Web Content Viewer

Top 10 CEDI Edits for January 2018

National Government Services Common Electronic Data Interchange (CEDI) has identified the following as the top ten edits that were received during January 2017 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 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 HICN is invalid.  Verify the HICN is entered exactly as it appears on the beneficiary's red, white, and blue Medicare card.

Logic: If Medicare IDs: 2010BA.NM109 must be 10-11 positions in the format of NNNNNNNNNA or NNNNNNNNNAA or NNNNNNNNNAN where “A” represents an alpha character and “N” represents a numeric digit.

-OR-

If Railroad ID: Subscriber Primary Identifier must be 7 - 12 positions in the format of ANNNNNN or AANNNNNN or ANNNNNNNNN or AANNNNNNNNN or AAANNNNNN or AAANNNNNNNNN where “A” represents an alpha character and “N” represents a numeric digit.

Edit Reference: X222.121.2010BA.NM109.020

3

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

4

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

5

CSCC A7: "Acknowledgement /Rejected for Invalid Information…"
CSC 255: “Diagnosis Code”

This Claim is rejected for Invalid Information within the Diagnosis code.

Logic: A diagnosis code pointed to by diagnosis code pointer (SV107-1, SV107-2, SV107-3, or SV107-4) is invalid for the claim line date of service.
Questions regarding the effective dates of a diagnosis code 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.

Edit Reference: X222.226.2300.HI01-2.050, X222.226.2300.HI02-2.040, X222.226.2300.HI03-2.040

6

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

7

CSCC A7: "Acknowledgement /Rejected for Invalid Information…"
CSC 500: "Entity’s Postal/Zip Code”
EIC IL: Subscriber

Subscriber Postal Zone or ZIP Code must be a valid US Postal Service Zip Code.

Logic: 2010BA.N403 must be a valid postal/zip Code.

Edit Reference: X222.125.2010BA.N403.020

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 that 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 and verify that 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 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

10

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

 

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: 2/9/18