The Advance Communication Engine System Edit Module (NGS-ACE) applies to Part B claims in Jurisdiction 6 (Illinois, Wisconsin and Minnesota), for all direct submitters as well as those who transmit claims via clearinghouses/billing services, as of 1/30/2022.
NGS-ACE applies front-end business level edits to your electronically submitted claims.
Claims that reject on these front-end edits are not transmitted through the claims adjudication system, MCS for processing. This allows you to correct any errors and resubmit your claim before the MCS receives them.
These edits assist in proactively alerting providers of potential claim issues and provide resources to assist with avoiding and resolving the impact of potential denials and appeals.
Some of the potential claim issues these edits help to identify include, but are not limited to, the following:
- Missing/Invalid modifiers
- Lack of medical necessity
- Noncovered services
- Invalid CPT/HCPCS codes
- Invalid POS
- Missing/Invalid diagnosis codes
The information for the edits are returned on the 277 Claim Acknowledgement (277CA) transaction that you currently receive.
NGS-ACE edits can be identified on the 277CA transaction by the presence of the 2200D and/or 2220D STC12 data element on the 277CA transaction.
After reviewing an NGS-ACE edit, if you choose not to change the claim so you can receive a denial or remittance advice, you can resubmit in its original format and it will pass through to MCS for normal processing.
There are many benefits associated to NGS-ACE such as:
- Improved billing inefficiencies
- Provide claim resolutions/resources
- Proactively alert providers of potential claim errors
- Reduced appeal/reopening requests
- Decreased denial rate
- Reduced administrative costs
- Reduced provider burden