Changelog

Stedi now rejects 837P professional and 837I institutional claims that bill for a drug or biologic without a valid unit count.

In professional and institutional claims, you bill for drugs or biologics by adding information about the drug to a service line, specifying what drug was administered and how much.

The line’s unit of measurement code – such as F2 (International Unit) or GR (Gram) – shows how the drug was measured. The line’s unit count reports the quantity administered in that measure.

Payers use the measurement code and unit count to verify dosage and pricing. Without a valid unit count, they can’t confirm the billed amount and may reject the claim, which can delay payment.

This edit – the industry’s term for an automated validation rule – catches the issue before it reaches the payer.

When this edit applies
A professional or institutional claim will fail this edit in the following cases:

• JSON API
  If you’re using one of Stedi’s JSON claim submission API endpoints, the edit fails if:

  • A service line contains a drugIdentification.measurementUnitCode value.
    AND

  • The service line’s drugIdentification.nationalDrugUnitCount field is less than or equal to ”0”.

• Raw X12
  If you’re using raw X12, the edit fails if:

  • Loop 2410 (Drug Identification) is present
    AND

  • The CTP-05 (Composite Unit of Measure) of Loop 2410 contains a value.
    AND

  • The CTP-04 (National Drug Unit Count)  of Loop 2410  is less than or equal to 0.

• Stedi portal
  If you’re using the Stedi portal’s professional claim form, the edit fails if:

  • Box 24 – Service Lines contains a service line with a Unit/Basis of measurement value and a Quantity less than or equal to zero.

    

Rejection errors
If you submit a claim that fails the edit using Stedi’s claim submission APIs or professional claim form, you’ll get back an error message in real time. If you’re using a JSON API endpoint, the response includes error details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid drug unit count. When reporting a drug unit qualifier, the drug count must be greater than zero (0.0). Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If you submit a claim that fails the edit using SFTP, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will contain a related claim status category code, claim status code, and error message. You can use the error message to correct and resubmit the claim.

Stedi now rejects 837P professional and 837D dental claims that relate to an auto or other accident but don’t include an accident date.

When you submit a professional or dental claim, you can indicate that the patient’s condition is related to an accident using a related causes code. Valid codes are AA (Auto accident), EM (Employment), and OA (Other accident).

If you provide a related causes code of AA or OA, payers also require an accident date – the date the injury occurred. Payers use this date to determine liability, coordinate benefits with other payers, and correctly adjudicate the claim.

If you don’t include the accident date in these cases, the payer may reject the claim, which can delay payment.

This edit – the industry’s term for an automated validation rule – catches the issue before it reaches the payer.

When this edit applies
A professional or dental claim will fail this edit in the following cases:

• JSON API
  If you’re using one of Stedi’s JSON claim submission API endpoints, the edit fails if:

  • The claimInformation.relatedCausesCode array contains AA (Auto accident) or OA (Other accident).
    AND

  • The claimInformation.claimDateInformation.accidentDate field is empty or missing.

• Raw X12
  If you’re using raw X12, the edit fails if:

  • The CLM11-1 (Related Causes Code)  or CLM11-2 (Related Causes Code) of Loop 2300 (Claim Information) contains AA (Auto accident) or OA (Other accident).
    AND

  • The DTP-03 (Accident Date) of Loop 2300 is empty or missing.

• Stedi portal
  If you’re using the Stedi portal’s professional claim form, the edit fails if:

  • The Auto accident? or Other? field of Box 11 – Is patient's condition related to is Yes.

  • Box 15 – Other Date does not contain a Date with a Qualifier of 439 (Accident)

Rejection errors
If you submit a claim that fails the edit using Stedi’s claim submission APIs or professional claim form, you’ll get back an error message in real time. If you’re using a JSON API endpoint, the response includes error details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "The Accident Date is missing. This date is required when the claim is marked as accident-related, Auto Accident, in Related Causes Code. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If you submit a claim that fails the edit using SFTP, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will contain a related claim status category code, claim status code, and error message. You can use the error message to correct and resubmit the claim.

Stedi now rejects 837I institutional claims that contain an invalid service line revenue code.

Revenue codes are standardized, 4-digit codes that hospitals and other care facilities use to identify the type of room, service, or supply billed on a service line. Example revenue codes include:

• 0450 – Emergency Room

• 0360 – Operating Room Services

• 0300 – Laboratory

Revenue codes are different from procedure codes, such as CPT or HCPCS codes. A procedure code describes what kind of care was delivered. A revenue code describes the type of facility associated with the charge.

Revenue codes are maintained by the National Uniform Billing Committee (NUBC). They are always 4 digits and start with a 0, 1, 2, or 3.

Revenue codes often drive how payers price and reimburse institutional claims. If a claim includes an invalid revenue code, the payers may reject the claim, which can delay payment.

This edit – the industry’s term for an automated validation rule – catches the issue before it reaches the payer.

When this edit applies
An institutional claim fails this edit if a service line revenue code:

• Is not exactly 4 digits

• Does not start with a 0, 1, 2, or 3

If you're using Stedi’s JSON institutional claim submission endpoint, you provide the revenue code in the serviceLineRevenueCode field for the service line.

In raw X12, you provide the revenue code for a service line in SV2-01 (Service Line Revenue Code) of Loop 2400 (Service Line Number).

Rejection errors
If you submit an institutional claim that fails the edit using Stedi’s institutional claim submission API endpoints, you’ll get back an error message in real time. If you’re using the JSON API endpoint, the response includes error details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "The Revenue Code value does not match the required format. Revenue codes must be 4 digits and have a valid leading digit of 0, 1, 2, or 3. Please review and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If you submit an institutional claim that fails the edit using SFTP, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will contain a related claim status category code, claim status code, and error message. You can use the error message to correct and resubmit the claim.

Stedi now rejects 837P professional, 837D dental, and 837I institutional claims that include duplicate payer responsibility level codes.

Payer responsibility level codes, also called payment responsibility sequence number codes, indicate which payer is supposed to pay first, second, and so on. For example, a code of P indicates the primary payer. A code of S indicates the secondary payer.

The process of determining this order is known as coordination of benefits (COB). Payers use this information to process secondary and tertiary claims correctly.

If a claim lists more than one payer at the same responsibility level – for example, two primary payers – the payer may reject the claim, which can cause payment delays.

This edit – the industry’s term for an automated validation rule – catches the issue before it reaches the payer.

When this edit applies
A claim will fail this edit when:

• JSON API
  If you’re using one of Stedi’s JSON claim submission API endpoints, the edit fails if the subscriber.paymentResponsibilityLevelCode field and/or any claimInformation.otherSubscriberInformation.paymentResponsibilityLevelCode fields contain a duplicate value.

• Raw X12
  If you’re using raw X12, the edit fails if Loop 2000B (Subscriber Hierarchical Level) and/or Loop 2320 (Other Subscriber Information) contain a duplicate SBR-01 (Payer Responsibility Sequence Number Code) value.

• Stedi portal
  You can’t fail this edit using the Stedi portal’s professional claim submission form. Currently, the form only supports claims to a single primary payer. Secondary and tertiary claims aren't supported.

This edit does not fail if a claim lists multiple payers with a responsibility level code of U (Unknown). A code of U doesn’t indicate a specific payment order, so duplicates are allowed.

Rejection errors
If you submit a claim that fails the edit using Stedi’s claim submission APIs, you’ll get back an error message in real time. If you’re using a JSON API endpoint, the response includes error details in the errors array:

{
  "errors": [
    {
      "code": "33",
      "description": "Invalid payer responsibility submitted. Duplicate payer responsibility codes were detected: [P, S, S]. Payer responsibility values within a claim must be unique. Correct and resubmit.",
      "followupAction": "Please Correct and Resubmit"
    }
  ]
}

If you submit a claim that fails the edit using SFTP, Stedi will reject the claim with a 277CA claim acknowledgment. The acknowledgment will contain a related claim status category code, claim status code, and error message. You can use the error message to correct and resubmit the claim.