Top 10 Edits in April 2023

For April 2023, National Government Services, Inc. (NGS) Common Electronic Data Interchange (CEDI) has identified the following top ten edits returned on the 277CA for 5010A1 formatted claims. The edit as returned on the 277CA, the reference and description of the edit are provided below.

Reminder: If CMNs or DIFs are included on electronic claims and the from date of service is on or after January 1, 2023, the claims will be rejected by CEDI. Claims with dates of service prior to January 1, 2023 should still include CMN and DIF information in accordance with DME MAC processing and policy guidelines.

5010A1 edits are not specific to the definitions provided.  Edit codes received can apply to multiple Edit References.  If you 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 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 website 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”

Edit Reference: X222.351.2400.SV101-2.020

When the Product or Service ID Qualifier in the 2400.SV101 = "HC", the Procedure Code in the 2400.SV101-2 must be a valid HCPCS Code for the Service Date in the 2400.DTP03 (DTP01 = "472"). 

The HCPCS can be verified with the PDAC.

This rejection can also be caused by sending an invalid HCPCS and modifier combination.  If additional information is needed concerning the validity of the combination, please contact the DME MAC Jurisdiction where the claim will be processed.

2

CSCC A7: “Acknowledgement /Rejected for Invalid Information…”
CSC 453: “Procedure code modifier(s) for service(s) rendered”

Edit Reference: X222.351.2400.SV101-3.040

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

3

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

Edit Reference: X222.121.2010BA.NM109.020

The subscriber’s Medicare ID number is invalid.  Verify the MBI is entered correctly.

The MBI 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 (excluding S, L, I, O, B, Z), or numeric 0-9.

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”

Edit Reference: X222.087.2010AA.NM109.050

The Billing Provider’s NPI in the 2010AA.NM109 is not associated with the submitter in the 1000A.NM109. Therefore, 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 website (https://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.

5

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

Edit Reference: X222.121.2010BA.NM109.030

This Claim is rejected for Invalid Information for a Subscriber's contract/member number. The 2010BA NM109 must be an MBI.

6

CSCC A7: “Acknowledgement /Rejected for Invalid Information…”
CSC 480: “Entity’s claim filing indicator”
EIC PR: “Payer”

Edit Reference: X222.295.2320.SBR09.020

Claim Filing Indicator Code must not = "MA" or "MB". Non-Medicare insurances will need to choose a valid code for the type of insurance being included in the claim file. "MA" and "MB" are not valid for Non-Medicare insurances.

7

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”

Edit Reference: X222.094.2010AA.REF02.050

Billing Provider Tax Identification Number in the 2010AA.REF must be associated with the Billing Provider’s NPI in the 2010AA.NM109.

Verify the information you are submitting matches the information on file with the NPPES and the NPEAST or NPWEST.

8

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

Edit Reference: X222.157.2300.CLM05-3.020

Claim Frequency Code must be "1".

9

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

Edit Reference: X222.196.2300.REF.010

The Payer Claim Control Number with the qualifier F8 must not be present.

10

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

Edit Reference: X222.380.2400.DTP03.080

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 where the claim would be processed based on the patient’s state code in the address provided on the claim.

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: 05/03/2023