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Companion Guide: Electronic Data Interchange 999 Acknowledgement and Submission Summary Report L I B R A R Y R E F E R E N C E N U M B E R : C L E L 1 0 0 5 0 R E V I S I O N D A T E : N O V E M B E R 2 0 1 1 V E R S I O N 1 . 0
Library Reference Number: CLEL10050 Document Management System Reference: Companion Guide – 999 Acknowledgement and Submission Summary Report Address any comments concerning the contents of this manual to: HP Systems Unit 950 North Meridian Street, Suite 1150 Indianapolis, IN 46204 Fax: (317) 488-5169 © 2011 Hewlett-Packard Development Company, LP. ECMAP™ is a trademark of Sybase, Inc. Sybase and the Sybase logo are trademarks of Sybase, Inc. All other trademarks are property of their respective owners. ® indicates registration in the United States. Specifications are subject to change without notice. All rights reserved.
Companion Guide – 999 Acknowledgement and Submission Summary Report
Revision History Document Version Number Version 1.0
Library Number: CLEL10050 Revision Date: November 2011 Version: 1.0
CO
Revision Date November 2011
Revision Page Number(s) All
Reason for Revisions New document. HIPAA 5010 version
Revisions Completed By Systems/ Publications
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Companion Guide – 999 Acknowledgement and Submission Summary Report
Table of Contents Section 1: Introduction .................................................................................. 1-1 Overview ..................................................................................................... 1-1 999 Functional Acknowledgement .............................................................. 1-1 Submission Summary Report ...................................................................... 1-1 Section 2: Acknowledgements ...................................................................... 2-1 999 Functional Acknowledgement – Outbound .......................................... 2-1 Section 3: EDI Submission Summary Report ............................................. 3-1 Purpose of Report ........................................................................................ 3-1 Format of Report ......................................................................................... 3-1 Detailed Field Descriptions ......................................................................... 3-2 Submission Summary Report Layout .......................................................... 3-4 Error Codes ................................................................................................. 3-5 Index ............................................................................................................... I-8
Library Number: CLEL10050 Revision Date: November 2011 Version: 1.0
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Companion Guide – 999 Acknowledgement and Submission Summary Report
Section 1: Introduction Overview The 5010 Companion Guide - Electronic Data Interchange 999 Acknowledgement and Submission Summary Report contains information specific to the 999 Functional Acknowledgement, and the EDI Submission Summary Report (SSR). These reports must be downloaded and reviewed to verify acceptance or rejection of electronic data interchange (EDI) data.
999 Functional Acknowledgement The 999 Functional Acknowledgement is an X12 transaction that acknowledges the receipt of the batch transaction and reports the acceptance or rejection of a functional group, transaction set, or segment. The IHCP returns the 999 within two hours of the batch submission.
Submission Summary Report The Submission Summary Report (SSR) is created to report the results of pre-adjudication edit checking to verify two levels of compliance, Health Insurance Portability and Accountability Act (HIPAA) compliance and Indiana Health Coverage Programs (IHCP)-specific compliance of 837D, 837I, and 837P transactions. SSRs are produced for each file received from a trading partner that contains an 837 transaction. The IHCP returns the SSR within two hours of the batch submission.
Library Number: CLEL10050 Revision Date: November 2011 Version: 1.0
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Companion Guide – 999 Acknowledgement and Submission Summary Report
Section 2: Acknowledgements 999 Functional Acknowledgement – Outbound The Indiana Health Coverage Programs (IHCP) generates an outbound 999 to acknowledge all inbound transactions received in batch mode. Interactive transactions do not report the acceptance of an interactive inbound transaction and generate an outbound 999 only when the interactive inbound transaction rejects for compliance errors. The following tables define the data elements of the 999 Functional Acknowledgement. Table 2.1 – Transaction Set Header Segment Name
Transaction Set Header
Segment ID
ST
Loop
N/A
Usage
Required
Segment Notes Example
ST*999*54321*005010X231~
Table 2.2 – Element ID (ST01-ST02) Element ID ST01
Usage R
Guide Description/Valid Values
Comments
Transaction Set Identifier Code 999 – Implementation Acknowledgement
ST02
R
Transaction Set Control Number
This number is assigned locally and matches the value in the corresponding SE segment.
ST03
R
Implementation Convention Reference
This field contains the same value as data element GS08.
Library Number: CLEL10050 Revision Date: November 2011 Version: 1.0
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Section 2: Acknowledgements
Companion Guide – 999 Acknowledgement and Submission Summary Report
Table 2.3 – Functional Group Response Header Segment Name
Functional Group Response Header
Segment ID
AK1
Loop
N/A
Usage
Required
Segment Notes
This segment responds to the functional group information in the interchange envelope. AK1*HC*8215*005010X222A1~
Example
Table 2.4 – Element ID (AK101-AK102) Element ID AK101
Usage R
Guide Description/Valid Values Functional Identifier Code HC – Health Care Claim (837) HS – Eligibility, Coverage or Benefit Inquiry (270)
Comments This is only a list of identifier codes used for 999s generated by the IHCP in response to inbound transactions.
HR – Health Care Claim Status Request (276) HI – Health Care Services Review Information (278) AK102
R
Group Control Number
This data element contains the value from the GS06 data element from the GS segment of the original file being acknowledged.
AK103
R
Version/Release/Industry Identifier Code
This is the value in GS08 from the functional group to which this 999 transaction set is responding.
Table 2.5 – Transaction Set Response Header Segment Name
Transaction Set Response Header
Segment ID
AK2
Loop
AK2
Usage
Situational
Segment Notes
This segment starts the acknowledgment of a transaction set. If there are no errors at the transaction set level, this segment is not returned. AK2*837*252525*005010X222A1*~
Example
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Companion Guide – 999 Acknowledgement and Submission Summary Report
Section 2: Acknowledgements
Table 2.6 – Element ID (AK201-AK202) Element ID AK201
Usage R
Guide Description/Valid Values Transaction Set Identifier Code 837 – Health Care Claim 270 – Eligibility, Coverage or Benefit Inquiry)
Comments This is only a list of identifier codes used for 999s generated by the IHCP in response to inbound transactions.
276 – Health Care Claim Status Request 278 – Health Care Services Review Information AK202
R
Transaction Set Control Number
This data element contains the value from the ST02 data element from the ST segment of the original file being acknowledged.
AK203
S
Implementation Convention Reference
This is the value in ST03 from the transaction set to which this 999 transaction set is responding.
Table 2.7 – Error Identification Segment Name
Error Identification
Segment ID
IK3
Loop
AK2/IK3
Usage
Situational
Segment Notes
This segment reports segment and looping errors in the submitted transaction. IK3*NM1*16*2010BA*8~
Example
Table 2.8 – Element ID (AK301-AK304) Element ID
Usage
Guide Description/Valid Values
Comments
IK301
R
Segment ID Code
This data element lists the two or three byte segment ID that contains the error, such as ST, SBR.
IK302
R
Segment Position in Transaction Set
This data element contains the sequential position of the segment ID identified in IK301. This count begins with 1 for the ST segment and increments by 1 from that point.
IK303
S
Loop Identifier Code
This data element identifies the loop where the erroneous segment resides.
Library Reference Number: CLEL10050 Revision Date: November 2011 Version: 1.0
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Section 2: Acknowledgements
Element ID IK304
Companion Guide – 999 Acknowledgement and Submission Summary Report
Usage R
Guide Description/Valid Values Segment Syntax Error Code 1 Unrecognized segment ID
Comments This data element describes the type of error encountered.
2 Unexpected segment 3 Required segment missing 4 Loop occurs over maximum times 5 Segment exceeds maximum use 6 Segment not in defined transaction set 7 Segment not in proper sequence 8 Segment has data element errors I4 Implementation “Not Used” segment present I6 Implementation dependent segment missing I7 Implementation loop occurs under minimum times I8 Implementation segment below minimum use I9 Implementation dependent “Not Used” segment present
Table 2.9 – Segment Context Segment Name
Segment Context
Segment ID
CTX
Loop
2100 - AK2/IK3
Usage
Situational
Segment Notes
This segment is used to identify the data that triggered the situational requirement. CTX*SITUATIONAL TRIGGER*SV2*45**1*234~
Example
Table 2.10 – Element ID (CTX01-CTX06) Element ID
Usage
Guide Description/Valid Values
Comments
CTX01
R
Context Identification
CTX01-1
R
Context Name
Always contains the value “SITUATIONAL TRIGGER”
CTX01-2
N/A
Context Reference
Not Used
CTX02
S
Segment ID Code
CTX03
R
Segment Position in Transaction Set
Code defining the segment ID of the data segment in error. The numerical count position of this data segment from the start of the transaction set.
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Companion Guide – 999 Acknowledgement and Submission Summary Report Element ID
Usage
Section 2: Acknowledgements
Guide Description/Valid Values
Comments
CTX04
S
Loop Identifier Code
The loop ID number for this data element in segments LS and LE
CTX05
S
Position in Segment
Code indicating the relative position of the data element or composite data structure in error
CTX05-1
R
Element Position in Segment
CTX05-2
S
Component Data Element Position in Composite
To identify the component data element position within the composite in error
CTX05-3
S
Repeating Data Element Position
CTX06
S
Reference in Segment
CTX06-1
R
Data Element Reference Number
CTX06-2
S
Data Element Reference Number
To identify the specific repetition of a data element in error To hold the reference number of a data element and optionally a component data element within a composite This element holds the reference number of the simple or composite element at segment level. This element holds the reference number of the simple element within acomposite.
Table 2.11 – Business Unit Identifier Segment Name
Business Unit Identifier
Segment ID
CTX
Loop
2100 - AK2/IK3
Usage
Situational
Segment Notes
This segment is used to identify the data that triggered the situational requirement. CTX*CLM01:123456789~
Example
Table 2.12 – Element ID (CTX01-CTX06) Element ID
Usage
Guide Description/Valid Values
Comments
CTX01
R
Context Identification
CTX01-1
R
Context Name
CTX01-2
N/A
Context Reference
CTX02
N/A
Segment ID Code
CTX03
N/A
Segment Position in Transaction Set
Not Used Not Used
CTX04
N/A
Loop Identifier Code
Not Used
CTX05
N/A
Position in Segment
Not Used
CTX06
N/A
Reference in Segment
Not Used
Library Reference Number: CLEL10050 Revision Date: November 2011 Version: 1.0
Refer to the IG for valid values
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Section 2: Acknowledgements
Companion Guide – 999 Acknowledgement and Submission Summary Report
Table 2.13 – Implementation Data Element Note Segment Name
Implementation Data Element Note
Segment ID
IK4
Loop
AK2/IK3/IK4
Usage
Situational
Segment Notes
This segment reports data element and composite errors in the submitted transaction. IK4*9**67*1~
Example
Table 2.14 – Element ID (AK401-AK405) Element ID
Usage
Guide Description/Valid Values
Comments
IK401
R
Position in Segment
This is a composite data element.
IK401-1
R
Element Position in Segment
This data element contains the sequential position of the simple data element or composite data structure. This count begins with 1 for the initial element and increments by 1 from that point.
IK401-2
S
Component Data Element Position in Composite
This data element identifies within the composite structure where the error occurs.
IK401-3
S
Repeating Data Element Position
This data element identifies the specific repetition of a data element that is in error
IK402
S
Data Element Reference Number
Reference number used to locate the data element in the Data Element Dictionary
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Library Number: CLEL10050 Revision Date: November 2011 Version: 1.0
Companion Guide – 999 Acknowledgement and Submission Summary Report Element ID IK403
Usage
Section 2: Acknowledgements
Guide Description/Valid Values Implementation Data Element Syntax Error Code
R
Comments This data element describes the type of error encountered.
1 Required data element missing 2 Conditional required data element missing 3 Too many data elements 4 Data element too short 5 Data element too long 6 Invalid character in data element 7 Invalid code value 8 Invalid date 9 Invalid time 10 Exclusion condition violated 12 Too many repetitions 13 Too many components I6 Code value not used in Implementation I9 Implementation dependent data element missing I10 Implementation “Not Used” data element present I11 Implementation too few repetitions I12 Implementation pattern match failure I13 Implementation dependent “Not Used” data element present IK404
S
Copy of Bad Data Element
This is a copy of the data element in error
Table 2.15 – Element Context Segment Name
Element Context
Segment ID
CTX
Loop
2100 - AK2/IK3/IK4
Usage
Situational
Segment Notes
This segment is used to identify the data that triggered the situational requirement. CTX*SITUATIONAL TRIGGER*CLM*43**5:3*C023:1325~
Example
Table 2.16 – Element ID (CTX01-CTX06) Element ID
Usage
Guide Description/Valid Values
CTX01
R
Context Identification
CTX01-1
R
Context Name
Library Reference Number: CLEL10050 Revision Date: November 2011 Version: 1.0
Comments Always contains the value “SITUATIONAL TRIGGER” 2-7
Section 2: Acknowledgements
Element ID
Usage
Companion Guide – 999 Acknowledgement and Submission Summary Report Guide Description/Valid Values
Comments
CTX01-2
N/A
Context Reference
Not Used
CTX02
R
Segment ID Code
CTX03
R
Segment Position in Transaction Set
CTX04
S
Loop Identifier Code
Code defining the segment ID of the data segment in error. The numerical count position of this data segment from the start of the transaction set. The loop ID number for this data element in segments LS and LE
CTX05
S
Position in Segment
CTX05-1
R
Element Position in Segment
CTX05-2
S
Component Data Element Position in Composite
CTX05-3
S
Repeating Data Element Position
CTX06
S
Reference in Segment
CTX06-1
R
Data Element Reference Number
CTX06-2
S
Data Element Reference Number
Code indicating the relative position of the data element or composite data structure in error
To identify the specific repetition of a data element in error
Table 2.17 – Transaction Set Response Trailer Segment Name
Transaction Set Response Trailer
Segment ID
IK5
Loop
2000 - AK2
Usage
Required
Segment Notes
This segment acknowledges the acceptance or rejection of a transaction and report errors. IK5*R*5~
Example
Table 2.18 – Element ID (AK501-AK506) Element ID IK501
Usage R
Guide Description/Valid Values
Comments
Transaction Set Acknowledgment Code A – Accepted E – Accepted, but errors were noted R – Rejected
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Library Number: CLEL10050 Revision Date: November 2011 Version: 1.0
Companion Guide – 999 Acknowledgement and Submission Summary Report Element ID IK502
Usage S
Guide Description/Valid Values Transaction Set Syntax Error Code 1 Transaction set not supported
Section 2: Acknowledgements
Comments Code indicating implementation error found based on the syntax editing of a transaction set
2 Transaction set trailer missing 3 Transaction set control number in header and trailer do not match 4 Number of included segments does not match actual count 5 One or more segments in error 6 Missing or invalid transaction set identifier 7 Missing or invalid transaction set control number 18 Transaction set not in functional group 19 Invalid transaction set implementation convention reference I6 Implementation convention not supported IK503
S
Transaction Set Syntax Error Code
Code indicating implementation error found based on the syntax editing of a transaction set
IK504
S
Transaction Set Syntax Error Code
Code indicating implementation error found based on the syntax editing of a transaction set
IK505
S
Transaction Set Syntax Error Code
Code indicating implementation error found based on the syntax editing of a transaction set
IK506
S
Transaction Set Syntax Error Code
Code indicating implementation error found based on the syntax editing of a transaction set
Table 2.19 – Functional Group Response Trailer Segment Name
Functional Group Response Trailer
Segment ID
AK9
Loop
N/A
Usage
Required
Segment Notes
This segment acknowledges the acceptance or rejection of a functional group and report the number of transaction sets originally included, received, and accepted. AK9*R*1*1*0~
Example
Library Reference Number: CLEL10050 Revision Date: November 2011 Version: 1.0
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Section 2: Acknowledgements
Companion Guide – 999 Acknowledgement and Submission Summary Report Table 2.20 – Element ID (AK901-AK909)
Element ID AK901
Usage R
Guide Description/Valid Values
Comments
Functional Group Acknowledgment Code A – Accepted E – Accepted, but errors were noted P – Partially Accepted, at least one transaction set was rejected R – Rejected
AK902
R
Number of Transaction Sets Included
AK903
R
Number of Received Transaction Sets
AK904
R
Number of Accepted Transaction Sets
AK905
S
Functional Group Syntax Error Code 1 Functional group not supported 2 Functional group version not supported
This data element contains the value from the GE01 data element from the GE segment of the original file being acknowledged.
Code indicating error found based on the syntax editing of the functional group header and/or trailer
3 Functional group trailer missing 4 Group control number in the functional group header and trailer do not agree 5 Number of included transaction sets does not match actual count 6 Group control number violates syntax 19 Functional group control number not unique with interchange AK906
S
Functional Group Syntax Error Code
Code indicating error found based on the syntax editing of the functional group header and/or trailer
AK907
S
Functional Group Syntax Error Code
Code indicating error found based on the syntax editing of the functional group header and/or trailer
AK908
S
Functional Group Syntax Error Code
Code indicating error found based on the syntax editing of the functional group header and/or trailer
AK909
S
Functional Group Syntax Error Code
Code indicating error found based on the syntax editing of the functional group header and/or trailer
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Library Number: CLEL10050 Revision Date: November 2011 Version: 1.0
Companion Guide – 999 Acknowledgement and Submission Summary Report
Section 2: Acknowledgements
Table 2.21 – Transaction Set Trailer Segment Name
Transaction Set Trailer
Segment ID
SE
Loop
N/A
Usage
Required
Segment Notes Example
SE*123*54321~
Table 2.22 – Element ID (SE01-SE02) Element ID
Usage
Guide Description/Valid Values
Comments
SE01
R
Number of Included Segments
This is the total number of segments included in this acknowledgment. This value includes the ST and SE segments.
SE02
R
Transaction Set Control Number
This number is assigned locally and matches the value in the preceding ST segment.
Library Reference Number: CLEL10050 Revision Date: November 2011 Version: 1.0
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Companion Guide – 999 Acknowledgement and Submission Summary Report
Section 3: EDI Submission Summary Report Purpose of Report The Submission Summary Report (SSR) is created to report the results of pre-adjudication edit checking to verify two levels of compliance, Health Insurance Portability and Accountability Act (HIPAA) compliance and Indiana Health Coverage Programs (IHCP)-specific compliance of 837D, 837I, and 837P transactions. The SSR is produced for each file received from a trading partner that contains an 837 transaction. The IHCP returns the SSR within two hours of the batch submission. Trading partners should download and view the SSR, as claims that are rejected are not processed and will not appear on the provider’s remittance advice. Trading partners can correct errors immediately, and resubmit the claim or claims.
Format of Report The SSR contains the following sections: Sender Summary • Total Claims Received • Total Claims Rejected • Total Claims Accepted • Total Billed Amount • Total Accepted Billed Amount Error Severity Summary • Rejecting Errors – total number of occurrences within the file • Non-Rejecting Warnings – total number of occurrences within the file • Total Errors - total number of rejecting and non-rejecting errors • Error Threshold – maximum number of errors displayed within the file • Errors Displayed - total number of errors displayed within the file Claim Information – only displays if the claim receives a rejecting or non-rejecting warning error • Billing Provider information • Patient Account Number, Other Payer ICN, Billed Amount, Member ID and Name Error Information • Error ID, SNIP Level, Severity and Error Message • Error Severity of Normal = Rejection • Error Severity of Warning = Accepted, but should be noticed and attempts made to fix the error on future submissions Rejected claims are due to Health Information Portability and Accountability Act (HIPAA) compliance errors and Indiana Health Coverage Programs (IHCP)-specific pre-adjudication editing. Rejected claims contain errors that prevent them from continuing through the claim processing cycle. For claims with multiple details, the entire claim is rejected, even though only one service line is in error. The fact that a claim is accepted does not guarantee payment of the claim. It only means that it contained the basic information needed for processing. Library Number: CLEL10050 Revision Date: November 2011 Version: 1.0
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Section 3: EDI Submission Summary Report
Companion Guide – 999 Acknowledgement and Submission Summary Report
Claims receiving a non-rejecting warning edit are accepted, but should be noticed and attempts made to fix the error on future submissions.
Detailed Field Descriptions Table 3.1 EDI Submission Summary Report, Field Descriptions Field
Description
Report Name
IHCP EDI Submission Summary Report
Executed Date Time
HH:MM and MM/DD/YY from the translated file
Trading Partner Name
Name of submitting trading partner
Sender ID
Interchange trading partner ID from the ISA envelope
Version
X12 version number from the ISA envelope
Transaction Type
Type of claim submitted electronically
ISA Control Number
Interchange control number from the ISA envelope
GS Control Number
Group control number from the ISA envelope
Total Claims Received
Number of claims received
Total Claims Rejected
Number of claims rejected for errors that prevent further processing. Claims receiving error Severity of Normal
Total Claims Accepted
Number of claims accepted for further processing
Total Billed Amount
Sum of all claim billed amounts in the batch file
Total Accepted Billed Amount
Sum of all claim billed amounts accepted for further processing
Rejecting Errors
Number of occurrences of rejecting errors in the batch file
Non-Rejecting Warnings
Number of occurrences of non-rejecting warning errors in the batch file
Total Errors
Total number of occurrences of rejecting and non-rejecting warning errors in the batch file
Error Threshold
Maximum number of errors displayed in the report. Any errors over the threshold will not be displayed.
Errors Displayed
Number of errors displayed in the report
THE FIELDS BELOW WILL ONLY BE DISPLAYED IF A CLAIM RECEIVES AN ERROR Transaction Control Number
Submitted Transaction Control Number
Billing Provider Primary ID
Submitted Billing Provider Primary ID
Taxonomy
Submitted Billing Provider Taxonomy
Patient Account No.
Submitted Patient Account number
Other Payer ICN
Submitted Other Payer ICN
Billed Amount
Submitted claim billed amount
RID
Submitted Member Identification number
Member
Submitted Subscriber last and first name
Error ID
Rejecting or non-rejecting warning error ID
SNIP Level
SNIP level of rejecting or non-rejecting warning error
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Companion Guide – 999 Acknowledgement and Submission Summary Report
Section 3: EDI Submission Summary Report
Field Severity
Description Error severity – Normal = Rejecting error Warning = Non-rejecting warning error
Error Message
Technical error message
Business Message
Business error message
Library Reference Number: CLEL10050 Revision Date: November 2011 Version: 1.0
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Section 3: EDI Submission Summary Report
Companion Guide – 999 Acknowledgement and Submission Summary Report
Submission Summary Report Layout
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Library Number: CLEL10050 Revision Date: November 2011 Version: 1.0
Companion Guide – 999 Acknowledgement and Submission Summary Report
Section 3: EDI Submission Summary Report
Error Codes The following table lists the possible error codes and descriptions received on the SSR. Table 3.1- Submission Summary Report, Error Codes and Descriptions Error Code
Error Description
X01
Encounter claim submitted by a non-MCO entity.
240
ESP member not eligible for High Risk insurer for dates of service. Rid=999999999999 From DOS: mm/dd/yyyy To Dos: mm/dd/yyyy
241
Duplicate original HIP ESP claim 9999999999999
242
HIP ESP void/replacement claim with different mom/daughter ICN. Mom ICN= 9999999999999 daughter ICN=9999999999999
243
HIP ESP void claim submitted, original not found. ICN: 9999999999999
243
Mom claim not found for ESP void. ICN: 9999999999999
244
HIP ESP void/replacement submitted, original claim was previously voided. ICN 9999999999999
244
ESP void/replacement of claim already voided. ICN 9999999999999
245
HIP ESP replacement claim submitted, original claim was not found. ICN 9999999999999
245
Mom claim not found for ESP replacement. ICN 9999999999999
246
HIP ESP replacement with all duplicate detail numbers. ICN: 9999999999999
250
HIP claim submitted for member not enrolled in Medicaid. RID: 999999999999
251
HIP member not eligible for dates of service. Rid=999999999999 From DOS: mm/dd/yyyy To Dos: mm/dd/yyyy
258
Crosswalk did not give 1 to 1 match for NPI 9999999999. Number of rows returned was 999.
259
Crosswalk did not give 1 to 1 match for NPI 9999999999. Number of rows returned was 0
260
Billing NPI must be submitted for health care claims.
262
First Steps claim submitted past end of First Steps program.
265
MCE Denied claim submitted as a replacement.
271
Void and Replacement claims for COBA are not accepted.
272
Invalid Type of Bill. Value: XXX
274
Invalid MCE Payer ID in NM109 on 2330B: XXXXX
274
MCE submitted claim without a valid Payer ID.
275
Only claims with this following Status can be voided: Paid, Suspended, Resubmit, CCF, Queue.
276
This Claim Type cannot be Voided (P, Q).
278
Claims with this Status cannot be replaced (J).
279
This Claim Type cannot be replaced (P, Q).
Library Reference Number: CLEL10050 Revision Date: November 2011 Version: 1.0
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Section 3: EDI Submission Summary Report
Error Code
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Companion Guide – 999 Acknowledgement and Submission Summary Report Error Description
280
Crossover A claims must contain crossover amounts (Medicare paid, deductible, coinsurance and blood deductible amounts) at the header level. Header value is: 999.99 Dtl value is: 999.99 type: X TOB: XXX
281
Provider Attachment Control Numbers are NOT unique for SAK provider. CAN=999999
283
MCO void/replacement request past filing limit.
284
Provider ID on original claim could not be determined.
284
Provider ID on submitted claim (999999999) does not match provider ID on original claim.
284
Service Location on submitted claim (X) does not match service location on original claim.
284
Member ID on submitted claim (999999999999) does not match the Member ID on the original claim.
284
MCE ID on submitted claim (999999999) does not match MCE ID on original claim.
284
MCE Region on submitted claim (X) does not match MCE Region on original claim.
285
Replacement request past filing limit. Please resubmit as a manual request.
286
Provider ID on original claim could not be determined.
286
Provider ID on submitted claim (999999999) does not match provider ID on original claim.
286
Service Location on submitted claim (X) does not match service location on original claim.
286
Member ID on submitted claim (999999999999) does not match the Member ID on the original claim.
287
Voids may only be submitted for non-denied original claims.
288
Mismatch in claim type submitted vs claim type for the given ICN. V/R ClmType: X OrigClmType: X
289
A void/replacement was already submitted for this claim. Please submit a void/replacement for the most current claim.
290
Provider submitted a replacement or void for a claim that was not found. Please identify claim to be voided or replaced and initiate another void or replacement if necessary.
290
Provider submitted a void and did not supply an ICN to identify the original claim. Please identify the claim to be voided and initiate another void if necessary.
290
Provider submitted a void for a claim that was not found. Please identify the claim to be voided and initiate another void if necessary. Value: 999999999
290
Provider submitted a replacement and did not supply an ICN to identify the original claim. Please identify the claim to be replaced and initiate another replacement if necessary.
290
Provider submitted a replacement for a claim that was not found. Please identify the claim to be replaced and initiate another replacement if necessary. Value: 999999999
291
A replacement was submitted for a claim that was previously voided. Please submit as an original claim.
292
MCE has denied this encounter.
293
CAS – Invalid Adjustment Reason Code: xxx Library Number: CLEL10050 Revision Date: November 2011 Version: 1.0
Companion Guide – 999 Acknowledgement and Submission Summary Report Error Code
Section 3: EDI Submission Summary Report
Error Description
295
Invalid data submitted for crossover/COB claim.
296
The patient must be the same as the subscriber. Patient ID: 999999999999 Subscriber ID: 999999999999
300 Series 300 Series
Scale is invalid for submitted value 99999.99. Field: “value of fieldname goes here”. Valid scale for this field is 9 Field Value -99999 is negative. Field: “value of fieldname goes here”
400 Series
Field Value 99x.xx is not numeric. Field: “value of fieldname goes here”
297
Diagnosis codes must be consecutive 1 - 8 contain no blanks.
298
Found Attachment Control Numbers are not unique. Duplicate on Detail: 99 ACN: 999999
298
Found Attachment Control Numbers are not unique. ACN: 999999
299
Claim contained more than the Maximum Detail records allowed for this claim type
804
INFORMATIONAL EDIT ONLY: Default provider table used for crosswalk: NPI 9999999999 crosswalked to LPI 999999999 A
900
Missing billing provider number
902
Invalid billing provider number: ProviderID_
903
Invalid provider service location: Provider ID/Service Location
903
Missing provider service location
911
Missing MCE/region Code for shadow claim
911
Missing region Code for shadow claim
999
Contact the EDI Solutions Helpdesk at 317-488-5061 or 1-877-877-5182
Library Reference Number: CLEL10050 Revision Date: November 2011 Version: 1.0
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Companion Guide – 999 Acknowledgement and Submission Summary Report
Index 9
F
997 Functional Acknowledgement...................... 1-1 Outbound ........................................................ 2-1
Field descriptions ................................................ 3-2 Functional group response Header ............................................................. 2-2 Trailer ............................................................. 2-9
A Acknowledgements ............................................. 2-1
I
B
Index .................................................................... I-9 Introduction Overview......................................................... 1-1
Biller Summary Report ................................ 1-1, 3-1 Error codes ..................................................... 3-6 Error descriptions ........................................... 3-6 Field descriptions............................................ 3-2 Field descriptions............................................ 3-2 Format ............................................................ 3-1 General error codes......................................... 3-6 Purpose ........................................................... 3-1 BSR, See Biller Summary Report........................ 1-1
D Data segment Note ................................... 2-3, 2-4, 2-5, 2-6, 2-7
E ECMAP™ HIPAA toolkit ................................................ 2-1 ECMAP™ ........................................................... 2-1 Error codes General ........................................................... 3-6
Library Number: CLEL10021 Revision Date: December 2009 Version: 5.0
R Revision History.................................................... iii
S Sybase, Inc. ......................................................... 2-1 ECMAP™....................................................... 2-1 HIPAA toolkit ................................................. 2-1
T Table of Contents .................................................. iv Transaction set Header ............................................................. 2-1 Trailer ........................................................... 2-11 Transaction set response Header ............................................................. 2-2 Trailer ............................................................. 2-8
I-8
