Rejection Message | Rejection Clarification | Action Items |
Claim Frequency Code Information submitted inconsistent with billing guidelines. Payer Assigned Claim Control Number. | The Payer has rejected the claim because the frequency code used with the Payer Control Number is not consistent with their system. Reasons for this rejection include the following: 1. The provider is not sending the correct Payer Control Number for the original claim. 2. The Provider is not using the correct frequency code for the claim type in box 22 (New/Resubmission/Cancellation). 3. The Payer doesn’t allow corrected or replacement claims. | Action items are below for each of the possible reasons: 1. Please confirm the Payer Control Number/Payer Claim # for the original claim. 2. Please confirm that the correct accepted frequency values for professional claims are being used: · For the first claim ever submitted, mark "Original" in box 22. · For a replacement or resubmission claim, mark "Resubmission" in box 22. · For a cancellation claim, mark "Cancellation" in box 22. 3. If there was an issue in box 22 where you selected the wrong type of submission or entered the incorrect Payer Control Number/Payer Claim #, please correct and resubmit the claim. Note: Box 22 requirements are entirely dependent on the payer's requirements. For example, Medicare only accepts Original claim submissions. |
H25390: THE 'PAYER CLAIM CONTROL NUMBER' (2300/REFERENCE IDENTIFICATION QUALIFIER EQUAL TO F8) WAS NOT FOUND BUT WAS EXPECTED BECAUSE THE 'CLAIM SUBMISSION REASON CODE' (HEALTH CARE SERVICE LOCATION INFORMATION-3) IS 7 OR 8. | The claim has been rejected due to an incorrect Original Claim ID in box 22. | If the claim is a resubmitted/corrected claim, please include the correct Payer Control Number/Payer Claim # for the original claim. Note: Please ensure that you are providing the Payer Control Number/Payer Claim #, not the claim's reference ID in box 22. |
Entity's health insurance claim number (HICN) Entity: Payer. | The claim has been rejected due to an incorrect Original Claim ID in box 22. | If the claim is a resubmitted/corrected claim, please include the correct Payer Control Number/Payer Claim # for the original claim. Note: Please ensure that you are providing the Payer Control Number/Payer Claim #, not the claim's reference ID in box 22. |
CLM Orig Ref # must be 15 Chars if CLM Submission Reason is 7 or 8. | The claim has been rejected due to an incorrect Original Claim ID in box 22. | If the claim is a resubmitted/corrected claim, please include the correct Payer Control Number/Payer Claim # for the original claim. Note: Please ensure that you are providing the Payer Control Number/Payer Claim #, not the claim's reference ID in box 22. |
Invalid format for Original Claim ID. Please resubmit with Valid ID. | The claim has been rejected due to an incorrect Original Claim ID in box 22. | If the claim is a resubmitted/corrected claim, please include the correct Payer Control Number/Payer Claim # for the original claim. Note: Please ensure that you are providing the Payer Control Number/Payer Claim #, not the claim's reference ID in box 22. |
Missing or invalid information for Payer BH100 or COACC. | The claim has been rejected because modifiers weren't used with the CPT code for a behavioral health claim. | As of 01/01/2018, all behavioral health claim CPT codes require a modifier for payer ID BH100 and COACC. Please include a modifier on each service line in box 24D and submit a corrected claim for further processing. |
Billing Provider not approved. | There are three possible reasons for this rejection reason: 1. You're not credentialed or enrolled with this payer. 2. Claims are being sent with incorrect billing information in box 33. 3. Claims are being submitted to the wrong payer ID in box 1. | Action items are below for each of the possible reasons: 1. If you're not credentialed or enrolled with the payer, you must contact the payer for further assistance. 2. If the claim was sent with different billing information in box 33 than what is on file with the payer, you need to verify and edit the billing information. 3. If the claim is submitted to the wrong payer ID in box 1, you need to verify the payer ID and resubmit. |
THE BILLING PROVIDER ID NPI-TAX ID IS NOT A RECOGNIZED PROVIDER ID FOR THIS SUBMITTER AND PAYER. | There are three possible reasons for this rejection reason: 1. You're not credentialed or enrolled with this payer. 2. Claims are being sent with incorrect billing information in box 33. 3. Claims are being submitted to the wrong payer ID in box 1. | Action items are below for each of the possible reasons: 1. If you're not credentialed or enrolled with the payer, you must contact the payer for further assistance. 2. If the claim was sent with different billing information in box 33 than what is on file with the payer, you need to verify and edit the billing information. 3. If the claim is submitted to the wrong payer ID in box 1, you need to verify the payer ID and submit the claim with the correct payer ID. |
Payer Claim Office Number (or PO Box#) is missing or incorrect. Verify with Authorization of Care letter or your authorizing Service Center. If the number was entered correctly, Magellan is not the payer. Business Message: Error was reported from Java rule. | The claim has been rejected due to an incorrect PO Box Address in box 1. | You need to review your PO Box information used on the claim and verify against the authorization of care letter or your authorizing service center. If incorrect, you must resubmit the claims with your assigned PO Box information. To edit the PO box being populated in box 1a, please follow the instructions on this guide: Adding and editing an insurance address. If correct, you need to contact the payer to update their database. |
Payment made to patient/insured/responsible party/employer. | The claim has been rejected as the claim has been paid to the client/subscriber. Normally, the claim is paid to the client if the providers are non-participating with the carrier (BCBS, HMO’s and some commercials). | If you want to ensure your client received their reimbursement, please contact your client to confirm that payment was received and bill them accordingly. If your client did not receive their reimbursement, please contact the payer to resolve this issue. |
Subscr: Claim failed Pre-Membership Validation. | The claim has been rejected by the payer due to a failed Pre- Membership Validation. | Please contact the payer to resolve this issue. |
Member ID number not valid for DOS. | The claim was rejected as the payer is unable to find the client in their database. There are three possible reasons for this rejection reason: 1. The claim was submitted to the wrong payer ID. Note: This is most likely the cause if this rejection was received on claims for multiple clients. 2. The client's demographics or insurance policy included on the claim was not eligible for the date of service billed. 3. The client is a newborn or recently added to the guarantor's insurance policy. | Action items are below for each of the possible reasons: 1. Please confirm the claim was submitted to the correct payer ID. If you confirmed the payer ID is correct, the member details should be reviewed. Please verify the Member ID, Client Name, DOB, and if they are the primary party or a dependent on the policy. If all information on the claim is correct, please contact the payer to investigate this issue. 2. Please verify if your client still has active coverage for the date(s) of service you are billing for. 3. If the client is a newborn or recently added to the policy, it is possible your client needs to be added to the policy by the Payer's EDI department. Please contact the payer to resolve this issue. |
Please Resubmit -Inv Member#. | The claim was rejected as the payer is unable to find the client in their database. There are three possible reasons for this rejection reason: 1. The claim was submitted to the wrong payer ID. 2. Note: This is most likely the cause if this rejection was received on claims for multiple clients. 3. The client's demographics or insurance policy included on the claim was not eligible for the date of service billed. 4. The client is a newborn or recently added to the guarantor's insurance policy. | Action items are below for each of the possible reasons: 1. Please confirm the claim was submitted to the correct payer ID. If you confirmed the payer ID is correct, the member details should be reviewed. Please verify the Member ID, Client Name, DOB, and if they are the primary party or a dependent on the policy. If all information on the claim is correct, please contact the payer to investigate this issue. 2. Please verify if your client still has active coverage for the date(s) of service you are billing for. 3. If the client is a newborn or recently added to the policy, it is possible your client needs to be added to the policy by the Payer's EDI department. Please contact the payer to resolve this issue. |
Patient eligibility not found with entity. | The claim was rejected as the payer is unable to find the client in their database. There are three possible reasons for this rejection reason: 1. The claim was submitted to the wrong payer ID. Note: This is most likely the cause if this rejection was received on claims for multiple clients. 2. The client's demographics or insurance policy included on the claim was not eligible for the date of service billed. 3. The client is a newborn or recently added to the guarantor's insurance policy. | Action items are below for each of the possible reasons: 1. Please confirm the claim was submitted to the correct payer ID. If you confirmed the payer ID is correct, the member details should be reviewed. Please verify the Member ID, Client Name, DOB, and if they are the primary party or a dependent on the policy. If all information on the claim is correct, please contact the payer to investigate this issue. 2. Please verify if your client still has active coverage for the date(s) of service you are billing for. 3. If the client is a newborn or recently added to the policy, it is possible your client needs to be added to the policy by the Payer's EDI department. Please contact the payer to resolve this issue. |
Subscriber and policy number/contract number not found. | The claim was rejected as the payer is unable to find the client in their database. There are three possible reasons for this rejection reason: 1. The claim was submitted to the wrong payer ID. Note: This is most likely the cause if this rejection was received on claims for multiple clients. 2. The client's demographics or insurance policy included on the claim was not eligible for the date of service billed. 3. The client is a newborn or recently added to the guarantor's insurance policy. | Action items are below for each of the possible reasons: 1. Please confirm the claim was submitted to the correct payer ID. If you confirmed the payer ID is correct, the member details should be reviewed. Please verify the Member ID, Client Name, DOB, and if they are the primary party or a dependent on the policy. If all information on the claim is correct, please contact the payer to investigate this issue. 2. Please verify if your client still has active coverage for the date(s) of service you are billing for. 3. If the client is a newborn or recently added to the policy, it is possible your client needs to be added to the policy by the Payer's EDI department. Please contact the payer to resolve this issue. |
Member ID must be valid. | The claim was rejected as the payer is unable to find the client in their database. There are three possible reasons for this rejection reason: 1. The claim was submitted to the wrong payer ID. Note: This is most likely the cause if this rejection was received on claims for multiple clients. 2. The client's demographics or insurance policy included on the claim was not eligible for the date of service billed. 3. The client is a newborn or recently added to the guarantor's insurance policy. | Action items are below for each of the possible reasons: 1. Please confirm the claim was submitted to the correct payer ID. If you confirmed the payer ID is correct, the member details should be reviewed. Please verify the Member ID, Client Name, DOB, and if they are the primary party or a dependent on the policy. If all information on the claim is correct, please contact the payer to investigate this issue. 2. Please verify if your client still has active coverage for the date(s) of service you are billing for. 3. If the client is a newborn or recently added to the policy, it is possible your client needs to be added to the policy by the Payer's EDI department. Please contact the payer to resolve this issue. |
MEMBER NUMBER CANNOT BE FOUND. | The claim was rejected as the payer is unable to find the client in their database. There are three possible reasons for this rejection reason: 1. The claim was submitted to the wrong payer ID Note: This is most likely the cause if this rejection was received on claims for multiple clients. 2. The client's demographics or insurance policy included on the claim was not eligible for the date of service billed. 3. The client is a newborn or recently added to the guarantor's insurance policy. | Action items are below for each of the possible reasons: 1. Please confirm the claim was submitted to the correct payer ID. If you confirmed the payer ID is correct, the member details should be reviewed. Please verify the Member ID, Client Name, DOB, and if they are the primary party or a dependent on the policy. If all information on the claim is correct, please contact the payer to investigate this issue. 2. Please verify if your client still has active coverage for the date(s) of service you are billing for. 3. If the client is a newborn or recently added to the policy, it is possible your client needs to be added to the policy by the Payer's EDI department. Please contact the payer to resolve this issue. |
The claim/encounter has invalid information as specified in the status details and has been rejected. Patient. individual receiving medical care not eligible for benefits for submitted dates of service. | The claim was rejected as the payer is unable to find the client in their database. There are three possible reasons for this rejection reason: 1. The claim was submitted to the wrong payer ID. Note: This is most likely the cause if this rejection was received on claims for multiple clients. 2. The client's demographics or insurance policy included on the claim was not eligible for the date of service billed. 3. The client is a newborn or recently added to the guarantor's insurance policy. | Action items are below for each of the possible reasons: 1. Please confirm the claim was submitted to the correct payer ID. If you confirmed the payer ID is correct, the member details should be reviewed. Please verify the Member ID, Client Name, DOB, and if they are the primary party or a dependent on the policy. If all information on the claim is correct, please contact the payer to investigate this issue. 2. Please verify if your client still has active coverage for the date(s) of service you are billing for. 3. If the client is a newborn or recently added to the policy, it is possible your client needs to be added to the policy by the Payer's EDI department. Please contact the payer to resolve this issue. |
Subscriber and Subscriber ID not found. | The claim was rejected as the payer is unable to find the client in their database. There are three possible reasons for this rejection reason: 1. The claim was submitted to the wrong payer ID. Note: This is most likely the cause if this rejection was received on claims for multiple clients. 2. The client's demographics or insurance policy included on the claim was not eligible for the date of service billed. 3. The client is a newborn or recently added to the guarantor's insurance policy. | Action items are below for each of the possible reasons: 1. Please confirm the claim was submitted to the correct payer ID. If you confirmed the payer ID is correct, the member details should be reviewed. Please verify the Member ID, Client Name, DOB, and if they are the primary party or a dependent on the policy. If all information on the claim is correct, please contact the payer to investigate this issue. 2. Please verify if your client still has active coverage for the date(s) of service you are billing for. 3. If the client is a newborn or recently added to the policy, it is possible your client needs to be added to the policy by the Payer's EDI department. Please contact the payer to resolve this issue. |
Subscriber not eligible for medical benefits for submitted dates of service. | The claim was rejected as the payer is unable to find the client in their database. There are three possible reasons for this rejection reason: 1. The claim was submitted to the wrong payer ID. Note: This is most likely the cause if this rejection was received on claims for multiple clients. 2. The client's demographics or insurance policy included on the claim was not eligible for the date of service billed. 3. The client is a newborn or recently added to the guarantor's insurance policy. | Action items are below for each of the possible reasons: 1. Please confirm the claim was submitted to the correct payer ID. If you confirmed the payer ID is correct, the member details should be reviewed. Please verify the Member ID, Client Name, DOB, and if they are the primary party or a dependent on the policy. If all information on the claim is correct, please contact the payer to investigate this issue. 2. Please verify if your client still has active coverage for the date(s) of service you are billing for. 3. If the client is a newborn or recently added to the policy, it is possible your client needs to be added to the policy by the Payer's EDI department. Please contact the payer to resolve this issue. |
H40138: Missing 'Related Causes Code' in CLM-11. Required for Accidents (when DTP-01=439 is used). | The claim has been rejected as you submitted this claim for an accident but did not include the correct information regarding the accident. | · If this claim is regarding an accident, please fill out the correct information in boxes 10b and 10c. · If this claim is not regarding an accident, please select the correct qualifier in box 14. |
Claim submitted to incorrect payer. PLEASE RESUBMIT CLAIM TO ANTHEM BLUE CROSS OF CA. | The claim has been rejected as it was submitted to the incorrect payer. | Use the correct Payer ID of BC001 instead of BS001 and resubmit the claim as an Original claim. |
Entity acknowledges receipt of claim/encounter. Note: This code requires use of an Entity Code. | The claim has been rejected at the payer's end for an entity issue. With this rejection reason, the payer should send additional information indicating who the 'Entity' is. Unfortunately, sometimes this information is not included. | The Entities that may be involved are: · Billing Provider · Rendering Provider (Address and Phone are not included on claim, but they may be referencing the NPI). · Member/Client/Patient Insured · Referring Physician |
Loop 2420A (Rendering Provider Name) is used. It should not be used when loop 2310B is used with the same information. Loop 2420A is defined in the guideline at position 5000. | This rejection indicates that the Billing NPI number (box 33a) and Rendering Provider NPI number (box 24j) included on the claim are the same. This rejection comes directly from the payer's requirements. This payer will not accept claims in which the Billing and Rendering Provider NPI are the same value. | If an organizational NPI is entered as the billing provider in box 33a, please confirm that it is not the same as the rendering provider NPI in box 24j. The rendering provider NPI should generally be an individual NPI. |
claim [service lines] [n] [rendering provider] (RENDERING PROVIDER NAME) IS USED. IT SHOULD NOT BE USED WHEN rendering provider IS USED WITH THE SAME INFORMATION. | This rejection indicates that the Billing NPI number (box 33a) and Rendering Provider NPI number (box 24j) included on the claim are the same. This rejection comes directly from the payer's requirements. This payer will not accept claims in which the Billing and Rendering Provider NPI are the same value. | If an organizational NPI is entered as the billing provider in box 33a, please confirm that it is not the same as the rendering provider NPI in box 24j. The rendering provider NPI should generally be an individual NPI. |
THE NUMBER OF ACCOMMODATIONS BILLED DOES NOT AGREE WITH THE DATES OF SERVICE. | The claim was rejected by the payer as the number of accommodations (Service Units) does not match the Date of service. | Please use Date of Service properly for the services rendered. For additional information and a resolution, you should contact the payer's provider services representative and resubmit the claim according to their instructions. |
Subscriber First Name contains invalid characters. 2000BA. NM1*04. | The claim was rejected as the subscriber's first name included invalid and/or special characters. | Please review the submitted first name on the claim. The claims needs to be resubmitted with the correct spelling of the Client/Subscriber first name. Please make sure the first name that you have entered does not contain invalid characters (e.g., symbols, parentheses, etc.). |
Subscriber Last Name contains invalid characters. 2000BA. NM1*03. | The claim has been rejected as the subscriber's last name has invalid and/or special characters. | Please review the submitted last name on the claim. The claims needs to be resubmitted with the correct spelling of the Client/Subscriber last name. Please make sure the last name that you have entered does not contain invalid characters (e.g., symbols, parentheses, etc.). |
Insured Last Name INVALID CHARACTER(S). | The claim has been rejected as the subscriber's last name has invalid and/or special characters. | Please review the submitted last name on the claim. The claims needs to be resubmitted with the correct spelling of the Client/Subscriber last name. Please make sure the last name that you have entered does not contain invalid characters (e.g., symbols, parentheses, etc.). |
H46235: The Rendering Provider must be different than claim level Rendering Provider. | The claim rejected because we detected the Rendering Provider information in every service line. The reason why this rejection reason appears is if you have different clinicians rendering those services and you manually edited the claim form to match the Rendering Provider information in every service line when the rendering taxonomy code (box 24i) is different. | You should create separate claims for each clinician, or you need to reassign the primary clinician. For example, if your client had 3 sessions with you and 1 with one of your clinicians, then create one claim for the 3 sessions with you, and a separate claim for the other clinician. This will ensure that the rendering taxonomy codes on the backend all match each other in each service line. |
Subscriber ID must be 9 or 11 digits. | The claim has been rejected due to an incorrect Member ID. | Please review the Subscriber/Member ID and ensure the claim is submitted with the correct information. If the client information is correct, contact the payer for further investigation. |
Three Prefix of Subscriber ID Not Found Prefix for entity's contract/member number. | The claim has been rejected as the Member ID does not include one of the appropriate prefixes. There are two possible causes for this rejection: 1. The claim was submitted to the wrong payer ID. This is most likely the cause if this rejection was received on claims for multiple patients. 2. The Member ID used in the claim does not include a prefix. | Blue Cross Blue Shield has an alpha-prefix at the beginning of all member primary IDs (Member ID). This alpha-prefix is very important for Blue Cross Blue Shield as the alpha-prefix is used to route claims to the appropriate state. Please review the Member ID card for the correct Member/Subscriber ID with the alpha-prefix and resubmit the claim. For more details, you can refer this: BCBS Prefix List. |
Missing or invalid information. SUBSCRIBER PRIMARY ID (SUBSCRIBER NAME LOOP, IDENTIFICATION CODE) MUST BEGIN WITH A ZGT, ZGC, ZGE, OR WZG ALPHABETIC PREFIX. | The claim has been rejected as the member ID does not include one of the appropriate prefixes. There are two possible causes for this rejection: 1. The claim was submitted to the wrong payer ID. This is most likely the cause if this rejection was received on claims for multiple patients. 2. The Member ID used in the claim does not include a prefix. | Blue Cross Blue Shield has an alpha-prefix at the beginning of all member primary IDs (Member ID). This alpha-prefix is very important for Blue Cross Blue Shield as the alpha-prefix is used to route claims to the appropriate state. Please review the Member ID card for the correct Member/Subscriber ID with the alpha-prefix and resubmit the claim. For more details, you can refer this: BCBS Prefix List. |
Subscriber ID (loop 2010BA, NM109) must begin with a three-character prefix followed by up to 14 characters with no spaces. For Federal Employee Program (FEP) subscribers, the subscriber ID must begin with the letter R followed by eight numbers with no spaces. | The claim has been rejected as the Member ID does not include one of the appropriate prefixes. There are two possible causes for this rejection: 1. The claim was submitted to the wrong payer ID. This is most likely the cause if this rejection was received on claims for multiple patients. 2. The Member ID used in the claim does not include a prefix. | Blue Cross Blue Shield has an alpha-prefix at the beginning of all member primary IDs (Member ID). This alpha-prefix is very important for Blue Cross Blue Shield as the alpha-prefix is used to route claims to the appropriate state. Please review the Member ID card for the correct Member/Subscriber ID with the alpha-prefix and resubmit the claim. For more details, you can refer this: BCBS Prefix List. |
The claim/encounter has been rejected and has not been entered into the adjudication system. Policy canceled. | The claim has been rejected as the client’s insurance policy included on the claim was not eligible for the date of service billed. | Please contact the payer to verify if this client's policy is active for the date of service. |
Insured or Subscriber: Policy canceled. | The claim has been rejected as the client’s insurance policy included on the claim was not eligible for the date of service billed. | Please contact the payer to verify if this client's policy is active for the date of service. |
The Description is required when submitting the non-specific procedure code 'VALUE'. | This claim has been rejected because the description is missing for the non-specific procedure code. Many insurance companies will require a CPT code line item note (Description) when using certain service codes (CPT codes) that are indicated as non-specific. Non-specific procedure codes are those that include their descriptors: · Not Otherwise Classified (NOS) · Unlisted · Unspecified · Unclassified · Other · Miscellaneous · Prescription Drug Generic · Prescription Drug, Brand Name | When billing with a procedure code containing any of the terms listed in the column to the left, you need to include a corresponding description of that procedure to be HIPAA-compliant. There is no crosswalk of non-specified procedure codes with corresponding descriptions. However, the claim will not be rejected if "Not Otherwise Classified" is submitted as the description. Please fill in Box 19 for the code description and select "Claim Service Line 1 Procedure Code Description" from the dropdown menu for the non-specific procedure code. Make sure the non-specific code is on the first line of service of the claim form. |
REJECTED CLAIM BECAUSE BOTH BILLING PROVIDER NPI AND TAXONOMY PRE-SENT BUT NOT VALID AGAINST. | This rejection indicates the Taxonomy code either in box 33b or box 24i entered on the electronic claim. The taxonomy code should be valid or match what the Payer has on file. | A taxonomy code is from a standard code set and indicates your profession. Please resubmit the claim with the correct Billing and/or Rendering Provider Taxonomy code. The taxonomy code entered under your Member Info must be present and match what the insurance companies have on file. It is very common for the insurance companies to use the taxonomy code that was supplied when receiving an NPI. To find out what taxonomy code is tied to your NPI, please following the below instructions: 1. Go to the NPPES website: NPPES NPI Registry. 2. In the search form, enter your NPI (billing NPI) and then click Search at the bottom. You should see the listed taxonomy code tied to your NPI. |
H52002: Rendering Provider Specialty Code '<value>' not found in Taxonomy Code Table. | This rejection indicates the Taxonomy code either in box 33b or box 24i is required and was not sent out properly on the electronic claim. The taxonomy code should be valid or match what the Payer has on file. | A taxonomy code is from a standard code set and indicates your profession. Please resubmit the claim with the correct Billing and/or Rendering Provider Taxonomy code. The taxonomy code entered under your Member Info must be present and match what the insurance companies have on file. It is very common for the insurance companies to use the taxonomy code that was supplied when receiving an NPI. To find out what taxonomy code is tied to your NPI, please following the below instructions: 1. Go to the NPPES website: NPPES NPI Registry. 2. In the search form, enter your NPI (billing NPI) and then click Search at the bottom. You should see the listed taxonomy code tied to your NPI. |
Cannot provide further status electronically. 91 - Invalid or Missing Taxonomy Code. | This rejection indicates the Taxonomy code either in box 33b or box 24i is required and was not sent out properly on the electronic claim. The taxonomy code should be valid or match what the Payer has on file. | A taxonomy code is from a standard code set and indicates your profession. Please resubmit the claim with the correct Billing and/or Rendering Provider Taxonomy code. The taxonomy code entered under your Member Info must be present and match what the insurance companies have on file. It is very common for the insurance companies to use the taxonomy code that was supplied when receiving an NPI. To find out what taxonomy code is tied to your NPI, please following the below instructions: 1. Go to the NPPES website: NPPES NPI Registry. 2. In the search form, enter your NPI (billing NPI) and then click Search at the bottom. You should see the listed taxonomy code tied to your NPI. |
Loop 2420F (Referring Provider Name) is used. It is not expected to be used when loop 2310A is not used. Loop 2420F is defined in the guideline at position 5000. | The claim was rejected because it was submitted with the Referring Provider details in box 17 when it's not required by the payer or it was incorrectly submitted to the payer. | Please correct the values and resubmit the claim accordingly: 1. Remove the Referring Provider Details. 2. If the referring provider is required, the referring provider information must be moved to the correct place and then you need to resubmit the claim. You need to select the correct option in box 17a's dropdown menu. Then you need to select "DN - the Referring provider on the claim level" instead of "DN - the Referring Provider Service Line 1" in box 17's dropdown menu. |
INDIVIDUAL RELATIONSHIP CODE SUBSCRIBER. | The claim has been rejected as the incorrect relationship designation is used for the subscriber and client. | Please select the correct relationship of the subscriber regarding the patient. If the subscriber is the client, the claim must be submitted with the relationship as "Self" in box 6. |
Individual relationship code (loop 2000B, SBR02) must equal Self. | The claim has been rejected as the incorrect relationship designation is used for the subscriber and client. | Please select the correct relationship of the subscriber regarding the patient. If the subscriber is the client, the claim must be submitted with the relationship as "Self" in box 6. |
H24402: The value '<NPI>' fails the check digit algorithm for the "HIPAA National Provider ID (NPI)". | The Eligible Scrubber rejected the claim due to the use of an invalid NPI on the claim form. | You need to confirm the NPIs (in box 24j, box 32a, box 33a, etc.) used on the claim and submit the claim with a valid NPI. |
Svc: Health Care Diagnosis Code, - Age inappropriate. | The payer rejected this claim because the Health Care Diagnosis Code (ICD-10) is not valid. There are a few known causes for this rejection: 1. The Diagnosis Code is not valid for any service factor including Date of Service, Age, CPT code, etc. 2. You used an incorrect Diagnosis Code for the Service. 3. The claim was billed for outpatient services but included the Diagnosis Code for an inpatient service. | Please follow these steps: 1. Please ensure the correct DOS, Age, CPT code(s)and other details are being used on the claim. If any additional information is needed, you need to contact the payer and resubmit the claim with the correct ICD-10 code(s). 2. Please review and resubmit the claim with the correct Diagnosis Code. Please check an updated ICD Code Book (or an online code resource) to make sure ALL diagnosis codes submitted on the claim are valid. 3. Please review the claim and resubmit the claim with the correct ICD-10 code as an admitting diagnosis can only be used for inpatient services and not for outpatient services. |
H10614: Missing Mandatory 'Health Care Diagnosis Code - Industry Code', required for HIPAA. | The payer rejected this claim because the Health Care Diagnosis Code (ICD-10) is not valid. There are a few known causes for this rejection: 1. The Diagnosis Code is not valid for any service factor including Date of Service, Age, CPT code, etc. 2. You used an incorrect Diagnosis Code for the Service. 3. The claim was billed for outpatient services but included the Diagnosis Code for an inpatient service. | Please follow these steps: 1. Please ensure the correct DOS, Age, CPT code(s)and other details are being used on the claim. If any additional information is needed, you need to contact the payer and resubmit the claim with the correct ICD-10 code(s). 2. Please review and resubmit the claim with the correct Diagnosis Code. Please check an updated ICD Code Book (or an online code resource) to make sure ALL diagnosis codes submitted on the claim are valid. 3. Please review the claim and resubmit the claim with the correct ICD-10 code as an admitting diagnosis can only be used for inpatient services and not for outpatient services. |
H25602: The Admitting Diagnosis was found but not expected because this claim is for outpatient services. | The payer rejected this claim because the Health Care Diagnosis Code (ICD-10) is not valid. There are a few known causes for this rejection: 1. The Diagnosis Code is not valid for any service factor including Date of Service, Age, CPT code, etc. 2. You used an incorrect Diagnosis Code for the Service. 3. The claim was billed for outpatient services but included the Diagnosis Code for an inpatient service. | Please follow these steps: 1. Please ensure the correct DOS, Age, CPT code(s)and other details are being used on the claim. If any additional information is needed, you need to contact the payer and resubmit the claim with the correct ICD-10 code(s). 2. Please review and resubmit the claim with the correct Diagnosis Code. Please check an updated ICD Code Book (or an online code resource) to make sure ALL diagnosis codes submitted on the claim are valid. 3. Please review the claim and resubmit the claim with the correct ICD-10 code as an admitting diagnosis can only be used for inpatient services and not for outpatient services. |
Missing or invalid information, the claim/encounter has invalid information as specified in the status details and has been rejected. Diagnosis code. | The payer rejected this claim because the Health Care Diagnosis Code (ICD-10) is not valid. There are a few known causes for this rejection: 1. The Diagnosis Code is not valid for any service factor including Date of Service, Age, CPT code, etc. 2. You used an incorrect Diagnosis Code for the Service. 3. The claim was billed for outpatient services but included the Diagnosis Code for an inpatient service. | Please follow these steps: 1. Please ensure the correct DOS, Age, CPT code(s)and other details are being used on the claim. If any additional information is needed, you need to contact the payer and resubmit the claim with the correct ICD-10 code(s). 2. Please review and resubmit the claim with the correct Diagnosis Code. Please check an updated ICD Code Book (or an online code resource) to make sure ALL diagnosis codes submitted on the claim are valid. 3. Please review the claim and resubmit the claim with the correct ICD-10 code as an admitting diagnosis can only be used for inpatient services and not for outpatient services. |
ICD 10 Diagnosis Code 4 must be valid. 2300.HI*04-2. | The payer rejected this claim because the Health Care Diagnosis Code (ICD-10) is not valid. There are a few known causes for this rejection: 1. The Diagnosis Code is not valid for any service factor including Date of Service, Age, CPT code, etc. 2. You used an incorrect Diagnosis Code for the Service. 3. The claim was billed for outpatient services but included the Diagnosis Code for an inpatient service. | Please follow these steps: 1. Please ensure the correct DOS, Age, CPT code(s) and other details are being used on the claim. If any additional information is needed, you need to contact the payer and resubmit the claim with the correct ICD-10 code(s). 2. Please review and resubmit the claim with the correct Diagnosis Code. Please check an updated ICD Code Book (or an online code resource) to make sure ALL diagnosis codes submitted on the claim are valid. 3. Please review the claim and resubmit the claim with the correct ICD-10 code as an admitting diagnosis can only be used for inpatient services and not for outpatient services. |
THE ICD10 DIAGNOSIS CODE WAS NOT VALID ON DATE IN CODE TABLE ICD10DIAGNOSTICS. | The payer rejected this claim because the Health Care Diagnosis Code (ICD-10) is not valid. There are a few known causes for this rejection: 1. The Diagnosis Code is not valid for any service factor including Date of Service, Age, CPT code, etc. 2. You used an incorrect Diagnosis Code for the Service. 3. The claim was billed for outpatient services but included the Diagnosis Code for an inpatient service. | Please follow these steps: 1. Please ensure the correct DOS, Age, CPT code(s)and other details are being used on the claim. If any additional information is needed, you need to contact the payer and resubmit the claim with the correct ICD-10 code(s). 2. Please review and resubmit the claim with the correct Diagnosis Code. Please check an updated ICD Code Book (or an online code resource) to make sure ALL diagnosis codes submitted on the claim are valid. 3. 3. Please review the claim and resubmit the claim with the correct ICD-10 code as an admitting diagnosis can only be used for inpatient services and not for outpatient services. |
TYPE OF BILL INVALID, MISSING OR INCOMPATIBLE WITH PROVIDER TYPE OR SERVICES BILLED. | The claim has been rejected due to use of an invalid bill type. As per the payer, the type of bill is not compatible with the provider type or billed service on the claim. | Please review and use the correct Bill code structure to resubmit the claim. Included is an online code resource to ensure that the submitted codes on the claim are valid: Type of Bill Code Structure resource. |
Service Location: Entity's Postal/Zip Code. | The claim has been rejected as an invalid service location zip code was sent on the claim. | Please verify that the 9-digit zip code submitted on the claim is valid. Please note that some payers will not accept "0000" as the last four digits of the zip code. To find the correct zip code, enter the service location address on file into this tool: USPS Zip Code tool. |
H54289: The last four digits of the zip + 4 code cannot be zeros (0). | The claim has been rejected as an invalid service location zip code was sent on the claim. | Please verify that the 9-digit zip code submitted on the claim is valid. Please note that some payers will not accept "0000" as the last four digits of the zip code. To find the correct zip code, enter the service location address on file into this tool: USPS Zip Code tool. |
Loop 2420D (Supervising Provider Name) is used. It should not be used when loop 2310B is used with the same information. Loop 2420D is defined in the guideline at position 5000. | The claim was rejected because it was submitted with the Supervising Provider details in box 19. These details are not required if they are the same as the Rendering Provider details in box 24j. | Please review and confirm that the Supervising provider details in box 19 are different from the Rendering Provider details in box 24j. The provider must correct the values and resubmit the claim accordingly: 1. If both Supervising and Rendering provider are the same, please remove the Supervising Provider Details from box 19 and resubmit the claim with only the Rendering Provider details. |
Duplicate of a previously processed claim/line. | This rejection message indicates the payer has received the exact claim or service before. This rejection has two possible causes: 1. The same claim was submitted within 48 hours of the last submission. 2. The corrected claim was submitted incorrectly in box 22. | Resolution steps will vary depending on the cause of the claim rejection. Please contact the payer as needed and follow the below instruction accordingly: 1. If the exact claim was submitted within 48 hours of the previous claim, please contact the payer to verify the status of the previous claim submission. Determine if the claim needs to be corrected and how to properly resubmit the claim. If the initial claim is still processing, this rejection will not affect the status of the initial submission. 2. Note: Box 22 requirements are entirely dependent on the payer's requirements. For example, Medicare only accepts Original claim submissions. |
H25584: THE GROUP OR POLICY NUMBER (SUBSCRIBER GROUP OR POLICY NUMBER) CANNOT BE 'NONE', 'NONE', OR 'NONE'. | The claim has been rejected due to the use of an invalid value as the Policy Number. | Please review the information used in the Policy Number field for your client's records and see if it matches with your client's ID card. If you don't have the Policy Number, please leave the field blank instead of using an incorrect value on the claim form. |
Billing NPI IS not authorized for Tax ID. | The claim has been rejected due to the use of an invalid combination of an NPI & Tax ID. | Please submit the claim with the correct billing NPI and Tax ID combination. The NPI and Tax ID must be present, and they must match what the insurance payers have on file. If you did submit with the correct NPI and Tax ID combination, please work with the payer to complete the credentialing process and ensure they update their database with the most up-to-date information. |
043: Billing provider Tax ID/EIN submitted does not match BCBSF files. | The claim has been rejected due to the use of an invalid combination of an NPI & Tax ID. | Please submit the claim with the correct billing NPI and Tax ID combination. The NPI and Tax ID must be present, and they must match what the insurance payers have on file. If you did submit with the correct NPI and Tax ID combination, please work with the payer to complete the credentialing process and ensure they update their database with the most up-to-date information. |
DETAILED EXPLANATION MISSING OR INVALID INFORMATION (21); COORDINATION OF BENEFITS CODE (550) | This claim was rejected as the client has a different Primary Insurance coverage. | Please verify your client's primary insurance. The claim must be submitted to their primary coverage. |
Billing Provider not found. | There are three possible reasons for this rejection reason: 1. You're not credentialed or enrolled with this payer. 2. Claims are being sent with incorrect billing information in box 33. 3. Claims are being submitted to the wrong payer ID in box 1. | Action items below for each of the possible reasons: 1. If you're not credentialed or enrolled with the payer, you must contact the payer for further assistance. 2. If the claim was sent with different billing information in box 33 than what is on file with the payer, you need to verify and edit the billing information. 3. If the claim is submitted to the wrong payer ID in box 1, you need to verify the payer ID and resubmit the claim. |
THE ICD10 DIAGNOSIS CODE WAS NOT VALID ON DATE IN CODE TABLE ICD10 DIAGNOSTICS | The payer rejected this claim because the Health Care Diagnosis Code (ICD-10) is not valid. There are a few known causes for this rejection: 1. The Diagnosis Code is not valid for any service factor including Date of Service, Age, and CPT code, etc. 2. You used an incorrect Diagnosis Code for the Service. 3. The claim was billed for outpatient services but included the Diagnosis Code for an inpatient service. | Please follow these steps: 1. Please ensure the correct DOS, Age, CPT code(s) and other details are being used in the claim. If any additional information is needed, you need to contact the payer and resubmit the claim with correct ICD-10 code. 2. Please review and resubmit the claim with the correct Diagnosis Code. Please check an updated ICD Code Book (or an online code resource) to make sure ALL diagnosis codes submitted on the claim are valid. 3. Please review the claim and resubmit the claim with the correct ICD-10. This is because an admitting diagnosis can only be used for inpatient services and not for outpatient services. |
VALUE OF ELEMENT ST03 IS INCORRECT. EXPECTED VALUE IS '005010X223A2'. TRANSACTION SET HEADER IS DEFINED IN THE GUIDELINE AT POSITION 0050. INVALID DATA 005010X222A1 | The claim has been rejected as it should be an Institutional Claim (837I) but was submitted as a Professional Claim. | Please confirm the information on the claim is accurate and resubmit it as an Institutional claim. |
TIN NOT FOUND, CHECK FOR TYPOS. IF TIN CORRECT, CONTACT YOUR PROVIDER REP Returned to Entity. | The claim has been rejected due to the use of an invalid combination of an NPI & Tax ID. | Please submit the claim with the correct billing NPI and Tax ID combination. Please make sure the NPI and Tax ID that you have entered are present and match what the insurance payers have on file. If you did submit with the correct NPI and Tax ID combination, please work with the payer to complete the credentialing process and ensure they have the most updated information in their database. |
Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services) | This error appears as a rejection in the Electronic Module. The payer is citing the specific rules of the plan in the processing of this claim or claims for this client. It may be that the provider is not affiliated with the facility, location, or the client's plan product type. | The error is coming directly from payer. Please contact and investigate this directly with the payer. |
Processed according to plan provisions (Plan refers to provisions that exist between the Health Plan and the Consumer or Patient) | This error appears as a rejection in the Electronic Module. The payer is citing the specific rules of the plan in the processing of this claim or claims for this client. It may be that the provider is not affiliated with the facility, location, or the client's plan product type. | The error is coming directly from payer. Please contact and investigate this directly with the payer. |
Entity's contract/member number. Note: This code requires use of an Entity Code. | The claim was rejected as the payer is unable to find the client in their database. There are three possible reasons for this rejection reason: 1. The claim was submitted to the wrong payer ID. Note: This is most likely the cause if this rejection was received on claims for multiple clients. 2. The client's demographics or insurance policy included on the claim was not eligible for the date of service billed. 3. The client is a newborn or recently added to the guarantor's insurance policy. | Action items below for each of the possible reasons: 1. Please confirm the claim was submitted to the correct payer ID. If you confirmed the payer ID is correct, the Member details should be reviewed. Please verify the Member ID, Client Name, DOB, and if they are the primary party or a dependent on the policy. If all information in the claim is correct, please contact the payer to investigate this issue. 2. Please verify if your client still has active coverage for the date(s) of service you are billing for. 3. If the client is a newborn or recently added to the policy, it is possible your client needs to be added to the policy by the Payer's EDI department. Please contact the payer to resolve this issue. |
Billing Provider Secondary Identification should not be used when National Provider ID is mandated for use. | REF (Billing Provider Secondary Identification) is not required by the payer. You either filled out the location number in box 1 and/or you filled out box 17a when it's not required. | Please remove this information from either: 1. Box 1 (the location number) 2. Box 17a (non-NPI ID of the referring provider and is a unique identifier or a taxonomy code) and resubmit the claim for processing. |
H20203: ELEMENT RELATED CAUSES INFORMATION03 IS PRESENT, THOUGH MARKED 'NOT USED' | The claim was rejected by our clearinghouse's scrubber because you submitted the claim selecting more than 1 option in box 10. | If this claim is regarding an accident, you need to select and fill out the correct information in either box 10b OR 10c instead of using both boxes. |
Missing or invalid information. CTN=90XI2RVJXWIL7S, Payer Claim Office Number (or POBox#) is missing or incorrect. Verify with Authorization of Care letter or your authorizing Service Center. If the number was entered correctly, Magellan is not the payer. Missing or invalid information. Payer Claim Office Number (or POBox#) is missing or incorrect. Verify with Authorization of Care letter or your authorizing Service Center. If the number was entered correctly, Magellan is not the payer. | This claim was rejected because, as per the Payer Magellan, the Claim Office Number (or PO Box Number) is missing or incorrect. | 1. You need to verify this with an Authorization of Care letter or an authorized Service Center. Please double check the information entered in box 1 (the PO Box number, the Payer, etc.) and then resubmit the claim with accurate details for the intended Payer. 2. If you find that everything was entered correctly, then Magellan is not the payer for your client. |
The claim/encounter has been rejected and has not been entered into the adjudication system. Missing or invalid information, patient relationship to insured must be 18 - self. | The claim was rejected by the Payer because the relationship code for the client was not "Self" in box 6. Please submit the claim with the correct relationship code. | The claim should be billed as "Self" in box 6. Please update box 6 to "Self" and resubmit the claim. |
ADJUSTMENT REQUEST WAS SUBMITTED WITH AN INCORRECT CLAIM NUMBER | This claim has been rejected because of an incorrect Payer Control Number/ Payer Claim # was submitted in box 22 of the claim form. | Please double-check box 22 and resubmit the claim with the correct Payer Control Number/ Payer Claim # of the original claim. |
INVALID MBR DOB | This claim has been rejected due to an incorrect date of birth on the claim form | Please double-check the client's date of birth and resubmit the claim with the correct date of birth. |
NCBLS specific claim rejection: Invalid member ID | This claim was rejected due to an invalid member ID. A claim that is submitted without the member ID suffix will be rejected for an invalid member ID. | Please verify the member ID from the member ID card. This member ID might be missing the 2-digit suffix which appears on the member's card. An Eligibility inquiry on the Blue Payer would return the correct suffix as well. Each member that is on the policy will have a unique 2-digit suffix (e.g., 01, 02, 03, etc.) Please resubmit the claim with correct member ID + Suffix. |
SCMCD specific claim rejection: The file contains a dependent claim. | For All SC Medicaid claims, there is no dependent coverage; the client is the only the subscriber. | Please don't send any dependent information on any SC Medicaid claims. For reference, please see the SC Medicaid HIPAA 5010 Companion guide. The rejected claim needs to be corrected with the client marked as an independent on the claim form and resubmitted.
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NEBLS specific claim rejection: Clm: BCBSNE Rule: BCBS Claim Control Number missing or invalid format | The claim has been rejected because the Payer Control Number/ Payer Claim # in box 22 was submitted in an invalid format. | NEBLS Payer Control Numbers/ Payer Claim #'s are always 12 digits. The first two digits are the year the claim was received. So, if the claims were received in 2018, they will all begin with “18”. Example: Payer Control Number/ Payer Claim # is "1021548501" and the claim was sent to Payer in 2018. The correct format to go in box 22 will be "181021548501". Please resubmit the claims again with Payer Control Numbers/ Payer Claim #'s with the appropriate format. |