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Quarterly Top Ten Professional EDI Edits for October 2019

National Government Services EDI has identified the following as the top ten edits that were received during October 2019 on the 277CA for 5010A1 formatted claims. The edit, its description, the edit logic and the Technical Report Type 3 (TR3) edit reference are provided below.

Edit Description How to Correct/Avoid
X222.087.2010AA.NM109.030

Description:


Logic:
A7:562:85


Billing provider identifier must be a valid NPI.

2010AA.NM109 must be a valid NPI on the crosswalk when evaluated with 1000B.NM109.
Verify that the billing provider identifier is a valid NPI on the crosswalk found on our website.
X222.087.2010AA.NM109.050

Description:







Logic:
A8:496:85


The billing providers’ NPI is not associated with the submitter ID number. The trading partner/submitter ID is not authorized to submit claims for the provider. If this error is received, the provider must complete and sign the appropriate form on the EDI website and return to EDI enrollment for processing.

2010AA.NM109 billing provider must be “associated” to the submitter (from a trading partner management perspective) in 1000A.NM109.
Verify the billing provider NPI is registered with the submitter ID prior to submitting claims.
X222.094.2010AA.REF02.050

Description:



Logic:

A8:562:128:85


Billing provider tax identification number must be associated with the billing providers’ NPI.

2010AA.REF02 must be associated with the provider identified in 2010AA.NM109.
The Tax ID must be the Tax ID submitted on the 855 form when enrolling the provider with Medicare.
X222.121.2010BA.NM109.020

Description:





Logic:
A7:164:IL


Invalid subscriber Medicare ID. HICN/MBI must be valid format. MBI format is 11 positions with CA AN N A AN N A A N N where C is a constrained numeric 1 through 9, A is alpha character A‒Z excluding S, L, O, I, B, Z, N is numeric 0 ‒ 9, AN represent A or N.

If Medicare HICN: 2010BA.NM109 must be 10‒11 positions in the format of NNNNNNNNNA or NNNNNNNNNAA or NNNNNNNNNAN where “A” represents an alpha character and “N” represents a numeric digit. Or If MBI: 2010BA.NM109 must be 11 positions in the format of C A AN N A AN N A A N N where “C” represents a constrained numeric 1 thru 9, A represents alphabetic character A‒Z but excluding S, L, O, I, B, Z, N represents numeric 0 through 9 and AN represents either A or N.
Verify that the HIC or MBI billed is valid as it appears on the beneficiary’s Medicare ID card.
X222.125.2010BA.N403.020

Description:



Logic:

A7:500:IL


The Subscribers ZIP Code must be a valid ZIP Code with the United States Postal Service. Please visit USPS to verify the ZIP Code used in the Subscriber address field.

2010BA.N403 must be a valid postal/ZIP Code.
Verify the 9-digit ZIP Code for the billing provider.
X222.196.2300.REF.010

Description:


Logic:
A7:732:464


Payer claim control number with qualifier of F8 must not be present.

2300.REF with REF01 = F8 must not be present.
Verify that the claim being submitted is an original claim.
X222.226.2300.HI01-2.050

Description:



Logic:
A7:254


The diagnosis code pointed to by diagnosis code pointer is invalid for the claim line date of service. And the A7:254 is right

If 2400.SV107-1, SV107-2, SV107-3, or SV107-4 is “1” and 2300.HI01-1 is “ABK” then 2300.HI01-2 must be a valid ICD-10-CM Diagnosis code on the date in 2400.DTP03 when DTP01 = “472,” based on the ICD-10-CM Diagnosis Code list table. If DTP02=RD8, use the “from” date to validate
The Diagnosis code is invalid for the date of service on the selected service line.
X222.262.2310B.NM109.030

Description:

Logic:
A7:562:82


Rendering provider ID must be a valid NPI.

2310B.NM109 must be a valid NPI on the Crosswalk when evaluated with 1000B.NM109, except when 2300.REF with REF01 = P4 and REF02 = 82.      


Verify the rendering provider NPI matches what is registered in PECOS.
X222.351.2400.SV101-2.020

Description:



Logic:
A7:507


The procedure code must be a valid HCPCS code for the service date.

When 2400.SV101-1 = HC, 2400.SV101-2 must be a valid HCPCS Code on the date in 2400.DTP03 when DTP01 = 472.
Verify that the HCPCS code is valid on the date the service was performed.
DUPLICATE CLAIM FOUND

Description:

Logic:
A3:78


Duplicate of an existing claim which is awaiting processing.

EDI determined that this claim was previously submitted
Ensure that appropriate processes are in place internally and with any third-party submitters to avoid the resubmission of previously submitted claims.

For more information regarding the 5010A1 front-end edits, please contact the EDI Help Desk by email by using the E-mail Inquiry Form.

Quarterly Top Ten Professional EDI Edits for July 2019
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