Payer-side edits are applied during which part of UB-04 processing?

• A. Pre-submission
• B. Post-submission
• C. Adjudication
• D. Data archival

Answer: (C)

Payer-side edits are checks run by the insurance payer during the adjudication stage of UB-04 processing. Once the claim is received, the payer applies its business rules to verify that codes are valid, that services are covered under the patient’s plan, and that the billing aligns with contract rules and other consistency checks. These edits help determine eligibility, coverage, and the correct payment amount before a final payment decision is issued.

Pre-submission edits, in contrast, are done before the claim leaves the provider/clearinghouse to catch formatting or completeness issues. Data archival is simply storing the claim after processing, not an active editing step. Post-submission isn’t the phase where payer-side edits are typically applied.