Claim Rejection/Denial Edits

Posted 28 June 2012 by aborgmeyer & filed under newsroom, Provider News.

Superior HealthPlan has implemented enhancement of the edits in our claims processing system to more closely align with HIPAA standards. A preliminary list of proposed edits was distributed in April 2012; included below is a comprehensive listing of edits that will result in the rejection (electronic claims) or denial (paper claims) if not submitted with the correct and appropriate information.

Thank you for being a provider for Superior HealthPlan. If you have questions about the edits described in this bulletin, please call Provider Services at 1-877-391-5921 Option 3.

 

Rejection/Denial Edit Descriptions
Accident information missing
Attending provider missing
Texas Health Steps (EPSDT) indicators missing or invalid
Member Date of Birth missing
Member Social Security Number invalid
Service Dates missing or invalid
Member demographic information missing or invalid
Provider demographic information missing or invalid
Provider Signature and date missing or invalid
Date of Service must be before receipt date
Billed/Charged amount Invalid/negative amount
Date of service “To” date before “from” date
Service unit(s) missing or invalid
Institutional Claim Service lines exceeding 97 per claim submission
Date of Service prior to Member Date of Birth
Occurrence code-date missing
Diagnosis codes (ICD-9) missing or invalid
Institutional claim – revenue code missing or invalid
Institutional claim -patient status missing or invalid
Institutional claim – Operating provider name/ NPI missing or invalid
Institutional claims admit type/source/date/hour missing or invalid
Institutional claims attending provider name/ NPI missing or invalid
Institutional claims bill type missing or invalid
Institutional claims discharge date/hour/status missing or invalid
Place of service missing or invalid
Procedure Code Modifier missing or invalid (if required)
Procedure Code (CPT/HCPC) missing or invalid