Revenue Management (EDI) Common Rejections and Fixes

PATIENT MUST BE THE SUBSCRIBER – For this insurance, relationship to insured MUST be S – Self. Spouses of the insured will have their own insurance card and a different member number.

INVALID PATIENT RELATIONSHIP – 3 places to check. 1 and 2. Go to patient, billing tab, confirm relationship to guarantor and relationship to insured is correct. 3. Pull up the claim line item on the ledger, click detail in the top right hand corner, then click on More Detail – correct relationship code on right if needed.

MISSING PRIOR PAYMENT AMOUNT – This was transmitted to the secondary insurance before the primary insurance’s payment was attached to the claim. This will almost always show up with INVALID OTHER SUB ADJ OR PMT DT.

INVALID OTHER SUB ADJ OR PMT DT – Could be a typo in the date of the primary insurance payment, or it is missing altogether.

MISSING PAYER CLAIM CONTRL NUMB – There is a valid Freq Type code being used, but the insurance cannot replace the old claim unless it has the claim control number assigned to it. This will be entered in the first field below the freq type field, and can be found on the Acknowledgement report from the transmission the claim was paid on. (Ex, Pt comes in 01/06/12, gets keyed, but there is a typo in the procedure, so it’s entered as a 99212 instead of 99213… claim goes through and gets paid. While posting payments you catch that the wrong code was used, so you want to resubmit it. Go pull the Acknowledgement report on the claim when it was paid and grab the “TSH CLAIM ID:” for this claim. It’s always a long number starting with 12. looks like this: 1207316105933097972.)

In Medical Billing, go to Ledger > Edit Charge > Additional > Additional 1 tab, enter the claim reference number in the appropriate Claim REF# field as follows:

Claim Ref # (1) – Enter the claim reference number when resubmitting a prior claim for the primary carrier (as specified in the charge billing order).

Claim Ref # (2) – Enter the claim reference number when resubmitting a prior claim for the secondary carrier (as specified in the charge billing order).

Claim Ref # (3) – Enter the claim reference number when resubmitting a prior claim for the tertiary carrier (as specified in the charge billing order).

NOTE: When claim frequency type code is 7 or 8, the claim control number should be sent in <OriginalRefNumber>123456789012</OriginalRefNumber> (HCFA > ClaimCore > Item > OriginalRefNumber) to populate Loop 2300 REF (Example: 2300 REF~F8~123456789012).

INCORRECT CLAIM FREQ TYPE CODE – In the line item of the claim, go to the Additional button. the Type Code box will be in the top right hand corner. This carrier does not like the choice that is in there. This field should only be used after an insurance has made a payment and something was keyed incorrectly on the claim. This allows you to re-submit the claim with the corrections.
**A corrected claim is a claim that was originally submitted with incorrect information and is being resubmitted.
When submitting a corrected claim electronically, update the Claim Frequency Code with:
7 = Replacement (replacement of prior claim).
8 = Void (void/cancel of prior claim).
The Explanation of Benefits (EOB), Explanation of Payment (EOP) or Claim Control number of the claim being disputed.
Reason why you are disputing the claim. Claim will be rejected if Claim Control number is missing, too.

MISSING/INV DIAGNOSIS CODE POINTER – Usually a diagnosis code was listed twice. I advise reviewing the claim and removing the duplicate. If that fails, re-enter the claim and then bill it.

MISSING PRIMARY DIAGNOSIS CODE POINTER – Make sure there is at least one diagnosis. probably just a typo when keying the charge initially.

MISSING SUBSCRIBER GROUP NAME – The 2000B SBR04 is missing for the carrier’s group name.
1. Make sure that the carrier plan name was filled in.
2. The plan name needs to be entered into the insurance carriers profile
3. Create a new insurance account plan on the patients account in order to select the account plan name.

MISSING SUBSCRIBER GROUP NUMBER – Pull up the patient, then click on the insurance button at the top. In the top left corner, there is the group number.

INVALID AMT/COB OUT OF BALANCE – This just means the math does not add up. Usually this is because the adjustment code (Maintenance – Configuration – Definitions- Adjustment) is missing a Group Code X12 or a Reason Code X12. If these are both present, this can be corrected by deleting and re-keying the adjustment on the claim.

INVALID SL PAID AMOUNT – This is almost always with the INVALID AMT/COB OUT OF BALANCE. Correcting one will correct the other, IF NOT Claim core > ServiceLine2 > ProfessionalService > AdjudicationInfo > ClaimLevelAdjustments > ClaimLevelAdjustment > Quantity. – Hardcode a 1 for the payor specified

INVALID ACTIVE SUB MEMBER ID – The Payor ID (CPID) found under Insurance – Billing Tab – Advanced Claims Tab is not a valid number. The active numbers can be found here.

INVALID INSURED ID NUMBER – The insurance member/plan number entered for the patient is not an active number – usually this is caused by billing an insurance that the patient did not have coverage through at the time of service.

INVALID ADJUSTMENT GROUP CODE – (Maintenance – Configuration – Definitions) The Group Code X12 selected for the adjustment on this claim is not valid for this type of adjustment and needs to be changed.

SERVICE NPI SAME AS BILLING NPI –
1. If this claim is for Place of Service 11 or 12, remove the facility.
2. If this is not at PoS 11 or 12, then compare the practice and facility names and addresses. They must be character for character identical for RH to scrub out the NPI.
3. The facility may have the wrong NPI.

DESTINATION PAYER MUST BE PRIMARY – Whatever insurance this was being sent to (in this case, Mutual of Omaha) has to be the primary insurance in order to receive payment.

INVALID ZIP CODE – Three places that could cause this. Check for a country code of USA and a 9-digit zip-code. Note: If you find that one of the zip code fields requires the full 9 digit zip code then you can find it by entering the 5 digit code into the USPS Zip Code Lookup Tool – http://www.usps.com/zip4/
1. The Practice Information
2. The Provider Profile
3. The Facility

Loop – Segment – Description – Zip Code Length
2010AA – N403 – Billing Provider Name – 9
2010AB – N403 – Pay-To Address Name – 5
2010AC – N403 – Pay-To Plan Name – 5
2010BA – N403 – Subscriber Name – 5
2010BB – N403 – Payer Name – 5
2010CA – N403 – Patient Name – 5
2310C – N403 – Service Facility Location Name – 9
2310E – N403 – Ambulance Pick-up Location – 5
2310F – N403 – Ambulance Drop-Off Location – 5
2330A – N403 – Other Subscriber Name – 5
2330B – N403 – Other Payer Name – 5
2420C – N403 – Service Facility Location Name – 9
2420E – N403 – Ordering Provider Name – 5
2420G – N403 – Ambulance Pick-Up Location – 5
2420H – N403 – Ambulance Drop-Off Location – 5

MISSING OTHER SUBSCRIBER INFORMATION – When re-billing the charge (print, print/review insurance claim), set the BYPASS PAYMENTS/ADJUSTMENTS (bottom option) to Y, to bypass that payment/adjustment

INVALID SERVICE LINE DESC – There is usually an invalid character in the Procedure Description. More often than not, it is a > or < to designate a shot for children under or over a certain age.

INVALID SL THROUGH DATE – There was a typo in one of the dates on this claim.

INVALID ADJ ADJUSTMENTS QTY – Claim core > ServiceLine2 > ProfessionalService > AdjudicationInfo > ClaimLevelAdjustments > ClaimLevelAdjustment > Quantity. – Hardcode a 1 for the payor specified

MISSING INSURANCE TYPE CODE – Claim Core > OtherSubscriber > OtherInsuranceTypeCode and OtherInsuranceTypeCodeSpecified. – Unsuppress.

INVALID SL ADJUD OTHER PAYER ID – This is usually because the 2ndary or tertiary insurance has a bad CPID in the advanced claims tab.

SL PRIOR PAY NOT ALLOWED – This is happening when sending a primary claim after the patient has made a payment and it has been attached to the charge line. There IS a setting to suppress Pt. payments when sending to the primary (Maintenance – Configuration – Settings – Insurance) If this is already turned on, resend the claim after making sure there are no insurance payments on it.

MISSING CLIA NUMBER –

Open the ClaimConfigurationUtility in PPART. Under ClaimCore > Item > ClaimSupplimentalInfo > CLIANumber
Select the option that says Practice User Defined CLIA.
Verify that in Practice Maintenance, Other Data Tab that the PCLIA ID id present and populated with the CLIA number.

Rx Fill History & Recording Patient Consent

Use The Rx Fill History with e-Prescribing in Medisoft Clinical or Lytec MD

The Rx Fill History tab under the Rx/Medications section of the patient’s chart is a valuable tool that is designed to help physicians reconcile medication in order to prevent adverse drug interactions or overdose.

Note: The Rx Fill History tab is only available to providers enrolled in ePrescribing.

The Rx Fill History tab displays pharmacy fill events downloaded to your system from the patient’s Pharmacy Benefits Manager. This feature allows you to see details of what medications your patient is actually obtaining from pharmacies, whether they were prescribed by you or another physician.

You can obtain or refresh the fill history by clicking the Update Fill Hx button, which will initiate a live download of data from the patient’s Pharmacy Benefits Manager. (This feature is limited to what the Pharmacy Benefits Manager provides. It may not contain a complete list of all medications for any particular patient, and it may not be available for all patients.)

Once data has been downloaded you can view detailed information about a prescription by selecting the prescription from the list and clicking the Show Detail button. The Medication Fill History Detail screen will appear with detailed information about the prescription.

You can use the Fill History to update the Current Medications list by clicking the Add to Current Meds button.

Considerations Regarding Patient Privacy& Practice Liability:

It is up to the practice to make sure they are gaining patient consent before accessing a patient’s medication history through their e-prescribing/EMR software system. Surescripts does not provide any sort of form/template for gaining patient consent. As a network, Surescripts does not mandate how a prescriber obtains consent-whether this is done orally or in writing (although the prescriber must act in accordance with the applicable law where they are practicing).

Sample wording for a signed consent:

“I understand that performing a medication reconciliation in order to prevent adverse drug interactions and overdose is a critical component to my care. By signing this form I authorize my provider to query and review my medication fill history including drug, dose, form, strength, prescribing provider, and pharmacy.”

Optional Security Settings:

Access Levels can be used to limit access to the Rx Fill History features to only those users that should have access. Your system administrator grants or denies access to these features by going to Maintenance/Setup/Access Levels, selecting the access level and hitting the Edit button.

On the Records tab the “Rx Fill History Request” should only be checked for users that should have the ability to request the fill history information. And “Rx Fill History” should be checked for users that should have access to view the Rx Fill History tab of the Medications Screen.

By default the system is setup with the assumption that either a written or oral consent has been obtained, however there is a feature that can be enabled to require users to record in the patient record that consent has been obtained. This would prevent the download of fill history data for any patients that had no indication that consent had been obtained.

To set this feature up the Administrator must edit the ppart.ini file (Found in the ppart directory on the server), changing the current setting of “RxFillHxCheckConsent=OFF” to “RxFillHxCheckConsent=ON”

The next step is to create a new question under the patient demographics screen. The “Other Data” tab in the patient’s chart is a place where you can create custom fields to record information on a patient that is not otherwise tracked in the chart. We will setup a question on this tab to indicate whether or not the patient has given consent to obtain Rx Fill History.

Select Maintenance/Configuration/Define Other Data/Patient

When the Patient Define Other Data Select screen appears, click on the New button.

Enter Rx Fill Hx OK? in the Label field, select Text from the Type drop-down list, and select 1 Character from the Length drop-down list. Enter a Description and hit OK.

The Rx Fill Hx OK? field will now appear on the Other Data tab of the Patient screen.

You will need to establish a workflow where patients (or, for minor patients, their guardian) are informed that their pharmacy benefits provider provides information about the medications they have had filled at retail and mail-order pharmacies, and asked for their consent to request that data for medications prescribed by all providers, providers at your site, or not at all. You can enter the following values in the Rx Fill Hx OK? field based on the patient’s response:

– Enter “Y” if the patient gives consent for all providers.

– Enter “P” if the patient gives consent for providers at your site.

– Enter “N” if the patient does not give consent.

Note: The response must be entered in as a single character and must be in uppercase for the feature to work.