Health plans often program into their claims processing systems certain criteria that, if unmet, will prompt further investigation of a claim. In an automated claims processing system, these criteria may signal the need for further review when, for example:

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Edits in an automated claims processing system are criteria or rules that, if unmet, trigger further review or investigation of a claim. They help ensure that claims meet specific requirements before approval.

Health Plans Often Program into Their Claims Processing Systems Certain