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Top 10 CEDI Edits for August 2018

National Government Services Common Electronic Data Interchange (CEDI) has identified the following as the top ten edits that were received during August 2018 on the 277CA for 5010A1 formatted claims. The edit, its description, the edit logic, and the TR3 edit reference are provided below.

5010A1 edits are not specific to the definitions provided.  Edit codes received can apply to multiple Edit References.  If you have received one of the edit codes but the listed explanation does not fit your situation, please review the CMS Edit Spreadsheet on the CEDI website for other possibilities causing your rejection. 

Note: Category A3, Status 247 is not a front end rejection. This is stating that the rejection is at the line level. Please read further into the 277CA report for subsequent error codes.

CEDI offers a tool to view easy-to-understand descriptions associated with the edit code(s) returned on the 277CA for 5010A1 claims.  The tool allows you to enter the Claim Status Category Code (CSCC), the Claim Status Codes (CSCs), and the Entity Identifier Code (EIC) for the edit and returns the possible explanations for the cause of the edit.  The 277CA Edit Tool is located on the CEDI Web site https://www.ngscedi.com/ under the Self-Service Tools section.

# Top Ten Edits Received on the 277CA for 5010A1 Claim Files
1
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").  This can also be caused by sending an invalid HCPCS and modifier combination. The HCPCS can be verified with PDAC. If additional information is needed concerning the valid combination, please contact the DME MAC Jurisdiction where the claim will be processed.

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

2
CSCC A7: "Acknowledgement /Rejected for Invalid Information…"
CSC 164: "Entity's contract/member number"
EIC IL:  “Subscriber”
 

The subscriber Medicare ID number is invalid.  Verify the Medicare ID (HICN, Railroad, or MBI) is entered correctly. 

Logic: The subscriber Medicare ID number is invalid.  Verify the Medicare ID (HICN, Railroad, or MBI) is entered correctly. HICN: Subscriber Primary Identifier must be 10-11 positions formatted NNNNNNNNNA or NNNNNNNNNAA or NNNNNNNNNAN where “A” is an alpha character and “N” is a numeric digit. Railroad ID: Subscriber Primary Identifier must be 7-12 positions formatted ANNNNNN or AANNNNNN or ANNNNNNNNN or AANNNNNNNNN or AAANNNNNN or AAANNNNNNNNN where “A” is an alpha character and “N” is a numeric digit. MBI: Subscriber Primary Identifier must be 11 positions formatted C A AN N A AN N A A N N, (without spaces) where: "C" is numeric 1-9, "A" is alphabetic characters A-Z excluding S, L, I, O, B, Z, "N" is numeric 0-9 and "AN" is either alphabetic A-Z or numeric 1-9. 

Edit Reference: X222.121.2010BA.NM109.020

3
CSCC A7: "Acknowledgement /Rejected for Invalid Information…"
CSC 453: "Procedure Code Modifier(s) for Service(s) Rendered"
 

The procedure code modifiers in SV101 must not be duplicated within the same detail service line. 

Logic: The procedure code modifiers in SV101 must not be duplicated within the same detail service line. 

Edit Reference: X222.351.2400.SV101-3.040

4
CSCC A8: "Acknowledgement /Rejected for Invalid Information…"
CSC 496: "Submitter not approved for electronic claim submission on behalf of this entity"

EIC 85: “Billing Provider”
 

The Billing Provider NPI is not associated with submitter. The Trading Partner/Submitter ID is not authorized to submit claims for the supplier. If this error is received, the supplier must complete and submit the appropriate form on the CEDI Web site (www.ngscedi.com). 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.

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

5
CSCC A8: "Acknowledgement/Rejected for relational field in error"
CSC 562: “Entity’s National Provider Identifier (NPI)”
CSC 128: “Entity’s tax id”
EIC 85: “Billing Provider”
 

Billing Provider Tax Identification Number must be associated with the billing provider’s NPI. Verify that the information you are submitting matches the information on file with the NPPES and NSC.

Logic: 2010AA.REF must be associated with the provider identified in 2010AA.NM109. 

Edit Reference: X222.094.2010AA.REF02.050

6
CSCC A7: "Acknowledgement /Rejected for Invalid Information…"
CSC 453: “Procedure Code Modifier(s) for Service(s) Rendered”
 

Procedure Modifier must be valid for the Service Date. (DTP01 = “472”). 

Logic: 2400.SV101-3 must be valid procedure modifier on the date in 2400.DTP03 when DTP01 = “472”. 

Edit Reference: X222.351.2400.SV101-3.020

7
CSCC A7: "Acknowledgement /Rejected for Invalid Information…"
CSC 732: “Information submitted inconsistent with billing guidelines”
CSC 464: “Payer Assigned Claim Control Number” 

Payer Claim Control Number with REF01 = "F8" must not be present. 

Logic: 2300.REF with REF01 = "F8" must not be present. 

Edit Reference: X222.196.2300.REF.010

8
CSCC A7: "Acknowledgement /Rejected for Invalid Information…"
CSC 562: "Entity’s National Provider Identifier (NPI)"
EIC 85: “Billing Provider”

Billing Provider Identifier must be a valid NPI on the Crosswalk. Verify the NPI and DME PTAN are linked together.  To establish a crosswalk, verify the supplier's information listed on the NPPES web site matches the information at the NSC.

If you have questions about these matches please contact the NSC at 866-238-9652. 

Note: PECOS can also affect your crosswalk. PECOS is the system used by the NSC for DME suppliers to enroll in Medicare. Suppliers can log in to PECOS and verify their NPI is listed correctly. For assistance with PECOS, call 866-484-8049. 

Logic: 2010AA.NM109 must be a valid NPI on the Crosswalk when evaluated with 1000B.NM109. 

Edit Reference: X222.087.2010AA.NM109.030

9
CSCC A7: "Acknowledgement /Rejected for Invalid Information…"
CSC 535: “Claim Frequency Code” 

Claim Frequency Code must be "1". 

Logic: 2300.CLM05-3 must be "1". 

Edit Reference: X222.157.2300.CLM05-3.020

10
CSCC A7: "Acknowledgement /Rejected for Invalid Information…”
CSC 510: “Future Date”
CSC 187: “Date(s) of service” 

The service end/to date is greater than the date this claim was received.  Questions regarding proper billing policy should be directed to the DME MAC Jurisdiction where the claim will be processed based on the patient’s state code in the address provided on the claim. 

Logic: When 2400.DTP02 = RD8 and the second date is a future date, the reported procedure code must be categorized by the DME MAC as an Inexpensive Supply, PEN Amino Acid, PEN Enteral, PEN Immunosuppressant Drug, PEN Kits/Supplies, PEN Lipids, PEN Special Parenteral, or PEN Dextrose/Home Mix. 

Edit Reference: X222.380.2400.DTP03.080

 
For more information regarding the Front-end edits, please send an e-mail to the CEDI Help Desk at ngs.cedihelpdesk@anthem.com.

Post Date: 9/10/18