EDI Front End Clinical Edits

In the near future, NGS EDI will begin implementing EDI clinical business edits into the NGS EDI front end. These edits will assist in proactively alerting providers of potential claim issues and provide resources to assist with avoiding and resolving the impact of potential denials and appeals.

The new clinical business edits:

• Apply to Part B claims in Jurisdiction 6 (Illinois, Wisconsin and Minnesota) and Jurisdiction K (Connecticut, New Hampshire, New York, Maine, Massachusetts, Rhode Island, Vermont).
• Apply to all direct submitters and those who transmit claims via a clearinghouse/billing service.
• Can be identified on the 277CA transaction by the presence of the 2200D and/or 2220D STC12 data element on the 277CA transaction.

The information for the edit is returned on the 277 Claim Acknowledgement (277CA) transaction that you currently receive. After reviewing an NGS EDI clinical edit, if you choose not to change the claim you can resubmit the claim in its original format, and it will pass through to MCS for normal processing.

The first edit to be implemented is Mammography Certification.

Required edit: When billing HCPCS 77063, 77065, 77066, 77067 or G0279 a mammography certification number is required.

If a submitted claim is missing the required mammography certification number a 277CA will be generated and display:

STC*A1:19:PR*20240425*U*950~DTP*472*D8*20220828~SVC*HC:77063*950
*****1~STC*A3:23:41**U*********SMARTEDIT MAMMOGRAPHY CODES OF 77063, 77065, 77066, 77067 AND G0279 REQUIRE A CERTIFICATION NUMBER.

Posted 9/6/2024