Reading & Understanding EDI Responses

1. Reading & Understanding EDI Responses Understanding of EDI responses with a close look at cause and effect. LeeAnn Pavlick RCM Consultant

2. Agenda • Rejected by Centricity • Rejected by Clearinghouse • ClaimRemedi • Centricity EDI • Rejected by Carrier

3. Common Rejects Approving / Batching • Insured Last Name missing • Release of Information is missing • Payer ID is missing • Other Payer Id is missing from the Identification tab • Patient Relationship ANSI code is blank • Patient signature source ANSI code is missing • Benefit Accept Assignment is blank • Claim Header Note type is missing • Visit Facility’s CLIA Number is missing • The Insured ID cannot be blank • Other Insured ID is missing

4. Release of Information is missing Patient Signature Source ANSI code is missing Benefit Accept Assignment is blank

5. Insured ID cannot be blank Other Insured ID is missing

6. Other Payer ID is missing from Identification tab

7. Claim Header Note type is Missing Visit specific

8. Visit Facility’s CLIA Number is Missing

9. Visit Facility’s CLIA Number is Missing Set at either Company or Facility level

10. Visit Facility’s CLIA Number is Missing Procedure Fee Schedule setting requiring CLIA

11. Type of Bill cannot be blank Visit specific

12. Type of Bill cannot be blank Default from facility

13. Type of Bill cannot be blank Default from the Insurance Carrier

14. Unable to add charges or transactions due to missing information. Fee Schedule for Responsible Provider

15. Unable to add charges or transactions due to missing information. Fee Schedule for Responsible Provider

16. ErrorOutputFileUnable to retrieve provider information.

17. Cannot have more than one FQHC option per visit

18. UPLOADED: RELEASE OF INFORMATION CODE INVALID. INVALID FIELD VALUE = ARELEASE OF INFORMATION CODE INVALID. INVALID FIELD VALUE = A.:: OTHER PAYER RELEASE OF INFORMATION CODE MUST = "I" OR "Y". INVALID FIELD VALUE = A.RELEASE OF INFORMATION CODE INVALID. INVALID FIELD VALUE = N.

19. UPLOADED: SUBSCRIBER STATE INVALID. INVALID SUBSCRIBER STATE = SE.: INVALID ZIP CODE (75233) FOR SUBSCRIBER ZIP CODE (2010BA-N403).

20. UPLOADED: SUBSCRIBER STATE INVALID. INVALID SUBSCRIBER STATE = SE.: INVALID ZIP CODE (23592) FOR SUBSCRIBER ZIP CODE (2010BA-N403). Clean up of Zip Code table reduces errors in Patient Demographics

21. A Medicare/Medicaid policy cannot be secondary to another Medicare/Medicaid policy. UPLOADED: MEDICARE MAY NOT BE LISTED AS BOTH A PRIMARY AND SECONDARY PAYER. INVALID FIELD VALUE = MA. UPLOADED: MEDICARE MAY NOT BE LISTED AS BOTH A PRIMARY AND SECONDARY PAYER. INVALID FIELD VALUE = MB. UPLOADED: MEDICAID MAY NOT BE LISTED AS BOTH A PRIMARY AND SECONDARY PAYER. INVALID FIELD VALUE = MC

22. Only one Medicare /Medicaid carrier should be selected as an active carrier in the Patient demographics UPLOADED: OTHER PAYER CLAIM FILING INDICATOR CODE (2320-SBR09) MUST BE NOT EQUAL TO MA BECAUSE CLAIM FILING INDICATOR CODE (2000B-SBR09) EQUALS MA. OTHER PAYER CLAIM FILING INDICATOR CODE IS EQUAL TO MA.: MEDICARE MAY NOT BE LISTED AS BOTH A PRIMARY AND SECONDARY

23. CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION. ADDITIONAL INFORMATION IS SUPPLIED USING REMITTANCE ADVICE REMARKS CODES WHENEVER APPROPRIATE

24. CLAIM/SERVICE LACKS INFORMATION WHICH IS NEEDED FOR ADJUDICATION. ADDITIONAL INFORMATION IS SUPPLIED USING REMITTANCE ADVICE REMARKS CODES WHENEVER APPROPRIATE

25. PRECERTIFICATION/AUTHORIZATION/NOTIFICATION ABSENT. AMOUNT- $90.00 (CODE 197): Claim Control #120509834100 DENIED

26. PRECERTIFICATION/AUTHORIZATION/NOTIFICATION ABSENT. AMOUNT- $90.00 (CODE 197): Claim Control #120509834100 DENIED

27. PRECERTIFICATION/AUTHORIZATION/NOTIFICATION ABSENT. AMOUNT- $90.00 (CODE 197): Claim Control #120509834100 DENIED

28. CLAIM ORIGINAL REFERENCE NUMBER- REQUIRED; MUST BE ENTERED WHEN CLAIM FREQUENCY CODE IS EQUAL TO 7 OR 8 UPLOADED: MISSING ORIGINAL REFERENCE NUMBER (ICN/DCN) (2300-REF-F8). THIS SEGMENT IS REQUIRED BECAUSE CLAIM FREQUENCY/SUBMISSION REASON CODE EQUAL TO 7.: MISSING ORIGINAL REFERENCE NUMBER (ICN/DCN) (2300-REF-F8).

29. UPLOADED: CONDITION CODE 'A6' REQUIRED FOR CODES 90655, 90656, 90657, 90658, 90659, 90660, 90724, 90732, G0008, G0009 OR G9141.

30. UPLOADED: DIAGNOSIS MUST NOT BE DUPLICATED

31. UPLOADED: INVALID DIAGNOSIS 1 = V048. DIAGNOSIS IS EITHER NOT IN CODE SET OR IS NOT VALID FOR DOS. Should also be marked as In-Active in the EHR

32. UPLOADED: INVALID PRIMARY DIAGNOSIS = E8842. DIAGNOSIS CANNOT BE AN "E" CODE. "E" CODE MUST BE SECONDARY DIAGNOSIS.

33. NDC CODE MUST BE 11 NUMERIC. INVALID FIELD VALUE = 0009028002.

34. MISSING DRUG IDENTIFICATION NDC. FIELD IS REQUIRED BECAUSE PROCEDURE CODE = "J" CODEMISSING DRUG IDENTIFICATION NDC. FIELD IS REQUIRED BECAUSE PROCEDURE CODE = J1040 "J" CODE: MISSING DRUG IDENTIFICATION NDC. FIELD IS REQUIRED BECAUSE PROCEDURE CODE = J1040 "J" CODE: MISSING DRUG IDENTIFICATION NDC.

35. MISSING PROCEDURE CODE DESCRIPTION. FIELD IS REQUIRED BECAUSE PROCEDURE CODE J1040 IS USED

36. Required when, in the judgment of the submitter, the Procedure Code does not definitively describe the service/product/supply and loop 2410 is not used.ORRequired CPT is a non-specific Procedure Code. Non-specific codes may include in their descriptors terms such as: Not Otherwise Classified (NOC); Unlisted; Unspecified; Unclassified; Other; Miscellaneous; Prescription Drug, Generic; or Prescription Drug, Brand Name.

37. UPLOADED: MISSING TOOTH CODE. FIELD IS REQUIRED BECAUSE PROCEDURE CODE = SPECIFIED CODE D1351

38. UPLOADED: REVENUE CODE MUST BE 4 DIGITS. INVALID REVENUE CODE = 521 REPORTED FOR PROCEDURE 99214

39. UPLOADED: SUBSCRIBER ID INVALID FORMAT FOR MEDICARE. INVALID FIELD VALUE = 799998239.UPLOADED: SUBSCRIBER ID INVALID FORMAT FOR MEDICARE. INVALID FIELD VALUE = NONE.UPLOADED: SUBSCRIBER ID MUST <> "UNKNOWN", "NONE", "SELF" OR "123456789". INVALID FIELD VALUE = NONE.UPLOADED: SUBSCRIBER ID MUST BE ALPHANUMERIC. INVALID FIELD VALUE = ABC 64071522-1`. NO SPACES, DASHES, ETC. ALLOWED. Update multiple instances of the same carrier. Medicare A & Medicare B Medicaid & Medicaid Dental

40. Claim Balancing for Electronic Secondary • UPLOADED: TOTAL CLAIM CHARGE AMOUNT (60) DOES NOT EQUAL THE SUM (0) OF OTHER PAYER PAID AMOUNT (0) + ADJUSTMENT AMOUNTS (0) - PRIMARY PAYER

41. Balancing the Line Information Most frequent error in Electronic secondary claims is balancing. Each Line filed to secondary should balance Payment + Contractual Adjustment + Patient Responsibility = Fee 60.00 + 5.00 + 10.00 = 75.00

42. COB Information Payer Paid Amount only for those procedures selected as “File to Insurance” . If utilizing the GE Centricity File creator for 2nd claims the Remaining Patient Liability is also required.

43. Miscellaneous Clearinghouse/Payer Rejections • UPLOADED: WHEN MEDICARE IS PRIMARY, THE PROVIDER MUST WAIT 30 DAYS FROM THE MEDICARE PAYMENT DATE TO SUBMIT. SERVICE LINE ADJUDICATION DATE = 20140115 MUST OCCUR 30 DAYS BEFORE FILE CREATION DATE = 20140203 • BILLING PROVIDER SPECIALTY CODE (2000A-PRV03) = "19320000X" IS NOT A VALID SPECIALTY/TAXONOMY CODE. • THE MEMBER NUMBER CANNOT BE FOUND. PLEASE VERIFY USING THE ID CARD AND RESUBMIT ELECTRONICALLY INCLUDING THE ALPHA PREFIX. FOR ASSISTANCE, CALL THE 800 NUMBER ON THE CARD • 90834- PROCEDURE CODE WAS INVALID ON THE DATE OF SERVICE AMOUNT- $90.00 (CODE 181) / (CODE N56) • THIS CARE MAY BE COVERED BY ANOTHER PAYER PER COORDINATION OF BENEFITS. AMOUNT- $100.00 (CODE 22): • PRECERTIFICATION/AUTHORIZATION/NOTIFICATION ABSENT. AMOUNT- $65.00 (CODE 197) • CHARGES ARE COVERED UNDER A CAPITATION AGREEMENT/MANAGED CARE PLAN. AMOUNT- $100.00 (CODE 24)

44. Rejected by Payer • Results of 835 Electronic Remittance processing • A transaction posted to this visit for code XXXXX contained the medical remark of N129. • Received MIA code(s) of: N45, N30

45. http://www.wpc-edi.com/reference/ CO, PR & OA = Claim Adjustment Reason Codes (CARC) Mxx, MAxxNxx = Remittance Advice Remark Codes (RARC)

47. ClaimRemedi Clearinghouse Reports Prefix of CRDatafileCR – Clearinghouse response Prefix of CRDatafilePR – Payer Response Claim Control # -- ICN (will be returned on EOB / remittance file)

48. Centricity Clearinghouse Reports CLAIM LEVEL STC01 A2:20:PR - codes A2, 20 and PR defined on WPC-EDI website http://www.wpc-edi.com/reference/ Claim Status Category Codes Claim Status Codes

49. 277 / Acceptance / Denial Report Codes • Claim Status Category Codes • Claim Status Codes • Entity ID Codes

50. Helpful Websites • WPC-EDI • http://www.wpc-edi.com/reference/ • NPPES – NPI Lookup • https://npiregistry.cms.hhs.gov/NPPESRegistry/NPIRegistryHome.do • 5010 277 Reject Code Lookup Tool • http://www.ngsmedicare.com/ngs/portal/ngsmedicare/5010lookup • Zip code Lookup • https://tools.usps.com/go/ZipLookupAction!input.action • NGS Tools and Materials • http://www.ngsmedicare.com/ngs/portal/ngsmedicare/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOINvIKdHd1MTQwMfC0NDDwdzYLd3N0NjE0CTPQLsh0VAT5Pybc!/ • NGS Self-Service Center • http://www.ngsmedicare.com/ngs/portal/ngsmedicare/!ut/p/a0/04_Sj9CPykssy0xPLMnMz0vMAfGjzOINvIKdHd1MTQz8Q0zNDTxdXUz9vc3djA1MDPQLsh0VAeWljQE!/