/Non-payment criteria
Edits that lead to denial or non-payment when specific conditions are met:
Global period, qualifying service, and frequency outcomes
- Services performed during an active global period or without required qualifying services are considered included in another payment and may be denied (CES50/CES53 / CO-97 or CO-97/CO-107 mappings).
- Benefit maximums and frequency limits (119B / CO-119) apply and may cause denials when exceeded (typical daily or 30/90-day limits).
Optum CES Edit Codes and Code Mappings
| 017IBP | CES2: Inappropriate Specification of Bilateral Procedure |
| 023BDS | CES19: Invalid Date/Missing Service Date |
| 041IRC | M50: Missing/Invalid Revenue Code |
| 048RRH | M20: Submission of revenue code requires a HCPCS code |
| 04AAGE | CES9: Diagnosis is inconsistent with patients age |
| 006IPC | Invalid Procedure Code (mapped to CES13 / CO-16) |
| APP | Laparoscopic Appendectomy at Time of Other Major Procedure (mapped to CES33) |
| GK/GZ | Modifiers GK or GZ have multiple mapped outcomes including not billable (CO-45), physician interpretation only policy (CO-96), add-on without primary (CO-107), team surgeons not permitted (CO-54). |
| CES44 / CO-234 | Procedure code is bundled and not separately payable / This procedure is not paid separately |
| CES49 / CO-4 | Missing or invalid modifier / The procedure code is inconsistent with the modifier used or a required modifier is missing |
| CES6 / CO-16 | Claim lacks required Device Code / Device-dependent procedure reported without Device Code |
| CES1 / CO-107 | Add-on code reported without required primary procedure code / The related or qualifying claim/service was not identified on this claim |
| CES24 / CO-B16 | Claim lacks required qualifying visit/patient code / 'New Patient' qualifications were not met |
| CES50 / CO-97 | Service performed during active global period and not allowed / Benefit included in payment for another service |
Provider Responsibilities & Denial Risk
Authorizations/referrals do not override CES edits
Authorizations or referrals do not override claim edits. Edits applied to claims are considered to be a provider adjustment and not billable to the member.
Report required and consistent modifiers (CES49/CO-4) to avoid denial
Claims with missing or inconsistent modifiers will be denied under CES49 / CO-4 and can map to downstream outcomes such as 'This service is not billable to the member' (NOPAT / CO-45) or 'Claim lacks required qualifying visit/patient code' (CES24 / CO-B16); correct and consistent modifier reporting is required to avoid denial.
- CES49 / CO-4 = Deny missing/inconsistent modifier; may map to CO-45 (not billable to member).
- Missing/inconsistent modifiers can also map to CES24 / CO-B16 (lacks required qualifying visit/patient code) or other CES mappings shown in the modifier matrix.
Include complete discharge and provider information (CES16/CO-16)
Missing, incomplete, or invalid discharge information (CES16 / CO-16) triggers downstream edits including missing/invalid referring provider name, patient reason for visit required, missing/invalid revenue code, team/assistant surgeon restrictions, and Medicaid add-on primary procedure flags; submit complete discharge and provider data elements to prevent these edits.
- CES16 = CES17 / CO-16: Missing/incomplete/invalid referring provider name.
- CES16 = CES36 / CO-16: Patient reason for visit required.
- CES16 = M50 / CO-16: Deny missing/invalid revenue code.
- CES16 = CES55 / CO-54: Team surgeons not permitted / multiple assistant surgery not allowed.
- CES16 = CES38: Medicaid add-on procedure - primary procedure flagged.
Submit associated primary/qualifying procedures and observe global periods
Procedures that lack an associated payable procedure on the same claim or that occur during a global period or without required qualifying services will be adjusted or denied (e.g., CES44 / CO-234 → CES28 / CO-16 lacks payable procedure; CES1 / CO-107 and CES53 / CO-97 indicate add-on/ global-period conflicts). Ensure related primary procedures and qualifying services are submitted on the same claim and respect global periods.
- CES44 / CO-234 = CES28 / CO-16: Lacks payable procedure that must be submitted on the same claim.
- Add-on codes (CES1 / CO-107) reported without the required primary procedure will be denied.
- Services performed during an active global period (CES53 / CO-97) or within a global period may be excluded from separate payment.
Include required device codes/mileage for device-dependent procedures (CES6/CO-16)
Device-dependent procedures reported without the required device code or ambulance mileage will be denied (CES6 / CO-16); include the required device code(s) or mileage to avoid denial and related edits.
- CES6 / CO-16: Claim lacks required Device Code — will map to denials or other edits (e.g., CES39, CO-96, CES53, CO-97).
- Missing device codes can also trigger age/diagnosis, frequency, or benefit-maximum edits (e.g., CES9 / CO-9, 119B / CO-119).
Terms and Edit Code Definitions
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