Common Clearinghouse Rejections (TPS): What do they mean?

Rejection Message

Payer

Rejection Type

Information

MB – Subscriber and Other Subscriber Claim Filing Indicator Codes cannot both be MB. 2320.SBR*09 Not Payer Specific TPS Rejection What this means: The primary and secondary insurance on this claim are both listed as Medicare plans.  This is not valid.
Provider action: Check the patient’s insurance plans.  Only state Medicare plans should be listed as Medicare.  Others (including Medicare replacement plans) should be coded accordingly.
When RR Medicare is primary, a valid secondary payer id must be populated. [OT01] Rail Road Medicare TPS Rejection What this means: Railroad Medicare requires that the secondary insurance company have a payer ID, even if it is a claim that will drop to paper.
Provider action: Check the secondary payer.  Enter a valid payer ID, or if this is a paper claim, choose 00010.
Ambulance Pick-Up Location is required for Ambulance Claims. Not Payer Specific TPS Rejection What this means: One of the requirements for ambulance claims is that a pick up city, state and zip code are submitted on the claim.
Provider action: Add the pickup location to your claim.
Referring Provider Name is required When a referral is involved. Loop 2310A is Missing. It is expected Not Payer Specific Rejection What this means:  Whenever a referral number is sent on a claim, the payer also wants to know who referred the patient. This information must be on the claims. 
Provider action:
 Check to see if you are sending a referral number.  If yes, you would want to add the referring provider information so that these claims will go through.
Value of sub-element HI03-02 is incorrect. Expected value is from external code list – ICD-9-CM Diagno Chk # Not Payer Specific TPS Rejection What this means: A diagnosis code on your Claim may be invalid.
Provider action: Check all diagnosis codes on your claims, make sure they are coded properly to the ICD-9 code book.
Subscriber Primary Identifier is required. 2010BA.NM1*09 Not Payer Specific TPS Rejection What this means: Any time a subscriber is listed on the claim, the member ID must also be present.
Provider action: Check the patient/subscriber. Make sure there is a valid member ID listed
Insurance Type Code is required for non- Primary Medicare payer. Element SBR05 is missing. It is requir [OTER] Not Payer Specific TPS Rejection What this means: Claims may reject when the secondary insurance does not contain a valid payer ID, or if the Claim Filing Indicator is MB, MA, OF or 16 when it should be CI or another common code.
Provider action: Ensure that valid Payer Id’s are coming over on the claim, and Ensure that an accurate Claim Filing Indicator as MB, MA, OF, and 16
Secondary  Claims only allowed when Medicare is Primary [OT01] Blue Cross and Blue Shield of Maryland / Carefirst TPS Rejection What this means: Claims submitted through TriZetto that have the same payer For Primary and Secondary insurance may reject for “Gateway EDI Secondary Claim – If there is any invalid or missing data, rejections may follow. [OT01] Secondary Claims only allowed when Medicare is Primary [OT01].”
Provider action: Please submit the secondary claim on paper.
An invalid code value was encountered. Element PAT01 (Individual Relationship Code) does not contain a [OTER] Aetna TPS Rejection What this means: Claims to this payer may reject for ‘An invalid code value was encountered. Element PAT01 (Individual Relationship Code) does not contain a [OTER].’
Provider action:  Verify that you are not sending the same insured and patient name on the claims, if so correct and resubmit.
EPSDT Referral Information is required on
EPSDT Claims. 2300.CRC*ZZ
Multiple Payers TPS Rejection What this means: Due to a referring physician being present on the claims, an authorization number must be sent in the 2300 loop REF*G1 segment (box 23 of the HCFA-1500).
Provider action: Check to see if there is a referring provider. Is the provider present on the claim? If so, please add an authorization number.
Zip code not in range for state. [OT01] Not Payer Specific TPS Rejection What this means: Either the zip code or the state code are not correct for either of the addresses on the claim. (Payer, patient, office, etc.)
Provider action: Check all state and zip codes on the claim to confirm that they are correct. If unsure, you can use the zip code lookup onwww.usps.com.
Yes/No Condition or Response Code may be used only for Medicaid Payer. Element SV112 is used. It should [OTER] Not Payer Specific TPS Rejection What this means: For all non-Medicaid payers, the EPSDT indicator and the Family Planning Indicator are not valid.
Provider Action: Remove these codes from claims to all payers except Medicaid.
No Trading Partner associated with this
claim
Not Payer Specific TPS Rejection What this means: The payer ID submitted on the claim is invalid.
Provider action: The payer ID for the claim that rejected needs to be corrected. You can find a complete list of TriZetto payer ID’s by going to the Resources tab on your website, and clicking on payer list.
MB – Subscriber and Other Subscriber Claim Filing Indicator Codes cannot both be MB. 2320.SBR*09 Not Payer Specific TPS Rejection What this means: The primary and secondary insurance on this claim are both listed as Medicare plans. This is not valid.
Provider action: Check the patient’s insurance plans. Only state Medicare plans should be listed as Medicare. Others (including Medicare replacement plans) should be coded accordingly.
ERROR: Provider’s specialty code Not Payer Specific TPS Rejection What this means: The rendering provider information is either incomplete or missing from the TriZetto system, or it doesn’t match what is being sent on the claim.
Provider action: Check the rendering provider. Is it present on the claim? Is it a provider you have already added to TriZetto Provider Solutions?
ERROR: PAPER CLAIM, GATEWAY EDI IS
NOT SETUP TO PRINT THESE CLAIMS
[OT01]
Not Payer Specific TPS Rejection What this means: This claim is dropping to
Paper rather than being sent electronically and your office is not currently set up to use this product. It could be because of an invalid payer ID/payer name, or you may want to sign up for our paper claims
Product!
Provider action: Check the payer name/payer ID against our payer list. This can be found under the Resources tab on your TriZetto Provider Solutions website. Make sure you are using the correct payer information.
Payer Claim Control Number is required. Segment REF (Payer Claim Control Number) is missing. It is req [OTER] Not Payer Specific TPS Rejection What this means: We are not receiving the original reference number on this corrected/adjusted/voided claim.
Whenever you send this type of claim, the payer requires the original reference number of the claim you are trying to replace. This can be found on the remittance advice (also called ICN/Original Claim number).
Provider action: Check to make sure this original reference number is sent on your claims. If yes, please simply re-send as it did not come across at the time the original claim was submitted. If not, this would need to be added.
Description is required for non-specific procedure code. Sub-element SV101-07 is missing. It is requir [OTER] Not Payer Specific TPS Rejection What this means: When you use Not Otherwise Classified (NOC) Codes the 5010 implementation guide instructs that you use SV101-7 for use of the note (NTE) segment to include a description, 5010 specifically warns not to use the NTE segment.
Provider action: Verify you are sending a description of the code / service on the claim in the proper segment.
A data element with ‘Must Use’ status is missing. Element NM108 (Identification Code Qualifier) is mis ; An HIPAA syntax error occurred. If either of NM108, NM109 is present, then all must be present. Not Payer Specific TPS Rejection What this means: A required field, in either the NM108 and/or NM109, is missing from an NM1 segment.
Provider action: Identify which data element is missing from the NM1 segment and make appropriate corrections. The NM109 indicates a payer ID, patient/subscriber member ID, or an NPI.
The COB information does not balance Not Payer Specific TPS Rejection What this means: This error occurs on secondary claims when the primary paid amount, plus all the adjustments (ex. patient responsibility; contractual obligation), does not equal the total charge of the claim.
Provider action: Add the primary paid amount and all adjustments to ensure that amount matches the total charge on the claim.
Acknowledgement/Rejected for Invalid Information H51112 The last position of the Bill Type Code is not a valid NUBC Frequency code for this transaction Not Payer Specific TPS Rejection What this means: This payer does not accept a frequency code of 6 (corrected claim). They only allow 7 (replacement claim).
Provider action: Change from corrected claim to adjusted claim and re-submit.
ERROR: Provider’s specialty code Not Payer Specific TPS Rejection What this means: The rendering provider information is either incomplete or missing from the TriZetto system, or it doesn’t match what is being sent on the claim.
Provider action: Check the rendering provider. Is it present on the claim? Is it a provider you have already added to TriZetto Provider Solutions?
These claims were submitted as TEST and
Will not be processed.
Not Payer Specific TPS Rejection What this means: On the claim file that we received, there was an indicator (T) telling us this file was submitted as a test file (this indicator is located in the ISA 15 of the ANSI claim file).
Provider action: If you want this file to process, this indicator must be changed to a P, which means this is a production file.
Validator error – Extra data was encountered. Extra Sub-Element was found in the data file Not Payer Specific TPS Rejection What this means: In the ANSI 5010 format accepted by most payers, non-alpha- numeric characters can cause rejections. This is because they actually perform various functions in ANSI files. This rejection is caused when a colon is sent somewhere in the file that it is not supposed to be, which is basically in any text field.
Provider action: Check text fields such as payer name/address, note descriptions, provider information etc. Remove all non-alpha-numeric characters, especially colons (:).
Payer : Entity’s Postal/Zip Code Acknowledgement/Rejected for Invalid Information Not Payer Specific TPS Rejection What this means: One of the addresses on your claim has an invalid zip code.
Provider action: Verify all addresses submitted including both primary and secondary payer addresses are valid. You can verify the address and zip code by navigating to www.usps.com.
A data element with ‘Must Use’ status is missing. Element NM108 (Identification Code Qualifier) is mis ; An HIPAA syntax error occurred. If either of NM108, NM109 is received the other must also be present Multiple Payers TPS Rejection What this means: A required field, in either the NM108 and/or NM109, is missing from an NM1 segment.
Provider action: Identify which data element is missing from the NM1 segment and make appropriate corrections. The NM109 indicates a payer ID, patient/subscriber member ID, or an NPI.
Subscriber ID number must be 6 or 9 digits with 1-3 letters in front Palmetto GBA – RR
Medicare Part B
TPS Rejection What this means: Railroad Medicare claim numbers begin with one, two or three letters, and have six or nine digits after the letters.
Provider action: Verify the subscriber ID is being submitted in this format.
Auto Accident State is required if Related Causes Code is AA. 2300.CLM*11-4 Multiple Payers TPS Rejection What this means: The Accident information is required if the claim is for codes due to an Auto Accident, Employment Accident, or Other Accident of some sort.
Provider Action: Verify that you are intending to send the claim as an Accident claim. This identification as an accident is fueled by either the diagnosis codes or the procedure codes that are reported.
Auto Accident State is required if Related Causes Code is AA. 2300.CLM*11-4 Multiple Payers TPS Rejection What this means: The Accident information is required if the claim is for codes due to an Auto Accident, Employment Accident, or Other Accident of some sort.
Provider Action: Verify that you are intending to send the claim as an Accident claim. This identification as an accident is fueled by either the diagnosis codes or the procedure codes that are reported.
A data element is too short. The length of Element NM109 Identification Code) is ‘1’.
The minimum allowed length is ‘2’.
Multiple Payers TPS Rejection What this means: One or more of the NM.109 segments have a requirement of at least 2 digits, but only came over with 1 digit.
Provider Action: You will want to check the following to ensure valid information is being populated
Patient ID (Member ID Number) Number’s for Primary and Secondary Payers and or Payer ID numbers
ICD 10 Principal Diagnosis Code must be valid. 2300.HI*01-2 All Payers TPS Rejection What this means: This claim is being read as an ICD-10 claim and there is a diagnosis code that is not valid for this format, either on the global or payer specific level.
Provider Action: All necessary codes must be present, valid, and unique. In order for this claim to process, the diagnosis codes must be listed on the claim in the proper order, meaning you cannot have a
Diagnosis code 3 without having a diagnosis code 2. You must also have a diagnosis code listed on the claim only one time.
Billing Provider Address1 cannot be a PO
Box or Lockbox Address. 2010AA.N3*01
United Healthcare 87726 TPS Rejection What this means: The Billing Provider
Information may be Missing, Invalid, or not Credentialed with the payer as it is being sent on the claim.
Provider Action: Please verify all billing
Information that was submitted. Please TPS Rejection verify that all information is complete,
Valid, and matches your credentialing with
This payer.
The Billing provider information may
Include:
The Billing provider Taxonomy Code.
Referring Provider Last Name cannot
Contain numeric characters.
2310A.NM1*03
All Payers TPS Rejection What this means: The Referring Provider
Information may be Missing, Invalid, or not Credentialed with the payer as it is being sent on the claim.
Provider Action: Please review the Referring Provider information submitted on your claim and verify all information is completed and valid.
The Referring provider information will
Include both the provider’s name and NPI.
The referring provider’s NPI must be sent
As a 10 digit number.
If you submit your claims in the Print Image
Format, the provider’s name must be sent in a consistent format across every claim, meaning ‘last name, first name’ (ex. Doe, John), ‘first name last name’ (ex. John Doe), etc.
Failed Essence Eligibility for “Member not
Found.”
Essence GHP
57082
TPS Rejection What this means: This rejection will occur
When the submitted patient information is either not found or mismatched in the payer’s system for this date of service.This information could include: any patient
Demographic information, subscriber (if different from patient) demographic and relationship information, the insurance ID, group number or the payer information.
Provider Action: Essence sends us an up to date report with a list of the enrolled patients
For Essence Eligibility Rejections the patient must be listed on the report and information must match to the claim for it to pass test.
The list can be found under
\\nt1\s1_ot\EssenceMemberLookup
(Choose date closest to your rejection)
Payer Responsibility Sequence Number
Code cannot occur more than once
Within a claim. 2320. SBR*01
All Payers TPS Rejection What this means: This rejection will occur
When there are multiple payers listed on the claim and their sequence numbers are not listed or not unique. The Sequence number is the listing of the payer’s responsibility level, meaning primary payer, secondary payer, tertiary payer, etc. This is identified in the ANSI location – SBR01.Provider Action: Verify that the payer information listed on the claim is valid. Please verify that there is only one payer
Listed for the patient in the sequence listings of primary, secondary, tertiary, etc. Please verify that each payer has their sequence listed and it is valid.
If there is any question on the patient’s
Coverage, please verify this information
With the patient and the respective payers.
Mississippi Medicaid secondary claims
Cannot be sent electronically, or on paper, when Medicare is the primary payer
Medicaid of Mississippi
00514
TPS Rejection What this means: This rejection will occur
When Medicare is the Primary and Medicaid is the secondary – Medicaid will NOT take a secondary electronically or via paper when Medicare is the Primary payer they expect this to come from Medicare via the Crosswalk
Provider Action: Verify they are
Submitting the secondary claim to the proper payer – if it is Medicaid the patient will need to update their Patient Profile with the payers to ensure they both have accurate coverage information for the patient
The provider will also need to verify with Medicaid how to submit this claim.
A maximum of 8 Diagnosis Codes are allowed in 4010. Not Payer Specific Payer Rejection What this means: When the payer accepts claims in the 4010 format, only 8 diagnosis codes are allowed per claim.
Provider action: If there are more than 8 diagnosis codes, this claim has to be split into multiple claims.
Billing Provider TAX ID/NPI is not on
Crosswalk
Medicare Payer Rejection What this means: Generally this is because the provider numbers that are coming over on the claim (TID or SSN and NPI) are not the same as what the payer has in their system.
Provider action: Compare the numbers you are sending to those from your original credentialing. Does this payer know all of the provider numbers you are sending on the claim? Compare this claim to others that have gone through to this payer. Is anything different?
Pay To Affiliation Error| No Pay To
Provider Found
Cigna/ Great West Payer Rejection What this means: The payer is not able to locate the provider within the system.
Provider action: Please verify you are sending the valid group and rendering NPI number on the claims. Please also verify your tax ID number is valid.
Crosswalk did not give 1 to 1 match for NPI 1111111111. Number of rows returned was 0. Chk # Medicaid of Indiana / EDS Payer Rejection What this means: The payer does not recognize the provider matched to the NPI tax ID combination in their system.
Provider action: Check your NPI and tax ID numbers, are you sending the claim how you are credentialed with the payer, verify this provider is credentialed under the Billing NPI or individual provider NPI. You may need to contact the payer to retrieve this information.
Acknowledgement/Rejected for Invalid Information: Other Payer’s payment information is out of balance.
Acknowledgement/Rejected for Invalid Information: Other payer’s Explanation of Benefits/payment information.
Multiple Payers Payer Rejection What this means: The Payer has another insurance listed for the patient who must be billed prior to them.
Provider action: Verify each insurance for the patient. This can be verified on the client site when checking eligibility for the payer under other or additional payer.
Acknowledgement/Rejected for Missing
Information Adjudication or Payment
Date’
Blue Cross Blue Shield Payer Rejection What this means: Blue Cross Blue Shield
Only allows submission of secondary claims if it has been longer than 31 days after the primary payer paid their portion.
If it has not yet been 31 days, the claim will
Reject.
Provider action: Re-submit after 31 days from adjudication date by the primary payer.
AW1 P RENDERING PHYSICIAN IS
REQUIRED
Tricare Payer Rejection What this means: There are a few possible
Reasons for this rejection:
1.If the provider sends the claim with only the individual NPI in the billing loop and they are credentialed with a group NPI, then the claims will be rejected by the payer.
2.If the provider sends the claim with only the individual NPI in the billing loop and the entity type qualifier is 2 (non-person), then the claims will be rejected by the
Payer. If this is a print image client, an edit can be created to change the qualifier for this payer.
3.If the provider sends the claim with only the individual NPI in the billing loop and they are credentialed as a group entity, then the claims will be rejected by the payer. The provider will need to credential as an individual entity to be able to bill electronically with this NPI.
Provider action: Resubmission
Billing Provider Number is not found. Please correct and resubmit electronically. Multiple Payers Payer Rejection What this means: The information submitted in box 33 does not match to what the payer has on file.
Provider action: Check the information submitted on the claim in box 33. If any information needs to be updated, the provider will want to update this directly with the pay.
Billing Provider TAX ID/NPI is not on Crosswalk Medicare Payer Rejection What this means: Generally this is because the provider numbers that are coming over on the claim (TID or SSN and NPI) are not the same as what the payer has in their system.
Provider action: Compare the numbers you are sending to those from your original credentialing. Does this payer know all of the provider numbers you are sending on the claim? Compare this claim to others that have gone through to this payer. Is anything different?
Clm: The Discharge Date (2300, DTP) is only required on inpatient claims when discharge date is known. Multiple Payers Payer Rejection What this means: Whenever you send a discharge date on the claims, the place of service must represent an inpatient claim.
Provider action: Check the place of service. Inpatient is 21.
The Information in Address 2 should not match the information in Address 1. Multiple Payers Payer Rejection What this means: An address is duplicated
Somewhere on the claim.
Provider action: Check all addresses for payer, insured, billing address, etc., to verify you are not sending the same information in Address line 1 as Address line 2.
Third Party Repricing Organization (TPO) : Claim/service should be processed by entity Acknowledgement Chk # Preferred One Payer Rejection What this means: Chiropractors who submit to Preferred One may need to send their claims to HSM first for re-pricing.
Provider action: If you are a chiropractor, you would want to resubmit the claim to HSM payer ID 41150.
Value of element DTP03 (Assumed or Relinquished Care Date) is incorrect. Value for date or start period date is expected to be a date earlier than the Transaction Creation Date. Humana Payer Rejection What this means: Claims submitted to Humana May reject for “Value of element DTP03 (Assumed or Relinquished Care Date) is incorrect. Value for date or start period date is expected to be a date earlier than the Transaction Creation Date.” Per Our Trading Partner In Loop 2300 the Report End Date (DTP*091) must be before Transaction Creation Date (BHT*04), No claims will process if the DTP*091 is before the BHT*04.
Provider action: Submit claim after the Relinquished Care Date has passed Or Submit a paper claim.
The payer will not allow more than one drug code to billed on one claim Medicaid of Pennsylvania / EDS Payer Rejection What this means: Claims submitted to this payer may reject for “The Claim has more than one Service Line with Loop 2410.” This payer will not allow more than one drug code to be billed on one claim.
Provider action: Verify that you are only billing one drug code per claim.
Line information Acknowledgement/Returned as unprocessable claim’ Multiple Payers Payer Rejection What this means: Commercial payers do not accept $0 service lines.
Provider action: Check to verify your claims do not contain service lines with a $0 charge.
Subscriber not found Multiple Payers Payer Rejection What this means: Either the patient information or the payer where the claim was sent are incorrect or out of date.
Provider action: Check the patient’s ID card (not your software system). Confirm that the patient/subscriber information including patient name, date of birth, member ID, etc. are all correct. Confirm that the payer name and ID are also correct.
INVALID SPECIAL CHARACTERS REPORTED Multiple Payers Payer Rejection What this means: Invalid special characters have been found in your claim. Special characters include <, >, ^, #, etc.
Provider action: Verify you are not submitting invalid characters in your data.
PRIMARY CARE PHYSICIAN REQUIRED Medicaid of Arkansas / HP
Enterprise Services
Payer Rejection What this means: Medicaid is looking for a referring provider on the claim. This must be the correct primary care provider Medicaid has listed for the patient.
Provider action: Verify you are sending the appropriate referring provider and NPI on the claim.
Submitter : Other Carrier payer ID is missing or invalid Acknowledgement/Rejected for Invalid Information Medicaid of New Mexico Payer Rejection What this means: Payer Response: Patient should contact Medicaid to TERM coverage with other payer and/or add Medicaid as Primary Payer.
Provider action: Please verify the primary payer for this claim.
Entity’s commercial provider id. Amerigroup Payer Rejection What this means: Please see all three
Scenarios.
1. Not all patients’ plans require the taxonomy code to be validated. The ones that do will end up with a commercial id error if the taxonomy or NPI is not on file.
When there is no Active License Number on the state license site for a provider,
They are unable to load a provider in facets.
Which then will be “Mail back” for no
Active license or “unable” to verify License.
2. The NPI being used in the 2010AA loop
Is attached to another provider
3. The provider cannot bill to self under the tax id they’re using. The Provider is set up in the system under this TIN but he/she is linked to a group. They would need to resubmit with
The group in box 33 and the rendering provider in box 31 if this is the case.
Provider action: Check your claims for the information above and make any corrections necessary.
TPL COMPANY CODE AND OR NAME MISSING OR INVALID/
Acknowledgement/Returned as unprocessable claim: TPO rejected claim/line because payer name is missing
Medicaid of Arkansas Payer Rejection What this means: Secondary claims that rejected at Medicaid with the error message ‘TPL COMPANY CODE AND OR NAME MISSING OR INVALID/
Acknowledgement/Returned as unprocessable claim: TPO rejected claim/line because payer name is missing’, require a TPL third party liability code to
Be submitted on the claim.
Provider action: Check the secondary claim, did you submit your TPL code? This will replace the primary insurance payer ID.
SOCIAL SECURITY/EMPLOYEE # NOT FOUND – PLEASE CHECK ID CARD, CONTACT CLAIM OFFICE WITH QUESTIONS Multiple Payers Payer Rejection What this means: Some claims for this payer may reject with the error message “SOCIAL SECURITY/EMPLOYEE # NOT
FOUND – PLEASE CHECK ID”, this has to do
With the patients eligibility.
Provider action: Check eligibility for this patient. You will want to verify that the patient’s eligibility is valid, that they are sending a valid Member ID, Date of Birth, and name.
Segment has data element errors’ Loop:2400 Segment:NTE’ Invalid Character In Data Element’ Multiple Payers Payer Rejection What this means: The claim contains invalid special characters. Generally, this rejection is referring to a (`) received on the claim.
Provider action: Check to make sure any special characters are removed off of the claim.
Medicare Report Number is required Multiple Payers Payer Rejection What this means: The claim is missing the ICN (original reference number). This must be sent on secondary claims.
Provider action: Add the ICN number (REF*F8 on ANSI files) When the ICN number is sent for COB claims it is sent in the 2330B loop, the other payer loop.
When a replacement claim is sent, then
The ICN number is sent in the 2300 loop.
This is true for 4010 and 5010 claims.
CLIA CERTIFICATION REQUIRED FOR LAB PROCEDURE Medicaid of Arkansas Payer Rejection What this means: The CLIA number submitted is not on file with Medicaid.
Provider action: The CLIA will need to be registered with provider enrollment at Arkansas Medicaid.
Submitter : Entity not found Acknowledgement/Returned as unprocessable claim Submitter not approved for electronic claim submissions on behalf of this entity Not Payer Specific Payer Rejection What this means: The information submitted in box 33 does not match to what the payer has on file.
Provider action: You will want to confirm ALL information in box 33 matches the payer system and is approved for electronic submission. This will include provider/office name, entity type, address, NPI, tax ID, and in some cases submitter
ID.
Insured or Subscriber : Entity’s contract/member number Acknowledgement/Rejected for Invalid Information Multiple Payers Payer Rejection What this means: The member ID number is missing or invalid for this patient.
Medicare numbers should be 9 numeric followed by an alpha with no hyphens, punctuation or spacing. If the ID number is correct, compare the patient/subscriber information to the patient’s card. If the name is different at all, you would want to make it appear exactly as it does on the card.
Provider action: Correct the patient/subscriber information and resubmit.
Processed according to contract provisions (Contract refers to provisions that exist between the Health Chk # Multiple Payers Payer Rejection What this means: The NPI submitted on the claim is not registered in the payer’s system.
Provider action: Verify the provider’s contract by contacting provider services at the payer.
INVALID PROVIDER ID# NPINOM~ Tufts Health Plan Payer Rejection What this means: The payer is rejecting the claim due to unrecognizable provider information.
Provider action: Please verify you are submitting with the valid Group and Rendering provider name and NPI. Please verify Tax ID number. Please verify you are enrolled with this payer.
Pending/Provider Requested Information – The claim or encounter is waiting for information that has already been requested from the Medical notes/report Multiple Payers Payer Rejection What this means: The payer is requesting further documentation
To process the claim. Usually it can be medical records for a date range or additional notes related to this service date.
Provider action: Have you reached out to the payer to see what documentation they are needing for this patient?
Product or Service ID Qualifier is required
And must be valid. 2400.SV1*01-1
Multiple Payers Payer Rejection What this means: The payer wants notes in the SV101-7 segment on the claims. We have written edits that will move these notes to the correct segment, but the following criteria must be met: In the SERVICE LINE NOTES (2400 NTE segment),
The very beginning of the note must have the letters NOC (not otherwise classified) so that our system recognizes that this needs to be sent in this segment. If NOC is not sent at the beginning, the edit will not work. If the notes are sent in the claim level (2300 NTE/box 19), the edit will not work.
Provider action: Make sure you are sending a SERVICE LINE note that begins with NOC.
MULTIPLE SERVICE LOCATION ERROR: MULTIPLE SERVICE LOCATIONS EXIST – THE SERVICE LOCATION MUST BE PROVIDED Multiple Payers Payer Rejection What this means: The REF*LU segment is missing from the 2310C loop which contains the 9 digit service facility zip code followed by the service location code.
Provider action: Check the service facility loop 2310C. Is the REF*LU present on the claim and does it match what is in the payers system?
Due to special Medicaid requirements, a
Paper secondary cannot be generated
For this claim
Media-Cal
00149
Payer Rejection What this means: This rejection will occur
When a claim is trying to drop to paper in our system and we are not currently contracted to print claims for your office or the payer will not accept paper claims. This could mean that the claim is does not
Payer Rejection having an electronic route to be
Transmitted or it could mean that the claim does not have the correct payer information.
Provider Action: Verify that you are
Sending correct payer information.
2300-180-REF02-127 CLAIM NUMBER IS
INVALID
Tricare
57106
Payer Rejection What this means: This rejection will occur
When the claim was submitted to Tricare with an ICN (Original Reference Number) that does not meet their requirements.
The ICN must have 13 characters, no hyphens, all capital letters, and 4 ending zeros. The claim is rejected by the payer because it is unable to locate that claim reference number in their system.
Provider Action: Please verify the information that you are sending on your Claim and confirm that it matches the
Remittance.
This is the ANSI location of REF*F8 in the
2330B loop.
If your remittance has the ICN number as
11 digits, please add two 00’s at the end
With no punctuation to correct this issue.
Cannot provide further status electronically – Please Resubmit if no remittance has been received Davis Vision
00157
Payer Rejection What this means: The payer has submitted a rejection report, however, there may not be any details as to why the claim rejected.
Provider Action: Payer is indicating there was an issue with the claim, please re- submit if no Remittance is received
Acknowledgement/Returned as unprocessable claim-The aim/encounter has been rejected and has not been
Entered into the adjudication system. Entity not found.
Multiple Payers Payer Rejection What this means: One or more of the Entities were not found or another issue may be occurring.
Provider Action: You will want to run Eligibility on the patient to ensure they are eligible, if the patient is eligible it is recommended to request a payer call for further information on the claim rejection Don’t forget you will always need a copy of the Member ID card for escalated issues.
Onset of Current Illness or Symptom Date cannot be a future date. 2300.DTP*431 Aetna
60054
Payer Rejection What this means: The Onset of Current Illness or Symptom Date is required for the initial medical service or visit performed in response to a medical emergency when the date is available and is different than the date of service.
Provider Action: Verify that you are sending the Symptom Date. This information may be required based upon a procedure or diagnosis code or the payer’s specifications. This date cannot be a future date from either the submission or service date.
Acknowledgement/Rejected for relational field in error. : Claim submitted to incorrect payer Anthem Blue Cross Blue
Shield
47198
Payer Rejection What this means: The claim was submitted to the incorrect payer
Provider Action: The claim will need to be re-submitted to the correct processing payer
Member Found in Multiple Plans Eye Med Vision Care
31165
Payer Rejection What this Means: The payer has identified that this patient has more than one insurance coverage
Provider Action: The provider / Patient will want to ensure they are billing to the correct insurance carrier or using Group Name / Group Number as applicable
Unknown Provider/Location Association Multiple Payers Payer Rejection What this means: The Payer is rejecting the claims due to mismatched information in their systems
Provider Action: The Provider will want to ensure they are submitting their Billing / Rendering information as the payer has it in their systems – This could also mean they are missing a Service Facility Segment on the claim.
THE TRANSACTION HAS BEEN REJECTED AND HAS NOT BEEN ENTERED INTO THE ADJUDICATION SY
STEM: DIAGNOSIS CODE POINTER IS MISSING OR INVALID
Multiple Payers Payer Rejection What This Means: The payer is rejecting the claim due to one or more of the diagnosis codes are not being pointed to Provider Action: This payer requires any diagnosis codes that are being submitted on the claim to be pointed to in the service lines – However service lines can only allow up to 4 pointers per line.
The provider will need to determine if they can point to that Diagnosis code, if not it will need to be removed.
CONTRACT NUMBER NOT FOUND Multiple Payers Payer Rejection What this means: The payer’s EDI system had an issue locating the patient in their database
Provider action: Check the Patients Eligibility / Member ID card to ensure it is correct and up to date. Also ensure that the claim is being submitted to the correct payer for processing
Acknowledgement/Rejected for Invalid Information-The claim/encounter has invalid information as specified in the Status details and has been rejected : Invalid characterInsured or Subscriber: Acknowledgement/Rejected for Invalid Information-The claim/encounter has invalid information as specified in the Status details and has been rejected : Entity’s health industry id number

Acknowledgement/Rejected for Invalid Information-The claim/encounter has invalid information as specified in the Status details and has been rejected : Statement from-through dates

Blue Shield Medical
00031
Payer Rejection What this means: This payer is rejecting for Member ID and Subscriber information not matching what is in their systems database
Provider action: The provider will need to ensure they are submitting claims to the correct payer, with the Subscriber information as it’s listed within their system and on the Member ID card.
PROCEDURE DESCRIPTION: INVALID; PROCEDURE DESCRIPTION INVALID FOR PAYER Blue Cross and Blue Shield of New Jersey (Horizon)
22099
Payer Rejection What this means: The Payer is rejecting the claim due to a Description of Service coming over.
Provider action: The description for the CPT or HCSPCS code will need to be removed, and the claim re-submitted
CATEGORY: ACKNOWLEDGEMENT/REJECTED FOR MISSING INFORMATION THE CLAIM/ENCOUNTER IS MISSING INFORMATION SPECIFIED IN THE STATUS DETAILS AND HAS BEEN REJECTED STATUS: CLAIM ADJUSTMENT INDICATOR ENTITY: BILLING PROVIDERCATEGORY: ACKNOWLEDGEMENT/REJECTED FOR MISSING INFORMATION THE CLAIM/ENCOUNTER IS MISSING INFORMATION SPECIFIED IN THE STATUS DETAILS AND HAS BEEN REJECTED STATUS: ENTITY’S HEALTH INSURANCE CLAIM NUMBER (HICN) ENTITY: PAYER Blue Cross Blue Shield of MN00956 Payer Rejection What this means: The REF*F8 Original Claim (ICN/DCN) Number is not valid or does not match the Payer’s systems
Provider action: Correct or Remove the number as needed
E30 P PROC CODE W/ MULTI UNITS INVALID/DATE OF SERV Blue Cross and Blue Shield of South Carolina57028 Payer Rejection What this means: When billing certain codes to the payer, they will only accept a unit of 1
Provider action: The site will need to check the billing guidelines for the codes, and submit the proper number of units per code
Need Text: Acknowledgement/Returned as unprocessable claim-The claim/encounter has been rejected and has not been entered into the adjudication system. : Missing/invalid data prevents payer from processing claim Medicaid of Wyoming00462 Payer Rejection What this means: The Payer has identified that there is information on the claim that is required to continue processing per their guidelines
Provider action: Insure that the proper Taxonomy Codes are coming over on the claim that support the type of services you are billing.
ERR 26: Provider/claim type not valid for
this submitter
Medicaid of California MEDI-
CAL00148
Payer Rejection What this means: The Payer was unable to locate the provider in their system for the type of claim submitted
Provider action: The Provider needs to ensure that the Group NPI Is credentialed with the Payer and enrollment is completed.
Rejection/ Error Message Present on Admission Indicator for reported diagnosis code(s) Acknowledgement/Returned as unprocessable’
Status Resolved
Cigna and other payers62318 Payer Rejection What this means: Either the Provider did not list a Present on Admission Indicator, or the Billing Providers taxonomy is exempt from the POA standards and is missing.
Provider action: The provider will either need to add a Present on Admission indicator, or add the Billing Taxonomy Code on the claim if they are Exempt from these types of codes.
INVALID RELATED ADMISSION DATECommunity Health
INVALID RELATED ADMISSION DATE Community Health Choice60495 Payer Rejection What this means: The site is submitting an admission date on the claim when it is not expected by the payer.
Provider action: If the place of service does not include the following then the admission date is not allowed.
21, 41, 42, 51, 52, 54, 55, 56, and 61.
Medicare Report Number is required Blue Cross Blue Shield Payer Rejection What this means: The claim is failing
Because they were expecting other payer claim control number, the Medicare claim number (ICN) (loop
2330B REF*F8).
Provider Action: Add the Medicare
Claim ID in box 22 and resubmit the claim. Need to get the Medicare claim ID (ICN) from the Medicare EOB.
Rejection: P445 CONTRACT IS MEDICARE ADV AND SOP IS BL Blue Cross Blue Shield Payer Rejection What this means: Each MI BCBS payer ID
Has its own Claim Filing Indicator.
Provider Action: Whatever payer ID the client sends to us, we will change the CFI (claim filing indicator) to the appropriate one.

Payer ID EMC CFI Payer Name
77710 EMC 777 BL MI BCBS
77910 EMC 779 HM MI BCBS Blue Care Network
00778 EMC 778 MB MI BCBS Medicare plus
77911 EMC 791 FI MI BCBS Federal
7771M EMC 777 HM MI BCBS Medicaid Complete

Even though each payer has a different EMC, the claims are still routed to the same place. The claims are then sent to the appropriate payers per the Claim Filing Indicator.

Leave a Reply

Your email address will not be published. Required fields are marked *