Availity Health Information Network guide/payer_specific_transaction_edits.pdfAvaility® Health Information Network Batch Electronic Data Interchange (EDI) Companion Guides Payer Specific

Availity® Health Information Network

Batch Electronic Data Interchange (EDI)

Companion Guides

Payer Specific Transaction Edits

Version 11.08 - Updated 08/20/2011

Availity, L.L.C.

P.O. Box 550857

Jacksonville, FL 32255-0857

August 2011

Payer Specific Updates

Error Codes Error Messages Error Descriptions Updates Loop Element Trans

Types

3938afb Service Line Date is required on outpatient claims. Segment DTP (Service Line Date) is missing. It is

required on outpatient claims when revenue, procedure,

HIEC or drug codes are reported in the SV2 segment.

New Edit

68050, 68053

68057, 68058

SHP11

2400 DTP03 837I

3938b51 Last Menstrual Period may be used only for female patient. Segment DTP (Date - Last Menstrual Period) is used. It is

not expected to be used when patient is not female

(element DMG03 in loop 2010BA is not 'F').

Payers Added

68050, 68053

68057, 68058

SHP11

2300 DTP03 837P

prof.SFB The patient (2010CA) or subscriber (2010BA) first and last name fields can contain letters and

spaces only. Special characters are not allowed.

Special characters are not allowed in the

subscriber/patient name fields.

Edit Relaxed

68050, 68053

68057, 68058

SHP11

2010BA NM103

NM104

837P

S206P The date of the last menstrual period (loop 2300, DTP*484) cannot be the same as the onset

of similar symptoms or illness (loop 2300, DTP*438).

The date of the last menstrual period (loop 2300,

DTP*484) cannot be the same as the onset of similar

symptoms or illness (loop 2300, DTP*438).

New Edit

68050, 68053

68057, 68058

SHP11

2300 DTP03 837P

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EDI Payer Specific Transaction List

Error Codes Error Messages Error Descriptions Loop Element Trans

Types

Payers

810021 Element has a data type of ‘Numeric’ R. Leading zeros are not allowed. Leading zeros are not allowed. 2320 AMT*B6

CAS03

CAS04

837P

837I

38520, 57106

61125, 00720

00220

810021 Element has a data type of ‘Numeric’ R. Leading zeros are not allowed. Leading zeros are not allowed. 2430 CAS03

SVD02

SVD05

837P

837I

38520, 57106

61125, 00720

00220

810021 Element has a data type of ‘Numeric’ R. Leading zeros are not allowed. Leading zeros are not allowed. 2410 CTP03

CTP04

837P

837I

38520, 57106

61125, 00720

00220

810021 Element has a data type of ‘Numeric’ R. Leading zeros are not allowed. Leading zeros are not allowed. 2000B

2000C

PAT08 837P

837I

38520, 57106

61125, 00720

00220

810021 Element has a data type of ‘Numeric’ R. Leading zeros are not allowed. Leading zeros are not allowed. 2400 SV104 837P 38520, 57106

61125, 00720

00220, 59274

75137

810021 Element has a data type of ‘Numeric’ R. Leading zeros are not allowed. Leading zeros are not allowed. 2400 SV205 837I 38520, 57106

61125, 00720

00220, 59274

810021 Sub-Element HI01-05 has a data type of 'Numeric' R. Leading zeros are not allowed. Leading zeroes not allowed 2300 HI 837I 00611, 00851

00932, 93221

810024 Element CLM12 is a coded list element. Code '02' is not allowed. Element CLM12 is a coded list element. Code '02' is not allowed. 2300 CLM12 837P 00720

810024 Element SV103 is a coded list element. Code 'F2' is not allowed. Element SV103 is a coded list element. Code 'F2' is not allowed. 2400 SV103 837P 00720

810024 Element SV204 is a coded list element. Code 'F2' is not allowed. Element SV204 is a coded list element. Code 'F2' is not allowed. 2400 SV204 837I 00220

810062 An invalid code value was encountered. An invalid code value was encountered. 2300 CLM11 837P 00720

3939321 Value of element CAS02 is incorrect. Expected value is from external code list - Adjustment

Reason Code 139

Claim Adjustment Reason Code must be valid based upon the

code list.

2430 CAS02 837P

837I

94036, 00934

93093, 26374

26375, 26378

3939331 Value of element PRV03 is incorrect. Expected value is from external code list - Health Care

Provider Taxonomy Code (682). Segment PRV is defined in the guideline at position 003.

When present, the taxonomy code in PRV03 must be valid. 2000A, 2310A

2310B, 2420F

PRV03 837P

837I

01260, NIA11

SHP11, 68050

68053, 05130

WA001, OR001

00835, 00831

03102, AK001

00836, 26374

26375, 26378

39393fa Value of element CAS has been already used. Claim Adjustment Reason Codes are

expected to have unique values within segment CAS.

Claim Adjustment Reason Codes cannot be duplicated within the

same CAS category.

2320 CAS 837I

837P

14163

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Types

Payers

3939342 Value of element N403 is incorrect. Expected value is from external code list - ZIP Code (51)

when country is US. Segment N4 is defined in the guideline at position 030.

Must be a valid US Postal Service Zip Code. 2010AA, 2010AB

2010BA, 2010BB

2010BC, 2010CA

2310D, 2330A

2420C, 2420E

N403 837P 05130, WA001

OR001, 00835

00831, 03102

AK001, 00836

3939345 Value of element REF02 (Universal Product Number (UPN)) is incorrect. Expected value is

Universal Product Code (format is 12-14 digits where the last one is a check digit) when

REF01='OZ'.

When the Universal Product Number (UPN) (REF02) is incorrect;

the expected value is Universal Product Code (format is 12-14

digits where the last one is a check digit)

2400 REF02 837P 38520, 57106

61125, 00934

93093, AIDWA

3939381 Value of element REF02 (CLIA Identification) is incorrect. CLIA number format is 10

characters where the third character is the letter ‘D’.

CLIA ID is invalid. 2300 REF02=X4 837P 14163, 14164

01260, NIA11

CNTNM, 80705

63665, 66893

95379, 95388

95412, 95569

AIDWA, 91121

91051

3939382 Value of element REF02 (Universal Product Number (UPN)) is incorrect. Expected value is

Universal Product Code (format is 12-14 digits where the last one is a check digit)

When the Universal Product Number (UPN) (REF02) is incorrect;

the expected value is Universal Product Code (format is 12-14

digits where the last one is a check digit)

2400 REF02 837P 68050, 68053

68057, 68058

SHP11

3939384 Value of element AMT02 (Patient Estimated Amount Due) is incorrect. It may not be more than

value of element CLM02.

When the Patient Estimated Amount Due (AMT02) is incorrect; it

cannot be more than the total claim charge (CLM02).

2300 AMT02 837I 68050, 68053

68057, 68058

SHP11

3939386 Statement Dates is invalid. Statement Dates is invalid. 2300 DTP03 837I 00220

3939388 Date Last Seen is invalid: it is after Transaction Creation Date. Edit relaxed to allow future DOS 2300 DTP03 837P 04102, 04202

04302, 04402

00904, 04301

00882

3939389 Statement thru date is after transaction create date Statement thru date must not be after the file submission date 2400 DTP*472 837I 14163, 14164

SHP11, 68057

68053, 68050

68058

3939391 Value of element REF02 (Rendering Provider Secondary ID) is incorrect. Expected value is

Social Security Number (format is '9 digits or '000-00-0000'') when REF01='SY'.

Value of element REF02 (Rendering Provider Secondary ID) is

incorrect. Expected value is Social Security Number (format is '9

digits or '000-00-0000'') when REF01='SY'.

2010AA

2310B

REF02 837P 11345

3939392 Value of element REF02 (Referring Provider Secondary ID) is incorrect. Expected value is

UPIN (format is '1 alpha and 5 digits; or one of the values RES000, VAD000, PHS000,

RET000, INT000, SLF000, OTH000') when REF01='1G'

The UPIN is invalid 2310A REF02 837P AIDID, AIDWA

3939393 Value of element NM109 does not look like a valid Social Security Number according SSA

requirements.

If Social Security number (REF02=SY) is indicated, the number

should meet Social Security Administration enumeration

requirements.

2010AA, 2010AB

2010BA, 2010CA

2310A, 2310B

2310C, 2310E

2330A, 2330C

2420A, 2420B

2420D, 2420E

2420F

NM109 837P

837I

14163, 14164

3939396 Value of element NM102 is incorrect. Expected value is ‘1’ when Subscriber is the same

person as patient.

SBR02=18 (2000B) is present, then NM102 (2010BA) should be

a ‘1’

2000B

2010BA

SBR02 837P

837I

26374, 26375

26378, 77027

SHP11, 68057

68053, 68050

680583939396 Value of element NM102 is incorrect. Expected value is ‘1’ when the subscriber is the same

person as patient

Subscriber must be listed as an entity code ‘1’. 2010BA NM102 837P

837I

14163, 14164

77027





Types

Payers

3939453 The value of element DTP03 (Service Date) is incorrect. Expected value for date or start

period date should be a date earlier than the Claim Adjustment date specificed in loop 2330B.

Service date must be earlier than the primary payment paid date. 2330B DTP 837P CNTNM, 68050

68053, 68057

68058, SHP11

3939460 Value of element SBR01 is incorrect. Primary payer is not specified (elements SBR01 in loops

2000B/2320 do not have 'P' value). It's expected to be used when other payers are known to

be involved.

There must be a primary payer specified on claim. 2000B

2320

SBR01 837P

837I

80705, 63665

66893, 95379

95388, 95412

95569, 68057

68053, 68050

68058, SHP11

3939461 Value of element SBR01 is incorrect. Secondary payer is not

specified (elements SBR01 in loops 2000B/2320 do not have 'S' value).

It is expected to be used when tertiary payers are known to be involved.

SBR01 is incorrect. Secondary payer is not specified. 2000B/2320 SBR01 837P

837I

80705, 63665

95379, 95388

95412, 95569

66893

3939472 Value of element BHT04 (Transaction Set Creation Date) is incorrect. Expected value is Date

in format '19, 20 or 21 century'.

When the transaction creation date is prior to 1800, the claim will

be rejected.

BHT BHT04 837P

837I

PRINT, 68057

68053, 68050

68058, SHP11

3939472 Value of element DMG02 (Subscriber Birth Date) is incorrect. Expected value is Date in format

'19, 20 or 21 century'. Segment DMG is defined in the guideline at position 032.

When the subscriber date of birth is prior to 1800, the claim will be

rejected.

2010BA DMG02 837P

837I

HPN11, GTPA1

MCA11, VFP11

INET1. KLSY1

SCOK1. WITH1

TX1ST, NWDC1

PPMO1, FMCHP

SSC11, CIPA1

KMG11, GHEDI

AIDWA

3939472 Value of element DTP03 (Date - Initial Treatment) is incorrect. Expected value is Date in format

'19, 20 or 21 century'.

When the date of initial treatment is prior to 1800, the claim will be

rejected.

2300 DTP03 837P 10207, PRINT

3939472 Value of element DTP03 (Date - Onset of Current Illness/Symptom) is incorrect. Expected

value is Date in format '19, 20 or 21 century'.

When the onset of current illness/symptom date is prior to 1800,

the claim will be rejected

2300 DTP03 837P

837I

PRINT, AIDWA

3939472 Value of element DTP03 (Service Line Date) is incorrect. Expected value is Date in format '19,

20 or 21 century'. Segment DTP is defined in the guideline at position 455.

When the service line date is prior to 1800, the claim will be

rejected

2400 DTP03 837P

837I

PRINT, AIDWA

3939600 Value of sub-element is incorrect. E-code can not be used as Primary/Admitting/’Reason for

Visit’ diagnosis code.

Diagnosis codes beginning with ‘E’ are not allowed as the primary

diagnosis code.

2300 HI 837P

837I

14163, 14164

SHP11, 68057

68053, 68050

68058

3939612 HCPCS Procedure Code is invalid in Principal Procedure Information. HCPCS Procedure Code is invalid in Principal Procedure

Information.

2300 HI 837I 00220

3939615 Value of sub-element SV202-2 is incorrect. Expected value is from external code list - HIPPS

Code when SV202-01=ZZ

Product Service ID must be valid based upon the code list 2400 SV202-2 837I 94036, 80705

63665, 66893

95379, 95388

95412, 95569

3939642 Composite HI02 is used. It's not expected to be used when composite HI01 is missing. Diagnosis codes must be in consecutive order. 2300 HI 837I 00932, 00851

00611, 93221

SHP11, 68057

68053, 68050

68058, 26374

26375, 26378

8220001 If CLM20 = '11' (Other) then additional documentation is required using the NTE or PWK

segments. If the PWK segment is used, PWK02 must not be 'AA'.

If Delay Reason Code is Other (CLM20 = '11') then additional

documentation is required.

2300 CLM20 837P 00720

8220001 If CLM20 = '11' (Other) then additional documentation is required using the NTE or PWK

segments. If the PWK segment is used, PWK02 must not be 'AA'.

If Delay Reason Code is Other (CLM20 = '11') then additional

documentation is required.

2300 PWK 837I 00220

8220001 If CLM20 = '11' (Other), then PWK02 must not be 'AA'. If Delay Reason Code is Other (CLM20 = '11') then report

transmission code can not be 'Available on Request at Provider

Site'.

2300 CLM20

PWK02

837P

837I

00720, 00220





Types

Payers

8220001 Not Covered/Denied Amount cannot exceed the Service Line Charge Amount. Not Covered/Denied Amount cannot exceed the Service Line

Charge Amount.

2400 SV207 837I 00220

8220001 Only 'BR' should be used for Principal Procedure Qualifier. Only 'BR' should be used for Principal Procedure Qualifier. 2300 HI 837I 00220

8220001 Principal Procedure Date must be within the Statement Dates or equal to/greater than the

Admission Date.

Principal Procedure Date must be within the Statement Dates or

equal to/greater than the Admission Date.

2300 HI 837I 00220

8220001 Service Date DTP03 must be greater than or equal to Patient's Date of Birth. Service Date DTP03 must be greater than or equal to Patient's

Date of Birth.

2400 DTP03 837P 00720

8220001 SV104 Quantity, zero '0' is not a valid value. Zero '0' is not a valid value for quantity (SV104). 2400 SV104 837P 00720

8220001 The Patient Paid Amount (AMT02) must not exceed the Claim Charge Amount (CLM02). The Patient Paid Amount (AMT02) must not exceed the Claim

Charge Amount (CLM02).

2300 AMT 837I 00220

C113P The billing provider tax ID (2010AA, REF02) and the rendering provider tax ID (2310B, REF02)

must be identical.

The billing provider tax ID and the rendering provider tax ID must

be identical.

2010AB REF02 837P 53589

D102I Claim should not have a negative submitted charge amount (SV203) at the service

line (loop 2400). All values should be zero or a positive number

Claim charge cannot have a negative amount. 2400 SV203 837I 07003

D102P Claim should not have a negative submitted charge amount (SV102) at the service line (loop

2400). All values should be zero or a positive number

Claim charge cannot have a negative amount. 2400 SV102 837P 07003

0x39392ec Element PER07 is used. It is expected to be used only when element PER05 is used. Contact Information fields must not be skipped. 2010AA PER07 837P

837I

77027

3938aef Segment DTP is missing. It is required when claim was adjudicated and loop 2430 is not used Segment DTP is missing. It is required when claim was

adjudicated and loop 2430 is not used

2330B DTP 837I

837P

68050, 68053

68057, 68058

SHP11

3938aef Segment DTP is missing. It is required when claim was adjudicated and loop 2430 is not used. Claim Adjudication date is required when payer identified has

previously adjudicated the claim. The claim adjudication date is

also known as the EOB date or Check date.

2330B DTP 837P 14163, 14164

77027

3938aef Segment DTP is missing. It is required when claim was adjudicated and loop 2430 is not used Claim Adjudication date is required when line level adjudication

segment is not used. Claim Adjudication date at claim level is

required.

2320 DTP 837I

837P

CNTNM

3938af0 Segment AMT (COB Payer Paid Amount) is missing. It's expected to be used when segment

CAS is used (claim has been adjudicated).

Segment AMT (COB Payer Paid Amount) is missing. It's

expected to be used when segment CAS is used (claim has been

adjudicated).

2320 AMT02 837P 63665, 66893

80705, 95379

95388, 95412

95569

3938b00 Segment CRC (EPSDT Referral) is missing. Segment CRC for EPSDT Referral is required when CLM12 is

‘01’

2300 CRC 837P 38520, 57106

61125, 95827

HCDPBC

3938b00 Segment CRC (EPSDT Referral) is missing. It is required when element CLM12 is '01'. CRC Segment is missing 2300 CLM12 837P 35174, 95827

HCDPBC

3938b00 Segment CRC (EPSDT Referral) is missing. It is required when element CLM12 is '01'. CLM12 = ‘01’ (EPSDT), but 2300 CRC segment for EPSDT

Referral (CRC01 = ‘ZZ’) is missing.

2300 CRC 837P SHP11, 68053

68050, 95827

HCDPBC, 61160

3938b00 Segment DTP (Date - Last X-ray) is missing. It is required when element CR212 is 'Y' X-ray date (DTP01 = 455) is required when spinal manipulation is

indicated.

2300 DTP 837P 77027

3938b02 Segment CRC (DMERC Condition Indicator) is missing. It is required when segment CR3 is

used.

If DME certification (2400,CR3) is present on the claim, then the

DMERC Condition Indicator (2400,CRC) is required.

2400 CRC 837P 68050, 68053

68057, 68058

SHP11





Types

Payers

3938b0f Segment DMG is missing. It is required when Other Subscriber is a person (NM102 in loop

2330A is '1')

Other subscriber demographic information is required when Other

Subscriber is a person (2330A, NM102 is 1).

2320 DMG 837P

837I

38520, 57106

61125, WA001

00835, 00836

HPN11, GTPA1

MCA11, VFP11

INET1. KLSY1

SCOK1. WITH1

TX1ST, NWDC1

PPMO1, FMCHP

SSC11, CIPA1

KMG11, GHEDI

71063, TOPA1

AZ001, 03102

00831, 05130

OR001, 04120

04202, 04302

04402, 00952

00953, 13350

09102, 94036

3938b10 Subscriber Demographic Information is required when Subscriber is a Patient. When subscriber is the patient, date of birth and gender is

required.

2000B DMG 837P 95827, HCDPBC

3938b13 Segment REF is missing. It is required when elements NM108/09 are not used in this loop. Referring provider tax id is required when NM108/09 are missing. 2310A REF02 837P 14163, 14164

3938b4d Segment REF (Original Reference Number (ICN/DCN)) is used. It is not expected to be used

when CLM05-03 is not '7','8','X' or 'Y'

Original Reference Number (ICN/DCN)' should only be used

when the 'Claim Submission Reason Code' (CLM05-3) is 7, or 8

2300 REF = F8 837P 80705, 63665

66893, 95379

95388, 95412

95569, 14163

14164, SHP11

68053, 68057

68058

3938b4d Segment REF (Original Reference Number (ICN/DCN)) is used. It is not expected to be used

when CLM05-03 is not '7','8','X' or 'Y'.

Segment REF (Original Reference Number (ICN/DCN)) is used. It

is not expected to be used when CLM05-03 is not '7','8','X' or 'Y'.

2300 REF 837P 68050, 68053

68057, 68058

SHP11

3938b51 Segment DTP (Date - Last Menstrual Period) is used. It is not expected to be used when

patient is not female (element DMG03 in loop 2010BA is not 'F').

Last Menstrual Period date can only be present when Subscriber

Gender code is Female.

2010BA DMG03 837P 80705,63665

66893,95379

95388,95412

95569, 95827

HCDPBC

3938b60 Segment PAT is used. It is expected to be used only when Subscriber is the same person as

Patient (loop 2000B, SBR02 = '18').

Segment PAT is used. It is expected to be used only when

Subscriber is the same person as Patient (loop 2000B, SBR02 =

'18').

2000C PAT 837P SHP11, 68057

68053, 68050

68058

3938bb4 Segment AMT (Coordination of Benefits (COB) Patient Responsibility Amount) is missing. It is

required if patient is responsible for payment according to another payer's adjudication (CAS01

with 'PR' is used in loop 2320).

Segment AMT (COB Patient Responsibility Amount) is missing.

It's required if patient is responsible for payment according to

another payer's adjudication (CAS01 with 'PR' is used in loop

2320).

2320 AMT 837P

837I

80705, 63665

66893, 95379

95388, 95412

95569, NANPR

NAELM, NAHOI

NAHIN, NAHLX

NAING, NANWC

NAOAK, NASCR

NASWD, 14163

16164, CNTNM

3938bc5 Segment REF (Billing Provider Secondary Identification) is missing. Either EIN or SSN of

Provider must be carried in this REF segment when NM108 is 'XX'.

Segment REF (Billing Provider Secondary Identification) is

missing.

2010AA REF01 837P 48145, 95827

HCDPBC

3938bc5 Segment REF (Pay-To Provider Secondary Identification) is missing. Either EIN or SSN of

Provider must be carried in this REF segment when NM108 is 'XX'.

Segment REF (Pay-To Provider Secondary Identification) is

missing

2010AB REF01 837P 48145, 95827

HCDPBC





Types

Payers

3938c4c Loop 2320 is missing. It's expected to be used when other payers are known to be involved in

paying claim (SBR01 is 'S' or 'T').

Other payer information was received on the claim, but

information about the subscriber in the 2320 Loop was missing.

2320 SBR01 837P

837I

01260, NIA11

77027, 00934

93093, SHP11

68057, 68053

68050, 68058

94036

3938c57 Loop 2310C is missing. It is required when segment AMT (Total Purchased Service Amount) is

used

The Purchased Service Provider Name is required when the Total

Purchased Service Amount (2300 AMT*NE) is present.

2310C AMT01 837P 38520, 57106

61125, 35174

68050, 68053

68057, 68058

SHP11, 38338

HPN11, GTPA1

MCA11, VFP11

INET1. KLSY1

SCOK1. WITH1

TX1ST, NWDC1

PPMO1, FMCHP

SSC11, CIPA1

KMG11, GHEDI

71063, TOPA1

3938c58 Loop 2310B (Rendering Provider Name) is missing. It is expected to be used when loop

2420A is used with the same value in every loop 2400.

Loop 2310B (Rendering Provider Name) is missing. It is expected

to be used when loop 2420A is used with the same value in every

loop 2400.

2310B NM1 837P SHP11, 68057

68053, 68050

68058

3938c5f Loop 2420D (Supervising Provider Name) is used. It is not expected to be used when loop

2310E is not used.

Loop 2420D (Supervising Provider Name) is used. It is not

expected to be used when loop 2310E is not used.

2420D NM1 837P SHP11, 68057

68053, 68050

68058

3938c6b Loop 2430 (Line Adjudication Information) is used. It is not expected to be used when loop

2320 is not used.

Loop 2430 (Line Adjudication Information) is used. It is not

expected to be used when loop 2320 is not used.

2430 CAS

SVD

837P 00720

3938c7e Loop 2310E is missing. It is required when Billing/Pay-To Provider address is PO Box Loop 2310E is missing. It is required when Billing/Pay-To Provider

address is PO Box

2310E N3 837I LS328

3938ed5 Claim balancing is failed: total charge amount (CLM02) does not equal sum of line charge

amounts (SV102).

Claim balancing is failed: total charge amount (CLM02) does not

equal sum of line charge amounts (SV102).

2400 SV102 837P 00720, 10775

11345

3938ed5 COB service line balancing is failed : charge amount (SV102) does not equal sum of paid

amount (SVD02) and all line adjustment amounts (CAS)

COB service line balancing CLM02 SV102 837P 10775

3938edc COB claim balancing has failed (NM109 in loop 2330B): total charge amount (CLM02) does

not equal sum of paid amount (AMT02 in loop 2320) and all adjustment amounts (CAS in 2320

and 2430)

COB claim balancing has failed (NM109 in loop 2330B): total

charge amount (CLM02) does not equal sum of paid amount

(AMT02 in loop 2320) and all adjustment amounts (CAS in 2320

and 2430)

2320 AMT02 837I

837P

68050, 68053

68057, 68058

SHP11, D0328

00220, 00720

07003

3938edc COB claim balancing is failed for payer (NM109 in loop 2330B): total charge amount (CLM02)

does not equal sum of paid amount (AMT02 in loop 2320) and all adjustment amounts (CAS in

2320 and 2430).

COB Service Line Balancing Failed for payer - Total Charge

amount (CLM02) does not equal sum of paid amount (AMT02 in

Loop 2320) and all adjustment amounts (CAS in 2320 and 2430)

2320 AMT02 837P

837I

94036, 77027

00934, 93093





Types

Payers

3938edd COB service line balancing is failed : charge amount (SV102) does not equal sum of paid

amount (SVD02) and all line adjustment amounts (CAS). Segment SVD is defined in the

guideline at position 540.

COB Service Line Balancing Failed

Charge amount (SV102) does not equal sum of paid amount

(SVD02) and all lines adjustment amounts (CAS).

2300

2430

2430

SV102

SVD02

CAS

837P 00611, 00851

00932, 01260

93221, 68053

NIA11, 26374

26375, 26378

SHP11, 68050

14163, 14164

NANPR, NAELM

NAHOI, NAHIN

NAHLX, NAING

NANWC, NAOAK

NASCR, NASWD

00934, 93093

HPN11, GTPA1

MCA11, VFP11

INET1. KLSY1

SCOK1. WITH1

TX1ST, NWDC1

PPMO1, FMCHP

SSC11, CIPA1

KMG11, GHEDI

71063, TOPA1

3938edd COB service line balancing is failed : charge amount (SV102) does not equal sum of paid

amount (SVD02) and all line adjustment amounts (CAS). Segment SVD is defined in the

guideline at position 540.

COB Service Line Balancing Failed for payer

- Charge amount (SV102) does not equal sum of paid amount

(SVD02) and all lines adjustment amounts (CAS).

2430 SVD02 837P

837I

94036, 38520

57106, 61125

95112, 35174

35174, 37330,

54160

39392cb Element NM104 is missing. It is required when Other Subscriber is a person (NM102=1) Other subscriber name and policy number are required. 2330A NM1 837P

837I

14163, 14164

39392cb Element NM104 is missing. It is required when Referring Provider is a person. NM104 is present, must contain at least 1 alpha/numeric

character.

2310B NM104 837P 26374, 26375

26378

39392cb Element NM104 is missing. It is required when Referring Provider is a person. When name is present, must contain at least 1 alpha/numeric

character.

2310A NM104 837P 26374, 26375

26378

39392d1 Element CLM10 is missing. It is required when CLM09 is not 'N'. Patient signature source code (CLM10) is required when the

release of information (CLM09) is not N - No.

2300 CLM10 837P AIDWA, LABOR

95827, HCDPBC

53120, 00720

91121, 91051

39392ec Element PER07 is used. It is expected to be used only when element PER05 is used. PER data elements must not be skipped. 2010AA PER07 837P 14163, 14164

39392ef Element NM104 is used. It is not expected to be used when Billing Provider is not a person

(NM102 is not '1').

First Name (Element NM104) is used. It is not expected to be

used when Billing Provider is not a person (NM102 is not '1').

2010AA

2010AB

NM104 837P 94036, 00934

93093, 91051

AIDWA, 68058

SHP11, 68057

68053, 68050

39392ef Element NM105 is used. It is not expected to be used when Billing Provider is not a person

(NM102 is not ‘1’).

Element NM105 is used. It is not expected to be used when

Billing Provider is not a person (NM102 is not ‘1’).

2010AA

2010AB

NM105 837P 94036, 00934

93093

39392f1 Element PAT09 is used. It is not expected to be used when patient is not female (DMG03 in

loop 2010CA is not 'F').

If the Pregnancy Indicator equals 'Y', then Patient Gender Code

must equal 'F'

2000C PAT09 837P 80705, 63665

66893, 95388

95412, 95569

95379

39392f8 Element CR109 is used. It should not be used when CR103 is not 'X'. CR109 (Ambulance Round Trip Purpose Description) should not

be present unless CR103 (Ambulance Transport Code) equals ‘X’

(Round Trip).

2300 CR109 837P 04102, 04202

04302, 04402

68050, 68053

IL621, SHP11

09102

393931d Value of CL102 is incorrect. Expected value is from external code list - Admission Source

Code.

Admission source code must be valid as listed on the code

source.

2300 CL101 837I 26375, 26374

26378





Types

Payers

393931e Admission Source Code is invalid When Point of Origin Admission Code is 7 and the transaction

create date is on or after July 1, 2010.

2300 CL1 837I 00220

393933b National Drug Code must be 11 numeric LIN03 should contain 11 numeric 2410 LIN 837P 00932, 93221

00851, 00611

393933e Value of element SV105 is incorrect. Expected value is from external code list - Place of

Service Code (237).

Based upon Code Source 237, Place of Service code is invalid. 2400 SV105 837P 95827, HCDPBC

393938b Value of element REF02 (CLIA Number) is incorrect. Expected value is CLIA number (format

is '10 characters where the third character is 'D'').

When the CLIA ID present, it has to be 10 characters and the

third byte is a D.

2300 REF 837P 68050, 68053

68057, 68058

SHP11

393939e The identification code qualifier (loop 2010AB, segment NM108) must equal XX and the pay-to

provider identifier (loop 2010AB, segment NM109) must be a valid NPI. The payer does not

accept a tax ID as the pay-to provider identifier.

The identification code qualifier (loop 2010AB, segment NM108)

must equal XX and the pay-to provider identifier (loop 2010AB,

segment NM109) must be a valid NPI. The payer does not accept

a tax ID as the pay-to provider identifier.

2010AB NM108

NM109

837I 38338

393939e The National Provider ID (NPI) is required for this payer. Expected value for NM108 is 'XX.'

Please add the Provider's NPI to this transaction and resubmit for processing. Providers can

apply for an NPI online at https://nppes.cms.hhs.gov.

The National Provider ID (NPI) is required for this payer. 2010AA, 2010AB

2310A , 2310B

2310C, 2310D

2310E, 2420A

2420B, 2420C

2420D

NM108 837P 48145, 38338

39393AD Value of element PER06 is incorrect. Expected value is E-mail address when PER05='EM'. When the contact information (2010AA, PER) is 'EM' the email

address has to be in a valid email format.

2010AA PER 837P

837I

68050, 68053

68057, 68058

SHP11

39393b0 Value of element PER06 is incorrect. Expected value is Facsimile number (format is '10 digits')

when PER05='FX'.

When present or indicated, fax number must be 10 numeric. 2010AA PER05 837P 00611, 00851

00932, 68050

68053, 68057

68058, SHP11

39393b8 Value of element PER04 is incorrect. Expected value is Telephone number (format is ’10

digits’) when PER03 = ‘TE’

When present, telephone numbers must be 10 digits. 2010AA PER04 837P 00934, 93093

95827, HCDPBC

39393b8 Value of element PER04 is incorrect. Expected value is Telephone number (format is ’10

digits’) when PER03 = ‘TE’.

Communication telephone numbers must be 10 digits. 1000A, 2010AA

2330B, 2420E

PER04 837P

837I

38520, 57106

61125, 35174

95827, HCDPBC

94036

39393cb Value of element CRC03 is incorrect. Expected value is 'NU' when CRC02 is 'N'. When Certification Condition Indicator equals N-No, a condition

indicator is not required.

2300 CRC03 837P 95827, HCDPBC

39393cd Value of element SVD01 is incorrect. It must match corresponding Other Payer Identifier in

NM109 in 2330B loop.

Line adjudication payer id must match secondary payer id. 2430 SVD01 837P

837I

14163, 14164

77027, 95379

80705, 63665

66893, 95388

95412, 95569

61160

39393cf Value of element CRC03 is incorrect. Value ‘NU’ is not expected to be used when CRC02 is

not ‘N’

Value NU is not allowed when an EPSDT referral was given to the

patient.

2300 CRC03 837P 14163, 14164

77027, 95827

HCDPBC, 68050

68053, 68057

68058, SHP11

39393d0 Value of element NM109 is incorrect. It should be different from value of element SBR03

(group number)

Member id must not be the same as the member’s group

number.

2010BA NM109 837P

837I

CNTNM 14163

14164, 77027

68050, 68053

68057, 68058

SHP11

39393d0 Value of element NM109 is incorrect. It should be different from value of element SBR03

(Group or Plan Number).

When present, the group/plan number must be different from the

subscriber id.

2010BA SBR03 837P

837I

SHP11, 68057

68053, 68050

68058





Types

Payers

39393d1 Value of element N403 is incorrect. It should be formatted as 'XXXXXX' or 'XXX XXX' for

Canadian Zip Code.

If Country code (N404) is equal to CA, then the Postal code

(N403) must be in the correct format.

2010AA, 2010AB

2010BA, 2010BB

2010BC, 2010CA

2310D, 2330A

2420C, 2420E

N403 837P 80705, 63665

66893, 95379

95388, 95412

95569

39393d1 Value of element N403 is incorrect. It should be formatted as 'XXXXXX' or 'XXX XXX' for

Canadian Zip Code.

If Country code (N404) is equal to CA, then the Postal code

(N403) must be in the correct format.

2010AA, 2010AB

2010BA, 2010BB

2010BC, 2010CA

2310E, 2330A

2330B

N403 837I 80705, 63665

66893, 95379

95388, 95412

95569

39393ed Value of element REF01 has been already used in loop 2300. Elements REF01 are expected

to have unique values within loop 2300.

Duplicate REFs not allowed in Loop 2300. 2300 REF 837P

837I

00611, 00851

00932

39393f0 Value of element REF01 is incorrect. Value ‘EI’ should not be used when the referring

provider (2310A, NM108/09) is not used.

If Referring Provider Tax ID is present, then the NPI must be

present.

2310A REF01 837P 68050, 68053

68057, 68058

SHP11

39393f5 Rendering Provider Secondary Identification is a duplicate of Primary ID When the Rendering Provider Primary Identifier (2310B – NM109)

contains a qualifier of ‘24’ (Employer’s Identification Number), the

Rendering Provider Secondary Identification (2310B – REF01)

should not contain ‘EI’ (Employer’s Identification Number).

2310B REF02 837P 00934, 93093

38520, 57103

61125, 77027

53589, 00720

AIDWA

39393f5 Rendering Provider Secondary Identification is a duplicate of Primary ID. When the Rendering Provider Primary Identifier (2310B – NM109)

contains a qualifier of ‘34’ (Social Security Number)., the

Rendering Provider Secondary Identification (2310B – REF01)

should not contain ‘SY’ (Social Security Number)

2310B REF02 837P 00934, 93093

38520, 57106

61125, 77027

AIDWA

39393f5 Subscriber Secondary Identification is a duplicate of Primary ID. When the Subscriber Identifier contains a qualifier of ‘MI’

(Member ID), the secondary identifier (REF01) should not contain

‘1W’ (Member ID).

2010BA

2010CA

2330A

2330C

REF01 837I 53589, 00220

39393f5 Subscriber Secondary Identification is a duplicate of Primary ID. When the Subscriber Identifier contains a qualifier of ‘MI’

(Member ID), the secondary identifier (REF01) should not contain

‘1W’ (Member ID).

2010BA

2010CA

2330A

2330C

REF01 837P 53589, AIDWA

39393f5 Value of element REF01 is incorrect. Value '2U' should not be used when element NM108 is

'PI'. Segment REF is defined in the guideline at position 355.

The Other Payer Secondary Qualifier (2330B – REF01) should

not contain a ‘2U’ (Payer Identification Number) when 2330B –

NM109 contains a qualifier of ‘PI’ (Payer Identification Number).

2330B REF01 837P

837I

00611, 00851

00932, 93221

38520, 57106

61125, IL621

77027, AIDWA

39393f8 Value of element REF01 has been already used in loop 2010AA. Elements REF01 are

expected to have unique values within loop 2010AA. Segment REF is defined in the guideline

at position 035.

Element REF01 must be unique within Loop 2010AA, 2010AB

2010BA, 2010BB

2010BD, 2010CA

2310A, 2310B

2310C, 2310D

2310E, 2330A

2330B, 2330C

2330D, 2330E

2330G, 2330H

2420A, 2420B

2420C, 2420D

2420E, 2420F

REF01 837P

837I

00611, 00851

00932, 01260

93221, LS328

75137, 00932

01260, NIA11

77027, 68050

68053, 68057

68058, SHP11

TCHD1, SHMAP

EPNSH, SHPCH

WCMAP, UHSCH

CMSEB, UT3F

HLTHQ, SHCAR

SHEBP

39393fb Value of element CRC03 has been already used. Condition Indicator should be unique for

every CRC segment.

Multiple condition indicator values cannot be duplicated within the

same segment.

2300 CRC03 837P

837I

SHP11, 68057

68053, 68050

68058





Types

Payers

393945f Value of element SBR01 has been already used in loops 2000B/2300. Elements SBR01 are

expected to be different from SBR01 specified in loop 2000B and to have unique values within

loop 2300 excluding 'T' value.

Payer responsibility sequence number code can not be

duplicated.

2000B SBR01 837P

837I

80705,63665

66893,95379

95388,95412

95569, CNTNM

09102

393945f Value of element SBR01 has been already used in loops 2000B/2300. Elements SBR01 are

expected to be different from SBR01 specified in loop 2000B and to have unique values within

loop 2300 excluding 'T' value.

Payer responsibility sequence number code can not be

duplicated.

2320 SBR01 837I

837P

68050, 68053

68057, 68058

SHP11, CNTNM

393946e Value of element DTP03 (Service Line Date) is incorrect. Expected value for date should be

within a Statement Dates range.

Service Line Date should be with in dates of Service 2300 DPT03 837I LS328

39395df Sub-element SV101- 05 is used. It is not expected to be used when sub-element SV101-04 is

not used.

First available modifier field should be used. 2400 SV101 837P 14163, 14164

95827, HCDPBC

77027, AIDWA


not used.

First available procedure modifier field should be used 2400 SV202 837I 14163, 14164

63665, 66893

80705, 95379

95388, 95412

95569, 00851

00611, 00932

93221

39395df Sub-element SV202-04 is used. It is not expected to be used when sub-element SV202- is not

used. Segment SV2 is defined in the guideline at position 375.

SV101-05 is not expected when SV101-04 is not used 2400 SV101-05 837P 26374, 26375

26378, 77027

39395df When a procedure modifier SV202-04 is used. It is not expected to be used when procedure

modifier SV202-03 is not used.

When a procedure modifier SV202-04 is used. It is not expected

to be used when procedure modifier SV202-03 is not used.

2400 SV202 837I 68050, 68053

68057, 68058

SHP11

39395df When procedure modifier SV101-05 is used. It is not expected to be used when procedure

modifier SV101-04 is not used.

When procedure modifier SV101-05 is used. It is not expected to

be used when procedure modifier SV101-04 is not used.

2400 SV101 837P 68050, 68053

68057, 68058

SHP11


not used.

Modifier fields must not be skipped. 2400 SV101 837P 38520, 57106

61125, 35174

37330, 54160

39395ec Value of sub-element HI03-02 has been already used. Diagnosis Codes (primary and

secondary) are expected to be unique within claim.

Duplicate Diagnosis Codes are not allowed. 2300 HI 837P 14163, 14164

CNTNM, 68050

68053, 68057

68058, SHP11

39395ec Value of sub-element HI03-02 has been already used. Diagnosis Codes (primary and

secondary) are expected to be unique within claim.

Value of sub-element HI03-02 has been already used. Diagnosis

Codes (primary and secondary) are expected to be unique within

claim.

2300 HI 837I 68050, 68053

68057, 68058

SHP11

39395ee Duplicate procedure modifier. Procedure modifiers can not be duplicated. 2400 SV202 837I 14163, 14164

95827, HCDPBC

39395ee Duplicate procedure modifier. Duplicate Procedure Modifier Code found. 2400

2430

SV101

SVD03

837P 14163, 14164

95827, HCDPBC

39395ef Value of sub-element CLM11-03 has been already used. Related-Causes Codes are expected

to be unique within composite CLM11.

Value of sub-element CLM11-02 has been already used. Related-

Causes Code should be unique within composite CLM11.

2300 CLM11 837P 80705, 63665

66893, 95379

95388, 95412

95569, 77027





Types

Payers

39395f6 Value of sub-element SV107-01 is incorrect. Expected value is 1 through 8, inclusive.

Segment SV1 is defined in the guideline at position 370.

If present, the SV107 (Diagnosis Code Pointer) must contain a

value of 1 – 8 and reference an existing diagnosis code.

2400 SV107 837P IL621, 26374

AIDWA, 13350

94036, SHP11

68050, 68053

95112, 14163

00611, 00851

00932, 93221

05130, WA001

OR001, 00835

00831, 03102

AK001, 00836

CHPWA, 77027

LABOR, 91051

91121, M3IL1

M3IL2, M3FL2

M3FL3, M3FL4

M3FL5, M3FL6

M3FL7, M3FL8

M3CA1, 14164

26375, 26378

AIDOR, 95827

HCDPBC, 10775

01260, 38520

57106, 61125

53120

HPN11, GTPA1

MCA11, VFP11

INET1. KLSY1

SCOK1. WITH1

TX1ST, NWDC1

PPMO1, FMCHP

SSC11, CIPA1

KMG11, GHEDI

71063, TOPA1

393961a Value of sub-element HI01-02 is incorrect. Expected value is from external code list - ICD-9-

CM Diagnosis code (131) and a decimal point should not be used. Segment HI is defined in

the guideline at position 231.

Value of sub-element HI01-02 is incorrect 2300 HI 837P ALL

393962f Value of sub-element HI01-02 is incorrect. It looks like a local code from external code list 132 -

NUBC, Occurrence Codes. It is not allowed to use local codes after compliance date under the

HIPAA rules.

AmeriChoice allows occurrence code 54. 2300 HI01-02 837I 95378

393963c Composite HI02 is missing. Admitting Diagnosis is required on all inpatient admission claims

and encounters.

Admitting Diagnosis is required on all inpatient admission claims

and encounters.

2300 HI 837I 26374, 26375

26378, 00851

00932, 93221

00611

393963d Composite CLM11 is missing. It is required when segment DTP (Date - Accident) is used. When there is an accident date present, related cause

information is required.

2300 CLM11 837P 95827, HCDPBC

81002a Sub-Element SV101-04 length is '1'. The minimum allowed length is '2'. Segment SV1 is

defined in the guideline at position 370

Modifier fields must be two bytes in length 2400 SV101 837P All

81002b The length of Element SV105 is '3'. The maximum allowed length is '2'. Segment SV1 is

defined in the guideline at position 370.

Facility codes/Place of Service must be two bytes in length 2400 SV105 837P All

C100P LMP Date Missing. When the pregnancy indicator is Y-Yes, a last menstrual period

(LMP) date is required.

2000B

2000C

PAT09 837P 00720

C101I The attending physician name (loop 2310A, NM103, NM104) is required for Home Health

services.

Attending physician name is required for Home Health services. 2310A NM103

NM104

837I 00220, 07003





Types

Payers

C103I Qualifier code BR or BQ (loop 2300, HI01-1) is not allowed unless the type of bill (loop 2300,

CLM05-1) is an inpatient admission (11, 12, 18, 21, 28, 41, 65, 66, or 84).

ICD9-CM surgery procedure codes are not allowed on outpatient

claims. The surgery procedure code must be a CPT-4 procedure

code listed on the detail line charge.

2300 HI01-1 837I 00220, 07003

C104I Qualifier code BP or BO (loop 2300, HI01-1) is not allowed. Institutional claims with surgery must be coded with the ICD9-CM

Procedure Code rather than the CPT-4 procedure code.

2300 HI01-1 837I 00220, 07003

C105I A claim code segment (loop 2300, CL1) including admission type code, admission source

code, and patient status code is required for hospital inpatient admissions.

Claims for hospital inpatient admissions must include information

for admission type code, admission source code, and patient

status code.

2300 CL1 837I Edit Relaxed

00220, 07003

C106I The admission type code (loop 2300, CL101) is required for hospital inpatient admissions. The inpatient admission type code is missing. 2300 CL101 837I 00220, 07003

C107I The admission source code (loop 2300, CL102) is required for hospital inpatient admissions. The inpatient admission source code is missing. 2300 CL102 837I 00220, 07003

C108I The patient status (loop 2300, CL103) is required for hospital inpatient admissions. The inpatient admission patient status is missing. 2300 CL103 837I 00220, 07003

C109I The admitting diagnosis code (loop 2300, HI02-1) is required for hospital inpatient admissions. An admitting diagnosis code is required for inpatient admissions. 2300 HI02-1 837I 00220, 07003

C110I When the condition code qualifier BG is used (loop 2300, HI01-1), the condition code in HI01-2

must be a value other than 12 through 16 or 62 through 65. Please correct and resubmit the

claim.

Condition Codes 12 through 16 or 62 through 65 are not valid. 2300 HI 837I 38520, 57106

61125

C111P Invalid Character [^] received in Other Payer Name (loop 2330B, NM103). Invalid Character [^] received in Other Payer Name (loop 2330B,

NM103).

2330B NM103 837P SHP11, 68057

68053, 68050

68058

C112P Invalid Character [^] Received in Other Subscriber Address (loop 2330A, N301). Invalid Character [^] Received in Other Subscriber Address (loop

2330A, N301).

2330A N301 837P 00835, 00836

03102, 00831

C114I Invalid character (^) received in Other Payer Name (loop 2330B, NM103). Please correct and

resubmit.

Other Payer Name must not contain special characters. 2330B NM1 837I 38520, 57106

61125

C114P Invalid character (^) received in Other Payer Name (loop 2330B, NM103). Please correct and

resubmit.

Other Payer Name must not contain special characters. 2330B NM1 837P 38520, 57106

61125

C117P Other Payer Primary ID (loop 2330B, NM109) is invalid. Must contain at least two characters. Other Payer Primary ID (loop 2330B, NM109) is invalid. Must

contain at least two characters.

2330B NM1 837P 00836

C118P Invalid Character [^] Received in Other Insured Group Name (loop 2320, SBR04). Please correct and resubmit|Invalid Characters are not allowed for Other Insured Group Name

(loop 2320, SBR04)

2320 SBR 837P 00611, 00851

00932, 93221

C120P A prescription date (loop 2300, DTP*471) is required when billing for replacement lenses or

frames (loop 2300, CRC*E1, E2, or E3).

Prescription date is required when billing for replacement lenses

or frames.

2300 DTP 837P 3852, 57106

61125

D100P If the quantity for oxygen therapy certification (loop 2400, CR511) is greater than 88, then an

oxygen test find code must be present in either CR513, CR514, or CR515

Oxygen therapy certification cannot be greater than 88. 2400 CR511 837I IL621

D101P Total Purchased Service Amount (loop 2300, AMT-01=NE) is required when

Purchase Service Information (loop 2400, PS1) is present.

Total Purchased Service Amount (loop 2300, AMT-01=NE) is

required when Purchase Service Information (loop 2400, PS1) is

present.

2300 AMT01 837P 65055

D104I The ending date of service at the line level (loop 2400, DTP*472*RD8) must not be in the

future compared to the date Availity processed the claim.

The detail thru service date of service can not be in the future. 2400 DTP 837I 00720

D105P The approved amount' (2400-AMT*AAE) should be greater than or equal to the service line

paid amount (2430-SVD02).

The approved amount should be greater than or equal to the

service line paid amount.

2400 AMT 837P 00882, 04102

04202, 04302

04402, 00904

inst.3AM Secondary Claims Not Accepted Electronically For This Payer|2320 If the 2320 Loop (Other Subscriber Information) has Medicare

listed as the other coverage, reject the claim.

2320 SBR 837I CNTNM


https://test-apps.availity.com/availity/EDILogUtilServlet?act=viewclmsrc&batchId=0001898-2010092114505501&payerSequenceNumber=0&claimId=0






Types

Payers

inst.CLM01

MaxLength

Length of element CLM01 cannot exceed 20 characters. Patient control number cannot be greater than 20 characters in

length.

2300 CLM01 837I HPN11, GTPA1

MCA11, VFP11

INET1. KLSY1

SCOK1. WITH1

TX1ST, NWDC1

PPMO1, FMCHP

SSC11, CIPA1

KMG11, GHEDI

AHS01, 71063

TOPA1, 68050

68053, 68057

68058, SHP11

52629, WIMCE

00220

inst.H1B National Drug Code must be an 11 digit numeric value NDC code must be 11 numeric. 2410 LIN03 837I 52629, 01260

inst.HIE Value Code 80 not valid in this ANSI version. Continue to use QTY segment. Rejects institutional claims when Value Code of 80 is used on

ANSI format.

2300 HI02 837I 38520, 57106

61125

inst.K301 Invalid POA indicator. 4th Character must be Y, N, U, W or 1 and last character must be Z. When the fourth position in the POA does not equal Y, N, U, W or

1.

2300 K301 837I 53589

inst.SED In compliance with Minnesota statutes, Availity cannot submit paper claims to health plans on

behalf of Minnesota providers. As a result, Availity's Print-to-Paper service is no longer

available to Minnesota providers.

Print to paper service is not available for providers in the state of

Minnesota.

2010AA N402 837I PRINT

inst.SEF Availity cannot submit paper claims to health plans in the State of South Carolina. As a result,

Availity's print to paper service is no longer available for payers with South Carolina addresses.

Print to paper service is not available for payers in the state of

South Carolina.

2010BC N402 837I PRINT

inst.SEH The group/plan PHYSICIANS HEALTH PLAN OF SOUTH MICHIGAN (PHPSM) is no longer a

valid group/plan under payer ID 37330. If you have any questions, please call 1-800-394-7569.

For payer code 37330, claims submitted on or after 11/1/2009

(BHT04) will be rejected when the group/plan number begins with

"J" (2000B SBR03).

2000B

2000C

SBR03 837I 37330

inst.SEI The patient or subscriber ID in segment NM109 in loop 2010BA and/or loop 2010CA must

contain three numeric characters followed by three alpha characters

Applies to 2010BA loop only 2010BA NM109 837I MRCHP

inst.SEJ The patient or subscriber ID in segment NM109 in loop 2010BA and/or loop 2010CA must

contain eight alphanumeric characters

Applies to 2010BA loop only 2010BA NM109 837I MRIPA

inst.SEK The patient or subscriber ID in segment NM109 in loop 2010BA and/or loop 2010CA must


Applies to 2010CA loop only 2010CA NM109 837I MRCHP

inst.SEK The patient or subscriber ID in segment NM109 in loop 2010BA and/or loop 2010CA must


Applies to 2010CA loop only 2010CA NM109 837I MRCHP

inst.SEL The patient or subscriber ID in segment NM109 in loop 2010BA and/or loop 2010CA must


Applies to 2010CA loop only 2010CA NM109 837I MRIPA

inst.SEP The patient or subscriber social security number (SSN) must contain nine numeric digits.

These nine digits cannot be identical and the first digit cannot be a '8' or '9'.

The patient or subscriber social security number (SSN) must

contain nine numeric digits. These nine digits cannot be identical

and the first digit cannot be a '8' or '9'.

2330A REF02 837I 68050, 68053

68057, 68058

SHP11

inst.SFA A date (loop 2300, HI) is required only when an ICD-9-CM code is received (element HI01-1

equal to BR). For all other values, do not provide a date.

Only send a date when an ICD-9-CM code is received and a

value of 'BR' is received.

2300 HI 837I 68050, 68053

68057, 68058

SHP11

inst.SFL Secondary Claims Not Accepted Electronically For This payer Secondary Claims are not accepted electronically for this payer. 2320 SBR 837I 39151

inst.SFM The date of service is required for all service lines (loop 2400, segment DTP03) on institutional

outpatient claims.When a facility claim type of bill is 13 (outpatient), the date

of service is required on all service lines.

2400 DTP03 837I 68057, 68053

68050, 68058

SHP11, D0328

inst.SFP Claim should not have a negative submitted charge amount (SV102) at the service line (loop


Claim should not have a negative submitted charge amount

(SV102) at the service line (loop 2400). All values should be zero

or a positive number

2400 SV102 837I 68057, 68053

68050, 68058

SHP11

inst.U2A Payer requires admission type code. Regardless of value in CLM05-01, admission type code is

required when CL101 is present.

2300 CL101 837I CNTNM





Types

Payers

inst.WCE Your encounter was received with an incorrect payer ID. If this is an encounter, resubmit with

payer ID 59354. If this is not an encounter, use CH in Claim or Encounter Indicator field.

Encounters for Wellcare must be submitted using payer id 59354. BHT BHT06 837I 14163, 14164

P100I The value submitted for patient ID (loop 2010CA, NM109) is invalid. The patient id is invalid. 2010CA NM109 837I HPN11, GTPA1

MCA11, VFP11

KLSY1, SCOK1

WITH1, TX1ST

NWDC1, PPMO1

FMCHP, SSC11

CIPA1, KMG11

GHEDI, TOPA1

P100P The value submitted for patient ID (loop 2010CA, NM109) is invalid. The patient id is invalid. 2010CA NM109 837P HPN11, GTPA1

MCA11, VFP11

KLSY1, SCOK1

WITH1, TX1ST

NWDC1, PPMO1

FMCHP, SSC11

CIPA1, KMG11

GHEDI, TOPA1

prof.2GE01 The Information in Address 2 should not match the information in Address 1 The billing provider’s address in Address 2 should be different

than the one given in Address 1.

2010AA N302 837P 00934, 93093

prof.2GE02 The Information in Address 2 should not match the information in Address 1 The subscriber’s address in Address 2 should be different than

the one given in Address 1.

2010BA N302 837P 00934, 93093

prof.2GE03 The Information in Address 2 should not match the information in Address 1 The responsible party’s address in Address 2 should be different


2010BC N302 837P 00934, 93093

prof.2GE04 The Information in Address 2 should not match the information in Address 1 The ordering provider’s address in Address 2 should be different


2420E N302 837P 00934, 93093

prof.3AD Secondary Claims Not Accepted Electronically For This Payer If the 2320 Loop (Other Subscriber Information) is received, reject

the claim

2320 SBR 837P AIDOR, 39151

prof.3AM Secondary Claims Not Accepted Electronically For This Payer|2320 If the 2320 Loop (Other Subscriber Information) has Medicare

listed as the other coverage, reject the claim

2320 SBR 837P CNTNM

prof.5CH Referring Provider Org or Last Name Invalid Referring provider last name in 2310A NM103 cannot be all

numbers

2310A NM103 837P 53120

prof.BA5 Rendering Provider NPI Missing Rendering Provider NPI Missing 2310B NM109 837P GCVCP

prof.BAH Rendering Provider Name (Loop 2310B) is used. It's not required when segment PRV (loop

2000A) is used

Rendering Provider Name is not required when 2000A PRV is

used

2310B PRV 837P M3IL1, M3IL2

M3FL2, M3FL3

M3FL4, M3FL5

M3FL6, M3FL7

M3FL8, M3CA1

61160, NASWD

NASCR, NANPR

NAOAK, NANWC

NAING, NAHLX

NAHIN, NAHOI

NAELM, 10775

65055, SC359

prof.BCM Payer Requires Rendering Provider Tax ID Line level rendering provider requires tax id. 2420A REF 837P CNTNM

prof.BCN Payer requires rendering provider tax ID If 2310B loop is present, reject claim if rendering provider tax is

missing.

2310B REF01 837P CNTNM

prof.BCT10 Provider Secondary ID (Provider Commercial Number) Contains Non Numeric Characters. Provider number must not have alpha characters 2010AA, 2010AB

2310B, 2310A

2310C, 2310D

2310E, 2420A

2420C, 2420D

2420E, 2420F

REF = G2 837P 48145





Types

Payers

prof.BDE Invalid Character [^] Received in Referring Provider Organization/Last Name Unprintable character ‘^’ not acceptable in Referring Provider

Organization and/or last name

2310A NM103 837P 00836, 00835

00831, 03102

WA001, OR001

AZ001

prof.BDF Invalid Character [^] Received in Referring Provider First Name Unprintable character ‘^’ not acceptable in Referring Provider first

name

2310A NM104 837P 00836, 00835

00831, 03102

WA001, OR001

AZ001

prof.BDG Invalid Character [^] Received in Subscriber's Address. Unprintable character ‘^’ not acceptable in Subscriber's Address. 2010BA N301 837P 00836, 00835

00831, 03102

WA001, OR001

AZ001

prof.BMK Facility Prov Name Cannot Be the Same as Billing Prov Name Facility Provider Name 2310D cannot be the same as Billing

Provider Name 2010AA

2010AA

2310D

NM103 837P AIDOR

prof.CLM01

MaxLength

Length of element CLM01 cannot exceed 20 characters. Patient control number cannot be greater than 20 characters in

length.

2300 CLM01 837P HPN11, GTPA1

MCA11, VFP11

INET1. KLSY1

SCOK1. WITH1

TX1ST, NWDC1

PPMO1, FMCHP

SSC11, CIPA1

KMG11, GHEDI

AHS01, 71063

TOPA1, 68050

68053, 68057

68058, SHP11

52629, WIMCE

00720

prof.COC Coordination of Benefits (COB) Total Claim Before Taxes Amount was not expected because

the Payor Paid Amount (2320/AMT) is not present.

When total claim before tax amount is present, payer paid

amount is required.

2320 AMT01 837 94036

prof.COOKCHILDR

ENSSTAR

BBSBR

Rendering Provider Medicaid Number Must Be 9 Numeric Rendering Provider Medicaid ID must be 9 numeric characters

when present

2310B REF02 837P CCHP9

prof.COOKCHILDR

ENSSTAR

BBSBR

Rendering Provider Medicaid Number Must Be 9 Numeric The Billing Provider Medicaid TPI number must be present and 9

numerics.

2010AA REF02 837P CCHP9

prof.GBA Original Reference Number (ICN/DCN) Required Original Reference Number (ICN/DCN) Required. 2300 REF01 837P CHPWA, LABOR

00934, 93093

AIDOR

prof.GC4 Total Purchase Service Amount Missing AMT*NE - Required when Purchased Service Provider loop

2310C is present.

2300 AMT 837P 38520, 57106

61125, 35174

HPN11, GTPA1

MCA11, VFP11

INET1, KLSY1

SCOK1. WITH1

TX1ST, NWDC1

PPMO1, FMCHP

SSC11, CIPA1

KMG11, GHEDI

71063, TOPA1

prof.GFA The sum of service lines OTAF (2400 CN102) should equal claim OTAF amount (2300

CN102)

The sum of the service lines for OTAF must = the claim level

OTAF

2300 CN102 837P 04102, 04202

04302, 04402

00952, 00953

09102

prof.GHB Invalid Character [^] Received in Claim Note Text Unprintable character ‘^’ not acceptable in narrative and/or note at

the claim level.

2300 NTE02 837P 00836, 00835

00831, 03102

WA001, OR001

AZ001





Types

Payers

prof.GHC Value of element SV104 is incorrect, its value should be to a maximum of 999 Anesthia minutes must be 3 bytes or less. 2400 SV104 837P 91051

prof.GHE REF segment exists but NM109 primary ID is missing Service Facility Primary ID is required when Service Facility

Secondary ID is present.

2310D NM109 837P & 837I 35174

prof.GHI Invalid Character [^] Received in Claim Note Text Unprintable character ‘^’ not acceptable in narrative and/or note at

the service line.

2400 NTE02 837P 00836, 00835

00831, 03102

WA001, OR001

AZ001

prof.H1B National Drug Code Must Be 11 Numerics National Drug Code Must Be 11 Numerics. 2410 LIN03 837P 53120

prof.H1BSBR National Drug Code must be an 11 digit numeric value NDC code must be 11 numeric. 2400 LIN02 837P 52629

prof.HR2 Diagnosis Pointer Missing or Out of Sequence Diagnosis code pointer fields must not be skipped. 2400 SV107 837P COMMF, 26374

26375, 26378

00720

prof.HRP Diagnosis Code Missing For Pointer Diagnosis code missing 2400 SV107 837P 35174, 38520

57106, 61125

prof.NDC1 Invalid NDC code format. Must be 11 numeric. Spaces and / or hyphens not accepted. Please

correct and resubmit.

NDC code must be 11 numeric. 2400 LIN02 837P 00932, 93221

00851, 00611

13350, 61101

61102, 61105

65018, 72127

95348, 95885

HUMAR, Z0005

38333, OCH01

38334, CIMSA

NM505, 20149

20554, UNMSC

38336, 51062

MHHNP, 95092

95093, 00590

53589, 84980

00790, 00621

00840, 53120

14163, 14164

01260

prof.NDC2 Invalid NDC code according to Availity NDC code set. Please correct and resubmit. NDC code must be valid as listed on the current code set. 2400 LIN02 837P 13350, 61101

61102, 61105

65018, 72127

95348, 95885

HUMAR, Z0005

38333, OCH01

38334, CIMSA

NM505, 20149

20554, UNMSC

38336, 51062

MHHNP, 95092

95093, 53589

84980, 00790

00621, 00840

53120, 14163

14164





Types

Payers

prof.NDC3 The NDC is not active for this date of service. Please correct and resubmit. Based upon the current code set, the NDC is not active for this

date of service.

2400 LIN02 837P 13350, 61101

61102, 61105

65018, 72127

95348, 95885

HUMAR,Z0005

38333, OCH01

38334, CIMSA

NM505, 20149

20554, UNMSC

38336, 51062

MHHNP, 95092

95093, 53589

84980, 00790

00621, 00840

53120, 14163

14164

prof.POB Payer requires physical address for where services were rendered Rejection occurs when Billing provider address is a PO Box and

the facility address is not present or also has a PO Box listed.

2010AA

2310D

N301 837I 38520, 57106

61125

prof.QBB Billing Provider Secondary Id Missing or Invalid The billing provider REF segment must be present and the

REF01 must contain a qualifier of ‘LU’. Also, the REF02 must

contain an 8 digit alpha/numeric value.

2010AA REF01 837P GCVCP

prof.QGA Billing Provider NPI Missing The billing provider NPI must be present within Loop 2010AA

(NM108/NM109). The billing provider identification qualifier

(NM108) must be ‘XX’ and the billing provider NPI must be

present in NM109

2010AA NM108 837P GCVCP

prof.QGA Billing Provider NPI missing and is required The QGA message requires the 'XX' qualifier in LOOP ID -

2010AA (Billing Provider Name) segment ID, NM108 and the

National Provider Identifier in segment ID NM109.

2010AA NM109 837P 83490, 00079

00621

prof.RENREQ

SBR

Rendering Provider Name (Loop 2310B) is used. It's not required when segment PRV (loop

2000A) is used

2310B Rendering Provider Name is not required when 2000A

PRV is used.

2310B NM103

PRV03

837P PRIME

prof.RENREQ

SBR

Rendering Provider Name (Loop 2310B) is used. It's not required when segment PRV (loop

2000A) is used.

2310B Rendering Provider Name is not required when 2000A

PRV is used.

2310B NM1 837P 35174, 37330

48055, 54160

TOPTN, LS328

01260, NIA11

CHPWA, 94036

63665

prof.SA0 Patient relationship must be self If 2000B loop (Subscriber Information) does not list the patient

relationship as self, reject the claim.

2000B SBR02 837P CNTNM, 77072

prof.SCE Member ID must be a minimum of 9 characters. Member ID must be a minimum of 9 characters. 2010BA NM109 837P HCDPBCprof.SCF Member ID must be a minimum of 6 characters. Member ID must be a minimum of 6 characters. 2010BA NM109 837P 95827prof.SCO Subscriber ID invalid. Must be 9, 10 or 14 numeric If member id is not numeric and not 9, 10 or 14 digits, reject the

claim

2010BA NM109 837P CNTNM

prof.SCQ Subscriber ID Must Be 9, 10, or 11 Digit Alpha-Numeric. Subscriber ID Must be 9,10,or11 Digit Alph-Numeric 2010BA NM109 837P 94999

prof.SED In compliance with Minnesota statutes, Availity cannot submit paper claims to health plans on

behalf of Minnesota providers. As a result, Availity's Print-to-Paper service is no longer

available to Minnesota providers.

Print to paper service is not available for providers in the state of

Minnesota.

2010AA N402 837P PRINT

prof.SEF Provider Secondary ID (Provider Commercial Number) Contains Non Numeric Characters. Print to paper service is not available for payers in the state of

South Carolina.

2010BB N402 837P PRINT

prof.SEH The group/plan PHYSICIANS HEALTH PLAN OF SOUTH MICHIGAN (PHPSM) is no longer a

valid group/plan under payer ID 37330. If you have any questions, please call 1-800-394-7569.

For payer code 37330, claims submitted on or after 11/1/2009

(BHT04) will be rejected when the group/plan number begins with

"J" (2000B SBR03).

2000B

2000C

SBR03 837P 37330

prof.SEI The patient or subscriber ID in segment NM109 in loop 2010BA and/or loop 2010CA must


Applies to 2010BA loop only 2010BA NM109 837P MRCHP

prof.SEJ The patient or subscriber ID in segment NM109 in loop 2010BA and/or loop 2010CA must


Applies to 2010BA loop only 2010BA NM109 837P MRIPA





Types

Payers

prof.SEK The patient or subscriber ID in segment NM109 in loop 2010BA and/or loop 2010CA must


Applies to 2010CA loop only 2010CA NM109 837P MRCHP

prof.SEL The patient or subscriber ID in segment NM109 in loop 2010BA and/or loop 2010CA must


Applies to 2010CA loop only 2010CA NM109 837P MRIPA

prof.SEM The patient or subscriber social security number (SSN) must contain nine numeric digits.

These nine digits cannot be identical and the first digit cannot be a '8' or '9'

The secondary ID has to be nine characters and cannot be the

same digit.

2010BA REF 837P

837I

68050, 68053

68057, 68058

SHP11

prof.SEP The patient or subscriber social security number (SSN) must contain nine numeric digits.

These nine digits cannot be identical and the first digit cannot be a '8' or '9

The patient or subscriber social security number (SSN) must

contain nine numeric digits. These nine digits cannot be identical

and the first digit cannot be a '8' or '9

2330A REF02 837P 68050, 68053

68057, 68058

SHP11

prof.SFB The patient (2010CA) or subscriber (2010BA) first and last name fields can contain letters and

spaces only. Special characters are not allowed.

Special characters are not allowed in the subscriber/patient name

fields.

2010BA NM103

NM104

837P 68050, 68053

68057, 68058

SHP11

prof.SFF The patient and subscriber ID number in segment NM109 in loop 2010BA and/or 2010CA

must contain at least two alpha number characters.

Applies to 2010BA loop only 2010BA NM109 837P IL621

prof.SFH The patient signature source code (loop 2300, segment CLM10) is not required when the

release of information code is 'N' (loop 2300, segment CLM09)

The patient signature source code (loop 2300, segment CLM10)

is not required when the release of information code is 'N' (loop

2300, segment CLM09)|

2300 CLM10 837P 53120

prof.SFI The identification code qualifier (loop 2010AB, segment NM108) must equal XX and the pay-to

provider identifier (loop 2010AB, segment NM109) must be a valid NPI. The payer does not

accept a tax ID as the pay-to provider identifier.

The identification code qualifier (loop 2010AB, segment NM108)

must equal XX and the pay-to provider identifier (loop 2010AB,


a tax ID as the pay-to provider identifier.

2010AB NM108

NM109

837P 38338

prof.SFJ The identification code qualifier (loop 2010AA, segment NM108) must equal XX and the billing

provider identifier (loop 2010AA, segment NM109) must be a valid NPI. The payer does not

accept a Tax ID as the billing provider identifier.

The identification code qualifier (loop 2010AA, segment NM108)

must equal XX and the billing provider identifier (loop 2010AA,


a tax ID as the billing provider identifier.

2010AA NM108

NM109

837P 38338

prof.SFK When an internal control number (ICN/DCN) is included on the claim, it must contain 12

alphanumeric characters

When an internal control number (ICN/DCN) is included on the

claim, it must contain 12 alphanumeric characters

2300 REF02 837P 68057, 68053

68050, 68058

SHP11

prof.SFO Claim should not have a negative submitted charge amount (SV102) at the service line (loop


Claim should not have a negative submitted charge amount

(SV102) at the service line (loop 2400). All values should be zero

or a positive number

2400 SV102 837P 68057, 68053

68050, 68058

SHP11

prof.SS2 Subscriber First Name is Invalid The first position of the Subscriber’s first name cannot be a

space. The first position must be alpha or numeric

2010BA NM104 837P 53120

prof.WCE Your encounter was received with an incorrect payer ID. If this is an encounter, resubmit with

payer ID 59354. If this is not an encounter, use CH in Claim or Encounter Indicator field.

Encounters for Wellcare must be submitted using payer id 59354. BHT BHT06 837P 14163, 14164

prof.Y7DSBR Rendering Provider Taxonomy Code Missing or Invalid Rendering Provider Taxonomy Code Missing or Invalid 2310B PRV03 837P EPF03, EPF02

prof.YED LMP Date Missing When the pregnancy indicator is Y-Yes, a last menstrual period

(LMP) date is required.

2000B

2000C

PAT09 837P 00934, 93093

S101P The member ID (Loop 2010BA, Segment NM109) must be nine numeric digits. Member ID must be nine numeric 2010BA NM109 837P HCDPBC

S102P The member ID (Loop 2010BA, Segment NM109) must be eight numeric digits. Member ID must be eight numeric 2010BA NM109 837P 95827

S103P The payer does not accept a subscriber secondary ID (REF segment) in loop 2010BA The payer does not accept a subscriber secondary ID (REF

segment) in loop 2010BA

2010BA REF 837P

837I

39151

S104P The subscriber ID (loop 2010BA, MN109) must be six characters in the following format: the

first character must be a letter, the second character must be a letter or number, and the

remaining four characters must be numbers

The inmate CDCR number must be six characters in the following

format: the first character must be a letter; the second character

must be a letter or number; and the remaining four characters

must be numbers

2010BA NM1 837P

837I

CCIH

S105P The patient address is invalid (loop 2010BA, segment N3). Select an abbreviation from the

Institutional Abbreviation List located at http://www.correctcare.com/portal

The patient address should be the institutional abbreviation from

the Institutional Abbreviation List located at

http://www.correctcare.com/portal.

2010BA N3 837P

837I

CCIH

S108P Invalid character (^) received in Insured Group Name

(loop 2000B, SBR04). Please correct and resubmit.

Invalid character (^) received in Insured Group Name

(loop 2000B, SBR04). Please correct and resubmit.

2000B SBR04 837P 00851, 00611

00932, 93221





Types

Payers

S109P Insured City (loop 2010BA, N401) invalid. Must contain two alpha characters. Please correct

and resubmit.

Insured city must be two consecutive alpha characters. 2010BA N401 837P 91121, 91051

S110P Payer City (loop 2010BB, N401) invalid. Must contain two alpha characters. Please correct and

resubmit.

Payer city must be two consecutive alpha characters. 2010BB N401 837P 91121, 91051

S111P Invalid Character [^] Received in Subscriber Middle Name (Loop 2010BA, NM105) Invalid Character [^] Received in Subscriber Middle Name (Loop

2010BA, NM105)

2010BA NM1 837P AIDWA

S113I The value submitted for member ID (loop 2010BA, NM109) is invalid. The subscriber id is invalid. 2010BA NM109 837I HPN11, GTPA1

MCA11, VFP11

KLSY1, SCOK1

WITH1, TX1ST

NWDC1, PPMO1

FMCHP, SSC11

CIPA1, KMG11

GHEDI, TOPA1

S113P The value submitted for member ID (loop 2010BA, NM109) is invalid. The subscriber id is invalid. 2010BA NM109 837P HPN11, GTPA1

MCA11, VFP11

KLSY1, SCOK1

WITH1, TX1ST

NWDC1, PPMO1

FMCHP, SSC11

CIPA1, KMG11

GHEDI, TOPA1

S114I The value submitted for the member Id (loop 2010BA, NM109) is invalid. The member id must be 9, 10, or 14 digits and must not be equal

to all one's, two's, three's, etc.

2010BA NM1 837I CNTNM


Documents

Availity Health Information Network guide/payer_specific_transaction_edits.pdfAvaility® Health Information Network Batch Electronic Data Interchange (EDI) Companion Guides Payer Specific