January 2020 EDI Front End Quarterly Release - New and Modified Edits
The Part A and Part B edit changes are listed below:
Part A Edit Changes
| Edit Reference Number | Change | Reason for Change | Trading Partner/Results |
|---|---|---|---|
| X223.143.2300.CLM05-1.040 If Facility Type Code = 11, 12, 18, 21, 22, or 41 then Admitting Diagnosis must be present and Code List Qualifier Code must = BJ or ABJ |
New 277C Edit | New edit to validate admitting diagnosis code is present. | 277C Received with: CSCC A6: "Acknowledgement /Rejected for Missing Information…" CSC 232: "Admitting diagnosis" |
| X223.358.2320.CAS01.040 If Claim Adjustment Group Code = CR, OA, or PI: then Claim Adjustment Reason Code must NOT equal 45. |
New 277C Edit | New edit to check for claim adjustment group and reason code combination. | 277C Received with: CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 521: “Adjustment Reason Code” |
| X223.480.2430.CAS01.040 If Claim Adjustment Group Code = CR, OA, or PI: then Claim Adjustment Reason Code must NOT equal 45. |
New 277C Edit | New edit to check for claim adjustment group and reason code combination. | 277C Received with: CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 521: “Adjustment Reason Code” |
| X223.354.2320.SBR09.020 Claim Filing Indicator Code must not be = MA or MB. |
Revised 277T Edit | Updates to edit logic to correct missing Entity Identifier Code (EIC). | 277 Received with: CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 480: "Entity's claim filing indicator." EIC: PR "Payer" |
| X223.319.2310A.NM101.010 Attending Provider Name Entity Identifier Code must be present and a valid value. Valid value = 71 |
Revised 999 Edit | Update to the error code returned when Attending Provider Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2 |
| X223.326.2310B.NM101.010 Operating Physician Name Entity Identifier Code must be present and a valid value. Valid value = 72. |
Revised 999 Edit | Update to the error code returned when Operating Physician Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2 |
| X223.331.2310C.NM101.010 Other Operating Physician Name Entity Identifier Code must be present. Valid value = ZZ. |
Revised 999 Edit | Update to the error code returned when Other Operating Physician Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2 |
| X223.336.2310D.NM101.010 Rendering Provider Name Entity Identifier Code must be present and a valid value. Valid value = 82. |
Revised 999 Edit | Update to the error code returned when Rendering Provider Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2 |
| X223.341.2310E.NM101.010 Service Facility Location Name Entity Identifier Code must be present and a valid value. Valid value = 77. |
Revised 999 Edit | Update to the error code returned when Service Facility Location Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2 |
| X223.349.2310F.NM101.010 Referring Provider Name Entity Identifier Code must be present and a valid value. Valid value = DN. |
Revised 999 Edit | Update to the error code returned when Referring Provider Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2 |
| X223.377.2330A.NM101.010 Other Subscriber Name Entity Identifier Code must be present and a valid value. Valid value = IL. |
Revised 999 Edit | Update to the error code returned when Other Subscriber Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2 |
| X223.384.2330B.NM101.010 Other Payer Name Entity Identifier Code must be present and a valid value. Valid value = PR. |
Revised 999 Edit | Update to the error code returned when Other Payer Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2 |
| X223.456.2420A.NM101.010 Operating Physician Name Entity Identifier Code must be present and a valid value. Valid value = 72. |
Revised 999 Edit | Update to the error code returned when Operating Physician Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2 |
| X223.461.2420B.NM101.010 Other Operating Physician Name Entity Identifier Code must be present and a valid value. Valid value = ZZ. |
Revised 999 Edit | Update to the error code returned when Other Operating Physician Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2 |
| X223.466.2420C.NM101.010 Rendering Provider Name Entity Identifier Code must be present and a valid value. Valid value = 82. |
Revised 999 Edit | Update to the error code returned when Rendering Provider Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2 |
| X223.471.2420D.NM101.010 Referring Provider Name Entity Identifier Code must be present and a valid value. Valid value = DN. |
Revised 999 Edit | Update to the error code returned when Referring Provider Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2 |
Part B Edit Changes
| Edit Reference Number | Change | Reason for Change | Trading Partner/Results |
|---|---|---|---|
| X222.299.2320.CAS01.040 If Claim Adjustment Group Code = CR, OA, or PI: then Claim Adjustment Reason Code must NOT equal 45. |
New 277 C Edit | New edit to check for claim adjustment group and reason code combination. | 277C Received with: CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 521: “Adjustment Reason Code” |
| X222.484.2430.CAS01.040 If Claim Adjustment Group Code = CR, OA, or PI: then Claim Adjustment Reason Code must NOT equal 45. |
New 277 C Edit | New edit to check for claim adjustment group and reason code combination. | 277C Received with: CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 521: “Adjustment Reason Code” |
| X222.295.2320.SBR09.020 Claim Filing Indicator Code must not = MA or MB. |
Revised 277 Edit | CSC 480 description was incorrect, and CSC 480 requires an EIC, the EIC was missing. | CSCC A7: "Acknowledgement/Rejected for Invalid Information…" CSC 480: "Entity's claim filing indicator." EIC: PR "Payer" |
| X222.262.2310B.NM102.010 Rendering Provider Name Entity Type Qualifier must be present. Valid values = 1 or 2 |
Revised 999 Edit | Update to the error code returned when Rendering Provider name Entity Type Qualifier is missing. | 999 Received with: IK403 = 1: "Required Data Element Missing" |
| X222.257.2310A.NM101.010 Referring Provider Name Entity Identifier Code must be present and a valid value. Valid values = DN or P3 |
Revised 999 Edit | Update to the error code returned when Referring Provider name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.262.2310B.NM101.010 Rendering Provider Name Entity Identifier Code must be present and a valid value. Valid value = 82 |
Revised 999 Edit | Update to the error code returned when Rendering Provider Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.269.2310C.NM101.010 Service Facility Location Name Entity Identifier Code must be present and a valid value. Valid value = 77 |
Revised 999 Edit | Update to the error code returned when Service Facility Location Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.280.2310D.NM101.010 Supervising Provider Name Entity Identifier Code must be present and a valid value. Valid value = DQ |
Revised 999 Edit | Update to the error code returned when Supervising Provider Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.285.2310E.NM101.010 Ambulance Pick Up Location Entity Identifier Code must be present and a valid value. Valid value = PW |
Revised 999 Edit | Update to the error code returned when Ambulance Pick Up Location Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.290.2310F.NM101.010 Ambulance Drop Off Location Entity Identifier Code must be present and a valid value. Valid value = 45 |
Revised 999 Edit | Update to the error code returned when Ambulance Drop Off Location Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.313.2330A.NM101.010 Other Subscriber Name Entity Identifier Code must be present and a valid value. Valid value = IL |
Revised 999 Edit | Update to the error code returned when Other Subscriber Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.320.2330B.NM101.010 Other Payer Name Entity Identifier Code must be present and a valid value. Valid value = PR |
Revised 999 Edit | Update to the error code returned when Other Payer Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.430.2420A.NM101.010 Rendering Provider Name Entity Identifier Code must be present and a valid value. Valid value = 82 |
Revised 999 Edit | Update to the error code returned when Rendering Provider Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.436.2420B.NM101.010 Purchased Service Provider Name Entity Identifier Code must be present and a valid value. Valid value = QB |
Revised 999 Edit | Update to the error code returned when Purchased Service Provider Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.441.2420C.NM101.010 Service Facility Location Name Entity Identifier Code must be present and a valid value. Valid value = 77 | Revised 999 Edit | Update to the error code returned when Service Facility Location Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.449.2420D.NM101.010 Supervising Provider Name Entity Identifier Code must be present and a valid value. Valid value = DQ |
Revised 999 Edit | Update to the error code returned when Supervising Provider Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.454.2420E.NM101.010 Ordering Provider Name Entity Identifier Code must be present and a valid value. Valid value = DK |
Revised 999 Edit | Update to the error code returned when Ordering Provider Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.465.2420F.NM101.010 Referring Provider Name Entity Identifier Code must be present and a valid value. Valid value = DN or P3 |
Revised 999 Edit | Update to the error code returned when Referring Provider Name Entity Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.470.2420G.NM101.010 Ambulance Pick Up Location Entity Identifier Code must be present. Valid value = PW |
Revised 999 Edit | Update to the error code returned when Ambulance Pick Up Location Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
| X222.475.2420H.NM101.010 Ambulance Drop Off Location Entity Identifier Code must be present. Valid value = 45 |
Revised 999 Edit | Update to the error code returned when Ambulance Drop Off Location Identifier Code is missing or an invalid value. | 999 Received with: IK304 = 2: "Unexpected Segment" |
Additional CRs
Please be advised that while CMS-mandated quarterly release for January 2020 will be installed the weekend of 1/5/2020, the code set updates included with this release will not be effective in the EDI Front-End processing system until Wednesday, 1/8/2020. EDI claims sent prior to 1/8/2020 that include any of the new or updated codes will reject in the EDI front-end.
| Title and Description | Purpose | Trading Partner Impact |
|---|---|---|
| CR11394 (CAQH CORE CR) SUBJECT: Implement Operating Rules - Phase III ERA EFT: CORE 360 Uniform Use of CARC and RARC Rule - Update from CAQH CORE Med Learn Article: MLN Link |
This CR instructs the contractors and Shared System Maintainers (SSMs) to update systems based on the CORE 360 Uniform Use of CARC and RARC Rule publication. These system updates are based on the CORE Code Combination List to be published on or about 10/1/2019. The codes and associated messages are updated updated to in the updated versions of MREP and PC Print software. | Trading Partners should review the MedLearn Matters article for this CR so they are aware of the Business Scenario combinations and RARC/CARC updates to the PC PRINT and MREP software. There is a new MREP Codes.ini file, which will be available for download from the CMS website. There is a new version of PC Print which may be downloaded from our website under the Claims & Appeals tab > Electronic Data Interchange > Electronic Data Interchange Software link |
MBI Edit Reminder
The below edits may set if a HIC number is submitted on an 837 claim after 5:00 p.m. on 12/31/2019. It is strongly advised that in order to prevent unnecessary rejections, providers not wait until to the end of day to submit their files.
| Edit Reference Number | Trading Partner Impact/Results |
|---|---|
| X223.112.2010BA.NM109.020 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" |
277C Received with: CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 164: “Entity's contract/member number” EIC IL: “Subscriber” |
| X223.112.2010BA.NM109.040 If Serv Loc Fac Code is not = 11X, 32X or 41X. Or Claim Freq Type is not = 7, 8 or Q, Subscriber ID must be valid HICN or MBI based on submission date |
277C Received with: CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 164: “Entity's contract/member number” EIC IL: “Subscriber” |
| X223.150.2300.DTP03.040 If Serv Loc Fac Code is = 11X, 32X or 41X, and Claim Frequency Type Code is not = 7, 8 or Q, Subscriber Number must be a valid MBI when the first date in Claim Statement Dates, is greater than the MBI transition end date |
277C Received with: CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 164: “Entity's contract/member number” CSC 188: “Statement from-through dates” EIC IL: “Subscriber” |
| X222.121.2010BA.NM109.020 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" |
277C Received with: CSCC A7: "Acknowledgement /Rejected for Invalid Information…" CSC 164: “Entity's contract/member number” EIC IL: “Subscriber” |
| X222.121.2010BA.NM109.030 If the HIC/MBI format is valid, Subscriber Number must be a valid HICN or MBI based on the claim Receipt date (submission date). |
277C Received with: CSCC A7: "Acknowledgement/Rejected for Invalid Information…" CSC 164: “Entity's contract/member number” EIC IL: “Subscriber” |
Posted 12/6/2019