Clinical Relationship Logic

Clinical Relationship Logic pertains to the edits used to appropriately adjudicate claims in a claims processing system. As previously communicated, we have completed the transition of AmeriHealth Pennsylvania HMO members to a new claims processing platform, which will offer greater capabilities and enhanced functionalities for an improved overall customer experience.

Clinical Relationship Logic, or Code-to-Code Edits (e.g., Incidental, Integral, Component, Mutually Exclusive, etc.), is applied to claims submitted on the CMS-1500 claim form or through the 837P.

For more specific information on how the Clinical Relationship Logic is applied go to the Code-to-Code Edits page.