Top 10 Edits in October 2021

For October 2021, 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.

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 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.
 

3
 

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

Edit Reference: X222.226.2300.HI02-2.040

The diagnosis code pointed to by the charge line must be a valid ICD-10-CM Diagnosis code for the date of service on the charge line, based on the ICD-10-CM Diagnosis Code list table. If a span date is provided, the "from" date will be used to validate.
 

4
 

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.

MBI: 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.
 

5
 

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.
 

6
 

CSCC A7: "Acknowledgement /Rejected for Invalid Information…"
CSC 254: “Primary diagnosis code

Edit Reference: X222.226.2300.HI01-2.050

One of the diagnosis code's effective dates falls entirely outside the claim’s dates 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.
 

7
 

CSCC A7: "Acknowledgement /Rejected for Invalid Information…"
CSC 255: "Diagnosis code"

Edit Reference: X222.226.2300.HI03-2.040

The diagnosis code pointed to by the charge line must be a valid ICD-10-CM Diagnosis code for the date of service on the charge line, based on the ICD-10-CM Diagnosis Code list table. If a span date is provided, the "from" date will be used to validate.
 

8
 

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 NSC.
 

9
 

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.
 

10
 

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".
 


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: 11/04/2021