Know why the edit fired — before the claim goes out.
Most claim tools tell you something failed. They rarely tell you which rule fired, what published policy it came from, or what would actually clear it. ClaimEdits closes that gap — for the teams configuring the edits and the teams working around them.
An edit is a decision. It should be legible to both sides.
A remit arrives with a code and a terse description. It names the outcome, not the reasoning — and by then the claim has already been adjudicated.
Staff reverse-engineer the rule from experience, resubmit, and hope. The same edit fires again next month on a different claim, and the cycle repeats.
Both sides spend real money arguing about a rule that was published all along. Neither side benefits from the ambiguity.
The rules governing most of these decisions are public. The problem has never been secrecy — it is that the logic is scattered across tables, policies and configuration layers that almost nobody reads end to end.
How it works
Point it at the claim
Submit a claim line — codes, modifiers, diagnosis, place of service, dates. No integration required to start.
See every edit that fires
Procedure-to-procedure conflicts, medically unlikely units, modifier validity, frequency and age/sex rules — evaluated together, not one at a time.
Read the reasoning, not just the code
Each result cites the rule it came from and the source that publishes it, so the finding can be defended rather than guessed at.
Fix it before submission
See what would clear the edit — a supporting modifier, a corrected unit count, a documentation requirement — while the claim can still be changed.
Same rules. Two directions.
Payers ask whether an edit is configured correctly. Providers ask why it fired. Both questions run on the same published logic.
For payers
Configuration, payment integrity, and clinical editing teams
- Test configuration changes against real claim patterns before they reach production.
- Compare how your edit set behaves against published CMS baselines.
- Give configuration and payment integrity teams a shared, explainable reference.
- Cut the appeal volume that traces back to edits providers never understood.
For providers
Revenue cycle, denials management, and coding teams
- Catch edits pre-submission instead of learning about them on a remit.
- Understand the actual rule behind a denial, with its published source.
- Build appeals on cited policy rather than trial and error.
- Spot the recurring edits driving the most rework across your book.
Questions
- Where does the edit logic come from?
- Publicly published sources — CMS NCCI procedure-to-procedure edits, MUE tables, and payer medical policy as published. Every result cites what it came from, so you can verify it independently rather than trusting a black box.
- Is this a clearinghouse or a scrubber replacement?
- No. Scrubbers tell you a claim failed. ClaimEdits tells you which rule fired, why it fired, and what the published source actually says — the explanation layer most tools leave out.
- Do you need access to our claims system?
- Not to start. You can evaluate individual claim lines without any integration. Deeper workflows are a conversation once the basics prove useful.
- Does it work for both payers and providers?
- Yes, and deliberately so. Both sides are reasoning about the same published rules from opposite directions. The underlying logic is identical — what differs is the question being asked.
See it against your own claims
The fastest way to judge whether this is useful is to run it on edits you already argue about. Tell us what you're seeing and we'll set that up.