Claims Returned if edit check fails

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Claims are returned if edit check fails

All claims that fail to pass the “edit checks” in the Department of Education’s computer claims processing system will be returned to the originating center or institution to be corrected and resubmitted. The number of claims being rejected by the system has increased significantly over the last several months, according to Paul Haas, Financial Aid Accountant in the Department’s Financial Services office.

In the past, the Financial Services staff has extended the courtesy of contacting centers submitting rejected claims and correcting the problems over the telephone. With the number of rejected claims escalating each month, this will no longer be possible. It will be necessary for center personnel to submit claims that will pass these “edit checks.”

What is an edit check?

Edit checks are mathematical formulas written into the computer claims system that determine if the numbers reported on a claim are reasonable and allowable. There are nearly 100 formulas which each claim must pass. The following are some examples of the edit checks which the computer looks for:     

  • In Title XX centers, the number of Title XX participants must be at least 25% of the enrollment or licensed capacity, whichever is less.

  • The number of meals claimed in a category (free, reduced, paid) may not exceed the eligible enrollment, by category, multiplied by the number of days served.

  • The average daily attendance may not exceed the licensed capacity multiplied by the number of shifts.

  • The average daily attendance may not exceed the center’s enrollment. 

  • The number of sites claimed may not exceed the number of sites approved.

  • The number of all meals claimed may not exceed three meal per participant per day.

  • The number of major meals (breakfasts, lunches, suppers) claimed may not exceed two major meals per participant per day.

  • The average daily participation per meal type (breakfasts, lunches, suppers, snacks) may not exceed the average daily attendance (ADA).

It is extremely important that the numbers reported on claims are accurate. If centers and institutions report accurate numbers on their claims, the claim will not be rejected by these edit checks. CACFP institutions must take responsibility for the accuracy of the claims they submit. Expecting the Department of Education to fix these mistakes is no longer feasible or efficient.

Rejected Claims are Returned

Every claim which is rejected due to failure to pass the edit check will be returned to the originating institution with a letter indicating the error(s) that caused the claim to be rejected. It will be the responsibility of the center to correct the claim and resubmit it. If the corrected claim is not submitted by the 10th of the month, the claim will be processed and paid with the following month’s claims. Claims received more than 60 days after the deadline for the claiming month will not be paid at all. Institutions are encouraged to file claims as soon as possible, so if corrected claims need to be submitted, there is adequate time to resubmit claims before the 10th of the month.

Updated August 22, 2017 7:08pm