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46 11/2005
Claim Processing
Internal System Edits
♦ In addition to EDI edits, certain operating system edits may prevent the claim from
automatically adjudicating. These suspended claims may require additional
information to complete processing. It is important that the information requested
be provided in a timely manner.
Medical Review Process
♦ For claims requiring medical review, providers will be notified of the required
information to be submitted, as well as, where to mail the information.
♦ To avoid denials, it is important that the requested information be submitted
within the time period indicated on the letter of request.