Claim Rejection Errors and Resolutions

The claims may get rejected when the details supplied in the charge are missing or incorrect.  Sometimes the claims are rejected by the payer and sometimes they are rejected by the clearinghouse before being transmitted to the payer.

Below are the most common claim rejection errors exactly as they appear in the system and their proposed resolutions:

Claim Rejection Errors

Resolutions

An hipaa syntax error occurred. If either of nm108, nm109 is present, then all must be present. The syntax rule p0809 of segment nm1 is violated.

 
1.Navigate to Administration > Insurance Management screen.
2.Enter the Claim Submission Payer ID for the secondary payer.
3.Select the Filing Vendor from the drop-down list.

Error #: 40902 invalid data: 0 location: 2430 - cas03 * error: svc: the line adjustment amounts (cas03, 06, 09, 12, 15, 18) cannot be * equal to zero.

 
1.Search for the claims using the search option on the Payments screen.
2.Click the Plus icon corresponding to the claim to expand.
3.For the Transaction Type as credit adjustment, click the Modify link.
4.Enter the Check Number.
5.Enter or select the Check Date, Posting Date, and Received Date using the calendar icon.
6.If the adjustment amount is missing, do the following:
•On the Payments screen, click the Post Payment link corresponding to the claim.
•Select the Transaction Type as Credit Adjustment.
•In the Line Items section, enter the credit adjustment amount in the text box provided.

Claim rejection due to CLIA number not going with the claims.

 
1.A CLIA number can be entered at practice level and at facility level.
•To add the CLIA number at facility level, navigate to Administration > Facility Management screen.
•To add the CLIA number at practice level, navigate to Administration > Insurance Management > Manage Practice Level Fee Schedule screen.
2.Search for the claims using the search option on the New Charge screen.
3.Click the Edit icon.
4.In the Line Item Details section, select the CLIA check box before generating the claim.

Insurance type code required when Medicare is the secondary or the tertiary payer.

 
1.Navigate to Patients > Insurance screen.
2.Click the Edit icon corresponding to the Medicare insurance details. Select an appropriate insurance type code.
3.Rebill the claim from the New Charge screen.

Claim filling indicator

 
1.Navigate to Administration > Insurance screen.
2.Click the Edit icon.
3.Enter an appropriate claim filing indicator. For e.g., the claim filing indicator for Medicare is MEDICARE and Blue Cross Blue Shield is BCBS.

Acknowledgement / rejected for relational field in error. * entity's national provider identifier (npi). Note: this code requires use of an entity code. Entity description: billing provider or invalid pay provider * bill npi not setup

 
1.Contact the clearinghouse to confirm the NPI number which you are enrolled with, for the particular payer.
2.Configure the NPI for the provider. To configure the NPI, click Administration > Resource Management > Payer Rules.
3.Select the Billing NPI as Group or Individual.
4.Select the Secondary ID as EIN or SSN.

Acknowledgement/rejected for invalid information * ack/reject inval info - entity's id number. – subscriber.   acknowledgement/returned as unprocessable claim * ack/returned - subscriber and subscriber id not found
1.Navigate to Patients > Insurance screen.
2.Check if the policy number and subscriber details are valid.
3.Check if the policy is active with the payer.

Acknowledgement/returned as unprocessable claim tpl company code and or name missing or invalid

 
1.Navigate to Administration > Insurance screen.
2.Click the Edit icon to edit the payer.
3.Enter the code in the Third Party Liability code text box. This code can be found in the rejection message or the practice can call the payer to get the code.

SBR05 insurance type code required when Medicare is secondary or tertiary payer

 
1.Navigate to Administration > Insurance Management screen.
2.Click the Edit icon corresponding to the payer.
3.Select the Financial class and Insurance Type for the primary or secondary payer from the drop-down list.

Payer not found in database

 
1.Navigate to Administration > Insurance Management screen.
2.Click the Edit icon corresponding to the payer.
3.Search for a valid Payer ID from the MDOL website and enter the payer ID in the Claim Submission Payer ID text box.
4.If the payer ID is not available in the MDOL website, enter the SPRNT number in the Claim Submission Payer ID text box.

Acknowledgement/returned as unprocessable claim the claim/encounter * has been rejected and has not been entered into the adjudication system * status: duplicate of a previously processed claim/line
✍Please contact the EDI support for further explanation, as there could be multiple possibilities causing the rejection.

The medical claim is billed as a resubmission. Either the resubmission code or the original reference number is blank or invalid in box 22

 
1.Search for the claims using the search option on the New Charge screen.
2.Click the Edit icon corresponding to the claim.
3.Select the Rebill Type as Replacement [7] from the drop-down list.
4.Enter the Internal Control Number (ICN) which is displayed on the primary payer’s EOB.

Acknowledgement/rejected for invalid information - the claim/encounter has invalid information as specified in the status details and has been rejected. Entity not eligible for benefits for submitted dates of service. Entity description: patient
1.Navigate to Patients > Insurance screen.
2.Contact the patient for correct subscriber details and insurance covered.
3.Based on the patients reply, the practice may take necessary steps. For e.g., if the patient is not covered under any insurance, the patient may have to bear the expenses.

"* Service line 1 ordering provider required"

 
1.Search for the claims using the search option on the New Charge screen.
2.Click the Edit icon corresponding to the claim.
3.Click the Line Info link and click the Select: Ordering Provider tab.
4.Select the ordering provider from the drop-down list. To create a new ordering provider, navigate to Administration > Resource Management > Ordering Provider.

"* Batch transaction set id: 0001 * segment in error: ref * segment line position in transaction set: 13416 * loop id from 837: 2300 * 999 ik304 - segment error code: i9 * segment error code description: implementation dependent not used segment * present"
✍Please contact the EDI support for further explanation, as there could be multiple possibilities causing the rejection.

Comment: - "* sbr05 - insurance type code should be ommitted when payer is not Medicare * line: 212 loop: 2000b insurance type code"
1.Navigate to Patients > Insurance screen.
2.For the insurances other than Medicare, click the Edit icon.
3.Remove the Insurance Type Code selected.

* Missing mandatory segment dtp in loop 2430 * line: 56 loop: 2430 line adjudication date * missing mandatory segment dtp in loop 2430 * line: 69 loop: 2430 line adjudication date
1.Search for the claims using the search option on the Payments screen.
2.Click the Plus icon corresponding to the claim to expand.
3.For the Transaction Type as credit adjustment, click the Modify link.
4.Enter or select the Received Date using the calendar icon for all the line items.

Rejected at clearinghouse line level adjustment - other payer adjustment amount is missing or * invalid. (0) (13551)

1.Search for the claims using the search option on the Payments screen.
2.Click the Plus icon corresponding to the claim to expand.
3.For the Transaction Type as credit adjustment, click the Modify link.
4.Enter the Check Number.
5.Enter or select the Check Date, Posting Date, and Received Date using the calendar icon.
6.If the adjustment amount is missing, do the following:
•On the Payments screen, click the Post Payment link corresponding to the claim.
•Select the Transaction Type as Credit Adjustment.
•In the Line Items section, enter the credit adjustment amount as zero in the text box provided.

Comment: - "*’73710’ is a duplicate diagnosis code found in same hi segment. *line: 503 loop: 2300 other diagnosis code 9"

 
1.Search for the claims using the search option on the New Charge screen.
2.Click the Edit icon corresponding to the claim.
3.Remove the duplicate ICD code added.
4.Resubmit the claim.

Comment: - "* # error id error message snip type severity guideline properties * 25 0x39393f5 business message: * other payer secondary identifier is a duplicate of primary id. * 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 3550. * this error was detected at: * segment count: 8222 * element count: 1 * character: 192692 through 192694 * 4 - situational normal * id: 128 * iid: 31041 * name: reference identification qualifier * standard option: mandatory * user option: must use * max use: 1 * min length: 2 * max length: 3 * type: identifier"
1.Navigate to Administration > Insurance screen.
2.Click the Edit icon to edit the payer.
3.Remove the Third Party Liability code entered for the payer.

 

Comment: - "* missing mandatory segment dtp in loop 2430 * line: 74 loop: 2430 line adjudication date * missing mandatory segment dtp in loop 2430 * line: 79 loop: 2430 line adjudication date"

 
1.Search for the claims using the search option on the Payments screen.
2.Click the Plus icon corresponding to the claim to expand.
3.For the Transaction Type as credit adjustment, click the Modify link.
4.Enter the Check Number.
5.Enter or select the Check Date, Posting Date, and Received Date using the calendar icon.
6.If the adjustment amount is missing while sending the claim to secondary, do the following:
•On the Payments screen, click the Post Payment link corresponding to the claim.
•Select the Transaction Type as Credit Adjustment.
•In the Line Items section, enter the credit adjustment amount as zero in the text box provided.
7.On the New Charge screen, exclude the above line item by selecting the Exclude check box or delete the line item by clicking the Delete icon.

Comment: - "* replacement/cancel of prior claim missing original claim number"

 
1.Search for the claims using the search option on the New Charge screen.
2.Click the Edit icon corresponding to the claim.
3.Select the Rebill Type as Replacement [7] from the drop-down list.
4.Enter the Internal Control Number (ICN).
5.Click Save & Rebill.

Comment: - "* sbr09 (clm filing indicator) in loop 2000b must be 'mb' for Medicare claims * line: 296 loop: 2000b payer entity type qualifier"

 
1.Navigate to Administration > Insurance Management screen.
2.Click the Edit icon corresponding to the payer.
3.Select the Financial class as Medicare from the drop-down list.
4.Select the Insurance Type as Medicare Part B from the drop-down list.

"* Acknowledgement/returned as unprocessable claim * rendering Provider is required":: the npi going on box 33 is wrong.... The client is enrolled to bill with group npi but the individual npi is going with claims instead....”
1.Navigate to Administration > Resource Management > Payer Rules > Provider’s NPI Configuration screen.
2.Select the Billing NPI as Individual.
3.Resubmit the claim.