Claims edits

Claims edits

If you do not submit your claims through the Availity Portal, please follow the process below when submitting your claims to us electronically.

The following edits are all linked to established HIPAA rules. Our edits meet the rules of the HIPAA standards.

Listed below are examples of three higher volume edits:

Example one - Professional and Institutional claims:

This edit rejects claims when the National Provider Identifier (NPI) identifier in the Service Facility NM109 is the same as the one in the Billing Provider NM109.

Current process: The following is sent:

NM1-85-2-FACILITY NAME-XX-1295725133~
NM1-77-2-PROVIDER NAME-XX-1295725133~

Only send a NPI in the Service Facility loop when the Service Facility has a different NPI than the Billing Provider, otherwise send:

NM1-85-2-FACILITY NAME-XX-1295725133~
NM1-77-2-PROVIDER NAME~

The guideline to fix this edit is to remove anything past the Service Facility name or send a different NPI than what is in the Billing loop.

The examples two and three below are used in our compliance process. Information on how to correct the data that may cause an error is also listed.

Example two - Professional and Institutional claims:

An edit rejects claims when the description field is empty when a non-specific HCPCS or procedure code is sent. When this edit is encountered, the following has been sent; a code that contains any of these phrases:

Other

Unspecified

Brand name

Generic

Unclassified

Prescription drug

Unlisted

Miscellaneous

Not otherwise classified (NOC)

It will need additional information to get it through edits and processed. The description field must be populated because of the nonspecific description for the CPT/HCPCS code. Use the CPT or HCPCS manuals to view the full description. Here are two examples:

  • For Institutional claims -- SV2-0551-HC:99600-95-UN-1 (segment SV202-2)
  • For Professional claims -- SV1-HC:99600-12.25-UN-1 (segment SV101-2)

The guideline to fix this error is to send something in the description field that further explains information about the NOC or code.

  • For Institutional claims -- SV2-0551-HC:99600 Dexacortisone, 10%, 15 ml dose -95-UN-1 (segment SV202-7)
  • For Professional claims -- SV1-HC:99600 silver infused wound dressing, 2 inches wide, 4 feet long -12.25-UN-1 (segment SV101-7)

We recommend always sending the supply/device name, the strength, if applicable, and the dosage. This better explains the code so it can be paid correctly.

Examples include:

  • Acme Hearing aide
  • Wrist cuff adjustable crutch
  • FM transmitter with batteries
  • Dexacortisone, 10%, 15 ml dose
  • Silver infused wound dressing, 2 inches wide, 4 feet long

Example three - Professional claims only:

An edit rejects the claim when the date is the same in the Onset of Illness DTP and on one of the service line dates of service. This edit is generated only when the Onset of Illness date and the service line date of service are both in the same format.

DTP-431-D8-20131208~ and a DTP-472-D8-20131208 (both using the format ‘D8' for single date)

This edit will reject the claim when the same date at both locations is included regardless of the format. For example:

DTP-431-D8-20131208
DTP-472-RD8-20131208 – 20131209

The guideline to fix this error is not to send the same date for the Onset of Illness and the Date of Service.