Clinical Edits

Health Benefits Administration Software | Self Insurance Administration Software | Repricing Software | Claims Payment Software | Medicare Pricing Software | Benefit Plan Management software | Capitation Software | EDI software

Claims editing features provide the ability to integrate with third party edit tools as well as integrated Medicare and proprietary rules to perform bundling, unbundling, auditing and cost containment.


Medicare’s Correct Coding Initiative (CCI) edits are integral to VISOVA’s adjudication process. CCI edits enforce rules for Mutually Exclusive procedure codes and for Comprehensive / Component procedure codes for service bundling. These two rule sets are the basis for all proprietary claims edits system and yet they are free and freely available. Moreover, they are independently verifiable so there is none of the mysterious ‘black box’ approach that providers resist in the proprietary edit systems.


VISOVA’s proprietary edit tool: Quick Edits, allows you to define you own clinical edit criteria by client, provider, tax id, specialty, provider type, POS, Network, Payer, Product, Plan, ICD10, age, sex, CPT, modifiers, and revenue codes. You can choose to deny, bundle or change services on the claim as it considers other service lines on the claim or previously received and related claims.

Here are some examples of the situations that our edits tools can detect:

  • Evaluation and Management codes used too soon after a major procedure
  • Procedure codes that should be bundled together as another code
  • Procedures that should be denied when used with another code
  • Procedures that should be changed to another
  • Procedures not applicable to certain age groups
  • Procedures not applicable to certain genders
  • Procedures not compatible with certain diagnosis codes
  • Procedures requiring or excluding certain modifiers
  • And more.Our Dental Edit tool gives extended features related to surfaces, teeth, and dental categories to support the unique requirements of dental services.


Other third party edit tools have been integrated for in-line bundling and edit integration. Auto-audit, Med-Assets, others