Claim Editing

Increase claim payment accuracy and avoid improper costs by 1 to 3 percent

The facts

Healthcare payers operate in an environment characterized by high claim volume, fast-changing rules, and strict regulatory requirements. They face increasing cost pressures, potential provider abrasion, claim workflow disruptions, and compliance issues. To make matters worse, legacy editing systems may fail to keep current with new technologies and policy changes, and long implementations with inflexible systems slow down time to value. 

Enter Cotiviti’s Claim Editing solution, a software-as-a-service (SaaS) editing technology that can be deployed in the primary, secondary, or tertiary position to ensure the accuracy of claim payments, increase adjudication speed, and reduce payer technical and clinical resource needs—all with no disruption to current adjudication workflow and no delay in payment to providers.


Save 1 to 3 percent or more* of total annual paid claims

Increase auto-adjudication rates

Improve provider relations

Reduce operating costs

Achieve faster time to value

Ensure full compliance without paying more

Our comprehensive edit library contains hundreds of rule categories with many millions of edit possibilities that cover all the latest nationally recognized coding standards, including edits for the National Correct Coding Initiative (NCCI) sourced from the Centers for Medicare & Medicaid Services (CMS), American Medical Association, and many others. You get all the content with one implementation—no piecemeal delivery or extra license and implementation fees.


Increase accuracy with advanced editing logic and configurability

All the sourced guidelines in the world won’t elevate your payment accuracy if you can’t apply them as highly configurable editing rules. Cotiviti builds and maintains its editing rules on a flexible, knowledge-based rules engine that can look in real-time across full patient history and codify reimbursement policies and exceptions as they occur across lines of business, geography, and providers. This provides several advantages:

  •  Speed: Database-driven engines can be slower because there is so much data to analyze. Knowledge-based rules allow for faster editing, especially when looking at extensive history and customizations.
  • Optimization: Our rules engine allows us to optimize our edits to savings, sourcing, or other available parameters. For example, many systems have an edit hierarchy, so that once an edit fires, the claim stops processing. With Cotiviti’s solution, all potential edits for that claim fire, and the rules engine determines the most optimal edit to return.
  • Customization: Our solution allows us to inactivate any edit at any level. We can inactivate entire modules or just a certain code pair for a certain provider.


Reduce the administrative and operational costs of accurate claim editing

Cotiviti’s technology and full-service approach remove the burden from your technical and clinical teams, ultimately lowering your total cost of ownership while raising the bar on accuracy. With Cotiviti Claim Editing, you’ll get:

  • Increased auto-adjudication: Real-time, sub-second claim editing technology combined with our configurable rule logic means that more claims can process faster and with more accuracy, no matter the claim volume.
  • Faster time to value with no IT cost: Our SaaS model and service-oriented architecture (SOA) approach requires no hardware or IT support costs, and speeds up implementation and maintenance for realizing value more quickly. Implement our solution in as little as 60 days**, and get new or updated guidelines applied as edits in your system within 45–60 days of the publish date and generally before or on the effective date.
  • Full clinical content maintenance: Cotiviti’s team of registered nurses and clinical coding experts constantly monitor the relevant standards organizations to make sure that all edit updates and changes are in production within your system in a timely manner, greatly reducing your clinical staff’s burden.
  • Reduced quality assurance cost: Our SaaS model allows Cotiviti’s team to run extensive regression tests against payer data, providing high-quality releases.
  • Scalability: Our SaaS model and SOA enable Cotiviti to scale with your growth strategy.
  • Ongoing support: Our standard Claim Editing deployment includes in-depth standard and ad-hoc reporting as well as consultative reviews of claim data to determine ROI and recommend best practices.

Feel confident with proven results

No matter the line of business or membership size, plans have the potential to save 1 to 3 percent or more on their annual medical spend in the primary or secondary editing positions.


Example client savings* include:

$97 million in savings

(1.4 percent) as primary editor for a medium-sized regional payer

$271 million in savings

(0.88 percent) as secondary editor for a top-10 payer

* Based on Cotiviti client savings reports for 2017, not including multiple procedure payment reduction edits. Actual accepted edits and associated savings may differ slightly from reports.

** Claim Editing can be up and running in as little as 60 days for a batch-mode, off-the-shelf implementation, with an average of about 90 days for real-time, depending upon client resources.

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