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Top Ten Edits Received on the GENRPT for 4010A1 claim files |
Top Ten Edits Received on the 277CA for 5010A1 claim files |
| 1 |
C202: Ordering Provider Not Authorized
The edit indicates that the ordering provider submitted in the claim is not found on the CMS supplied PECOS file of providers/suppliers who are authorized to order durable medical equipment (DME) supplies. This is currently a warning edit and will not reject claims.
| CSCC A8: Acknowledgement / Rejected for relational field in error
CSC 496: Submitter not approved for electronic claim submissions on behalf of this entity.
EIC 85: Billing Provider
The NPI submitted is not linked to the Submitter ID under which the claim file was sent to CEDI. If this error is received, the supplier must complete and sign the appropriate form on the CEDI Web site (http://www.ngscedi.com) and return to CEDI for processing.
Note: For Vendors performing testing, this requires an NPI and Tax ID form. Send an e-mail to ngs.cedihelpdesk@wellpoint.com to request this form if needed.
Logic: 2010AA.NM109 billing provider must be "associated" to the submitter (from a trading partner management perspective) in 1000A.NM109.
Edit Reference: X222.087.2010AA.NM109.050 |
| 2 |
C200: Referring Provider Not Authorized
The edit indicates that the ordering provider submitted in the claim is not found on the CMS supplied PECOS file of providers/suppliers who are authorized to order durable medical equipment (DME) supplies. This is currently a warning edit and will not reject claims.
The referring provider does not need to be sent on DME claims. The referring provider may be removed from the submitted claim. However, if the information is sent, it will be checked as part of the CEDI front-end edits.
| CSCC A7: Acknowledgement /Rejected for Invalid Information…
CSC 562: Entity's National Provider Identifier (NPI)
EIC 82: Rendering Provider
The rendering provider NPI was not found on the crosswalk.
Logic: 2420A.NM109 must be a valid NPI on the Crosswalk when evaluated with 1000B.NM109.
Edit Reference: X222.430.2420A.NM109.030 |
| 3 |
C172: Invalid Procedure Code and/or Modifier
The procedure code, modifier, or procedure code and modifier combination is invalid. To resolve this error, verify the Healthcare Common Procedure Coding System (HCPCS) and modifier combination is valid.
If the procedure code, modifier, or combination is valid, verify the first position does not contain a space.
Helpful Tips to verify a Procedure Code/HCPCS and modifier combination:
Check the procedure code/modifier combination at http://www.dmepdac.com.
Contact the Customer Care department at the appropriate Jurisdiction:
Jurisdiction A: 866-590-6731
Jurisdiction B: 866-590-6727
Jurisdiction C: 866-270-4909
Jurisdiction D: 866-243-7272 |
CSCC A8: Acknowledgement / Rejected for relational field in error
CSC 021: Missing or invalid information
CSC 699: Question/Response from Supporting Documentation Form
If Form Identifier = '484.03" and Supporting Documentation with FRM01 = "1C" is present, then FRM04 Question Response must be present.
Logic: If 2440.LQ02 = '484.03" and 2440 FRM with FRM01 = "1C" is present, then 2440.FRM04 must be present.
Edit Reference: X222.494.2440.FRM04.045 |
| 4 |
C201: Referring Provider Not Authorized
The edit indicates that the ordering provider submitted in the claim is not found on the CMS supplied PECOS file of providers/suppliers who are authorized to order durable medical equipment (DME) supplies. This is currently a warning edit and will not reject claims.
The referring provider does not need to be sent on DME claims. The referring provider may be removed from the submitted claim. However, if the information is sent, it will be checked as part of the CEDI front-end edits.
| CSCC A7: Acknowledgement /Rejected for Invalid Information…
CSC 699: Question/Response from Supporting Documentation Form.
If Form Identifier ='484.03' and Question Number/Letter ='6A' or '6B', an occurrence of Question Number/Letter with the value of '6C' is required.
Logic: If 2440.LQ02='484.03' and 2440.FRM01='6A' or '6B', an occurrence of FRM01 with the value of '6C' is required.
Edit Reference: X222.494.2440.FRM01.040 |
| 5 |
C044: Subscriber Primary ID Invalid
The patient's Medicare ID (HICN) is invalid. Verify the number on the patient’s red, white, and blue Medicare card. |
CSCC A7: Acknowledgement /Rejected for Invalid Information…
CSC 510: Future date
CSC 699: Question/Response from Supporting Documentation Form.
Question Response must not be a future date.
Logic: 2440.FRM04 must not be a future date.
Edit Reference: X222.494.2440.FRM04.020 |
| 6 |
C171: Capped Rental – Modifier Missing
The item (whether for purchase or rental) is classified as a capped rental item (or possibly a pen pump item), and the required KH, KI, or KJ modifier (whichever is appropriate) was not submitted.
| CSCC A7: Acknowledgement /Rejected for Invalid Information…
CSC 21: Missing or Invalid Information
CSC 153: Entity ID Number
EIC PR: Payer
CSC 153: Entity ID Number
EIC 40: Receiver
Payer Identifier must be the same value as Receiver Primary Identifier. The Payer’s Identification Numbers are:
Jurisdiction A – 16003
Jurisdiction B – 17003
Jurisdiction C – 18003
Jurisdiction D – 19003
Logic: 2010BB.NM109 must be the same value as 1000B.NM109.
Edit Reference: X222.133.2010BB.NM109.025 |
| 7 |
B108: Billing Provider Not Authorized for Submitter
The NPI submitted is not linked to the Submitter ID under which the claim file was sent to CEDI. If this error is received, the supplier must complete and sign the appropriate form on the CEDI Web site (http://www.ngscedi.com) and return to CEDI for processing.
Suppliers who use a third party (e.g. a clearinghouse or billing service) must complete the Supplier Authorization Form.
Suppliers who submit their own claims and do not use a third party biller must complete the CMS EDI Enrollment Agreement
| CSCC A8: Acknowledgement / Rejected for relational field in error
CSC 306: Detailed description of service
Description must be present when Procedure Code requires a description/additional information.
Logic: 2400.SV101-7 must be present when 2400.SV101-2 is present on the table of procedure codes that require a description.
Edit Reference: X222.351.2400.SV101-7.020 |
| 8 |
C008: EIN/SSN Not on File with NPI
When C008 fires on its own, it can indicate the Tax ID (Employer Identification Number/Social Security Number) submitted on the claim does not match what is on file with National Plan and Provider Enumeration System (NPPES) or the National Supplier Clearinghouse (NSC).
Note: This edit can fire with the C003 Billing NPI Not on Crosswalk. If this occurs, please refer to edit C003 in the Front-End Error Manual for more information for resolving this error.
| CSCC A7: Acknowledgement /Rejected for Invalid Information…
CSC 507: HCPCS
When Product or Service ID Qualifier = "HC", the Procedure Code must be a valid HCPCS Code for the Service Date. (DTP01 = "472")
Logic: When 2400.SV101-1 = "HC", 2400.SV101-2 must be a valid HCPCS Code on the date in 2400.DTP03 when DTP01 = "472".
Edit Reference: X222.351.2400.SV101-2.020 |
| 9 |
C095: Diagnosis Code Invalid – Pointer 1
The diagnosis code pointed to as the first relevant diagnosis on the claim was not valid for the date of service. This is usually, but not always, the first diagnosis code on the claim. Contact the DME MAC Jurisdiction where the claim would be processed based on the beneficiary state code for assistance with the diagnosis code entered.
| CSCC A7: Acknowledgement /Rejected for Invalid Information…
CSC 698: Form Type Identifier.
Form Identifier must be a valid DMERC CMN Form
Logic: 2440.LQ02 must be a valid DMERC CMN Form.
Edit Reference: X222.492.2440.LQ02.020 |
| 10 |
C180: Service Date Greater than Receipt Date
The date of service entered in the claim is greater than the date the claim was submitted to CEDI. Verify that the date of service is valid and not a future date.
| CSCC A7: Acknowledgement /Rejected for Invalid Information…
CSC 187: Date(s) of service
The number of services entered for this line is invalid. In general rentals can only have one unit of service. Questions regarding proper billing policy of rental items should be directed to the DME MAC where the claim would be processed based on the patient’s state code in the address provided on the claim.
Logic: Reject the claim if 2400.DTP02=D8 or 2400.DTP02 = RD8 and the CCYYMM portion of the first date and the CCYYMM portion of the second date are equal and 2400.SV101-3, SV101-4, SV101-5 or SV101-6 = "RR" and 2400.SV104 is not = "1".
Edit Reference: X222.380.2400.DTP03.070
For more information regarding the 4010A1 Front-end edits, please review the CEDI Front End Report Manual located on the CEDI Web site at the following link http://www.ngscedi.com/outreach_materials/outreachindex.htm.
5010A1 edits are not specific to the definitions provided above. Edit codes received can apply to multiple Edit References. For more information regarding the 5010A1 Front-end edits, please send an e-mail to the CEDI Help Desk at ngs.cedihelpdesk@wellpoint.com.
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