Claim edits and repairs

Stedi checks each claim you submit for errors that could lead to rejections or denials.

Depending on the type of error, Stedi will either fix the issue automatically (repair) or reject the claim (edit rejection) with instructions explaining what to change before resubmitting. This process helps ensure claims are complete, accurate, HIPAA-compliant, and aligned with payer-specific rules before they reach the payer.

Catching and resolving issues early through claim edits and repairs streamlines claims processing so providers can get paid faster.

Repairs

Repairs are fixes that Stedi applies to claims before checking them against our library of claim edits. They fix problems with a known, deterministic solution, such as formatting issues. For example, if a phone number contains dashes or spaces, a repair might remove them so the claim passes validation.

We don't use repairs to change substantive or clinical content. For example, a repair won't change a CPT code in a claim to reflect a different procedure. That's a substantive change that requires resubmission.

Claim repairs don't require any action from you - they happen automatically, so you don't need to make changes or resubmit.

Edits

Claim edits are validation rules that check a specific requirement. For example, an edit might check that each phone number in the claim contains exactly 10 digits. Many of our repairs fix issues that would cause claims to fail one or more edits. For example, a repair may remove dashes in a phone number so it's in the right format for the edit validation. If the phone number still doesn't have 10 digits, the claim fails the edit.

Stedi runs our entire library of edits on each claim you submit. This applies to both new claims and claims you're resubmitting through Stedi.

When a claim fails one or more edits, Stedi doesn't send it to the payer. Instead, you'll see a validation error for each edit the claim failed. You'll need to fix the issues causing the edit failures before you can successfully submit the claim to Stedi.

Stedi's edit database

Stedi has a growing library of claim edits, including edits for specific payers. You can review a filterable, up-to-date list of all our claim edits in our Edits database.

There's no standardized universal library of claim edits. However, a large number of industry-standard edits originate from HIPAA rules (such as using ICD-10 as the standard coding system) and from Centers for Medicare & Medicaid Services (CMS) rules, such as the National Correct Coding Initiative (NCCI). NCCI edits were originally developed by CMS for Medicare, but many non-Medicare payers have adopted them or use them as a baseline.

Our goal is to eventually cover all non-provider-specific edits that can be deterministically applied to claims. You can submit requests for new edits or updates to existing ones through our Request a claim edit form.

SNIP framework

Edits are often categorized using the Strategic National Implementation Process (SNIP) framework. The framework was created by the Workgroup for Electronic Data Interchange (WEDI), which sets guidelines (but not standards) for how EDI should be implemented in healthcare.

Each SNIP type, or level, checks a different aspect of a claim's correctness. You can find the SNIP level of all of our edits in the Edits database.

SNIP Type 1: EDI Standard Integrity Testing

Edits that check whether the claim uses valid EDI syntax. Examples:

• Are the EDI segments in the right order?
• Do fields meant for numbers contain numbers?

SNIP Type 2: HIPAA Implementation Guide Requirement Testing

Edits that check whether the claim uses HIPAA-compliant X12 syntax. Examples:

• Invalid phone numbers
• Invalid date of birth
• Invalid billing provider address
• Missing primary payer

SNIP Type 3: HIPAA Balance Testing

Edits that check whether the billing amounts in the claim add up correctly. Examples:

• Non-zero adjustment amounts
• COB claims must be balanced
• Total claim charges must equal line-level charges

SNIP Type 4: HIPAA Inter-Segment Situation Testing

Edits that check whether fields are present or missing based on the presence of other fields. Examples:

• Missing accident date
• Missing admission source code

SNIP Type 5: HIPAA External Code Set Testing

Checks that fields that use official HIPAA-adopted code sets only contain valid values. For example, an edit could check for invalid ICD-10-CM diagnosis codes.

SNIP Type 6: Product Type/Type of Service Testing

Edits that check whether the claim is valid and in the right format for the type of healthcare service listed. These edits catch mismatches between the procedure code being billed and the type of claim or service category. Examples:

• Using a CDT dental code in an 837P professional claim.
• Billing a surgery CPT code under a diagnostic service type.
• Including a revenue code, which is used only in 837I institutional claims, in an 837P professional claim.

SNIP Type 7: Trading Partner-Specific Testing

Edits that check whether the claim complies with rules in HIPAA guides that apply only to government payers like Medicare and Medicaid. Examples:

• Invalid primary diagnosis on Medicare chiropractic claims
• Missing initial treatment date for Medicare chiropractic claims