Medicare Monthly Review Details

Fourth Quarter Top Ten EDI Part B EDI Edits 2021

National Government Services EDI has identified the following Top Ten Claim Edit Module (CEM) edits that were received during the last quarter of 2021 on the 277CA (Claims Acknowledgement) report for 837P 5010A1 formatted claims. The edit, its description, the edit logic and the Technical Report Type 3 (837P Implementation Guide) edit reference are provided below.

Edit Description How to Correct/Avoid
DUPLICATE CLAIM FOUND

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.
X222.087.2010AA.NM109.050

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 this provider.

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
X222.262.2310B.NM109.030

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.
X222.121.2010BA.NM109.020

Logic
A7:164:IL

Invalid subscriber ID. MBI must be valid format of 11 positions with CA AN N A AN N A A N N. Where C is a constrained numeric 1-9 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 : 010BA.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.
X222.121.2010BA.NM109.30

Logic
A7:164:IL

If the HIC/MBI format is valid, subscriber number must be a valid HICN or MBI based on the claim receipt date (submission date).
 
Verify the date of submission for MBI.
X222.094.2010AA.REF02.050

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.
X222.087.210AA.NM109.030

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.
X222.351.2400.SV101-2.020

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.
X222.196.2300.REF.010

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.
X222.157.2300.CLM05-3.020

Logic
A7:535

2300.CLM05-3 must be "1".
Code specifying the frequency of the claim; this is the third position of the Uniform Billing Claim Form Bill Type
Claim Frequency Code must be 1. Medicare Part B only accepts original 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.

Posted 1/18/2022