Duplicate Claim Editing Information

Jurisdiction K Part B Duplicate Claim Edit

National Government Services implemented a Part B duplicate claim edit in our EDI front-end processing system for Part B Providers in Jurisdiction K which includes the states of Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island and Vermont.

Providers are notified that a claim is a duplicate upon receipt of the 277 Claims Acknowledgement transaction. The claim does not get passed to the Part B claims processing system and it will not appear on the remittance advice.

Providers can identify a duplicate claim rejection on the 277CA transaction with the following claim status reject codes:

• CSCC: A3 ‒ Return as Unprocessable; the claim has been rejected and has not been entered into the adjudication system.
• CSC: 78 ‒ Duplicate of an existing claim/line, awaiting processing.

A claim is rejected as a duplicate if it matches all of the below criteria to another claim submitted within the last 45 days:

• Subscriber Information:
  • Subscriber Last Name (2010BA.NM103)
  • Subscriber First Name (2010BA.NM104)
  • Subscriber Name Suffix (2010BA.NM107)
  • Subscriber HICN/MBI (2010BA.NM109)
  • Subscriber Birth Date (2010BA.DMG02)
  • Subscriber Gender Code (2010BA.DMG03)
• All claim information

The following is not used in the duplicate editing process:

• Claim Level (2300 loop) REF01=D9 corresponding value sent (claim control number/identifier used by clearing houses).
• Service Line Level (2400 loop) REF01=6R corresponding value sent (line item control number).

To successfully submit a claim so it does not generate the claim duplicate edit:

• For claims originally rejected on the 277CA, the Provider/Submitter must correct the 277CA errors before resubmitting in order to bypass the duplicate edit.
• For claims originally accepted on the 277CA and sent on for processing and an issue is found, to resubmit that claim, changes need to be made at the claim or line level to not generate the claim duplicate edit.
• If the provider has to resubmit the claim with no changes at the Claim or Line level, they have to wait 45 days for the "claim and line level information" to fall off of the duplicate table to resubmit.

Note, this editing is not in place for J6 Part B Providers in the states of Illinois, Minnesota, and Wisconsin.

Posted 8/10/2023