Attention All CEDI Trading Partners, Suppliers, Billing Services, Clearinghouses, and Vendors
Top 10 CEDI Edits for June 2009
National Government Services CEDI has identified the following edits as the top ten edits that were received on the CEDI GenResponse Report (GENRPT) during the month of June. The edit, its description and tips to resolve the error are provided below.
For more information regarding the Front-end edits, please review the CEDI Front End Report Manual located on the CEDI Web site at the following link http://www.ngscedi.com/outreach_materials/outreachindex.htm.
For questions regarding the edits, please contact the CEDI Help Desk at 866-311-9184 or by e-mail at ngs.cedihelpdesk@wellpoint.com.
#1 - C172 Invalid Procedure Code and/or Modifier
The procedure code, modifier, or procedure code and modifier combination is invalid. To resolve this error, verify the HCPCS and modifier combination is valid.
If the procedure code, modifier, or combination is valid, verify the first position does not contain a space.
Helpful Tips to verify a Procedure Code/HCPCS and modifier combination:
§ Check the validity of the procedure code/modifier combination by using the Pricing, Data Analysis and Coding (PDAC) Web site www.dmepdac.com.
§ Check the Local Coverage Determination (LCD) at the DME MACs for guidelines on procedure codes and modifier usage for that LCD.
§ Reference the supplier manual at the DME MAC Jurisdiction(s).
§ Contact the Customer Care department at the appropriate Jurisdiction:
Jurisdiction A: 1-866-590-6731
Jurisdiction B: 1-866-590-6727
Jurisdiction C: 1-866-270-4909
Jurisdiction D: 1-866-243-7272
#2 - C008 EIN/SSN Not on File with NPI
When C008 fires on its own, it can indicate the Tax ID (Employer Identification Number/Social Security Number) that was submitted does not match what is on file with the NPPES or the National Supplier Clearinghouse (NSC).
Verify the information entered on the NPPES Web site matches what you are submitting. The NPPES Web site can be accessed at: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart
Note: This edit can fire with the C003 Billing NPI Not on Crosswalk. If this occurs, the Tax ID (Employer Identification Number/Social Security Number) may have been entered correctly in the claim; however, with the NPI not on the crosswalk, the Tax ID could not be verified. Please refer to edit C003 for more information for resolving this error.
#3 - C003 Billing NPI Not on Crosswalk
The edit C003 indicates there is no link between the NPI that was submitted and a PTAN/NSC. Verify the PTAN/NSC has been entered on the NPPES Web site as Medicare NSC and/or the supplier's information at NPPES and the NSC has the same information to create a match. The following information needs to be verified:
For Individuals:
§ The Social Security number (SSN) and PTAN/NSC number entered with NPPES must match the SSN and PTAN/NSC number on file with the National Supplier Clearinghouse (NSC).
§ If a match cannot be found, the SSN and Practice Address ZIP Code at NPPES must match the SSN and Practice Address ZIP Code at the NSC.
§ If the second match cannot be found, an active crosswalk record will not be created.
For Organizations:
- The Tax ID number (EIN), PTAN/NSC and Practice Address ZIP Code at NPPES must match the EIN, PTAN/NSC and Practice Address ZIP Code at the NSC.
- If the match cannot be found, an active crosswalk record will not be created.
The NPPES Web site can be accessed at: https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart
#4 - C095 Diagnosis Code Invalid - Pointer 1
The diagnosis code pointed to as the first relevant diagnosis on the claim was not valid for the date of service. This is usually, but not always, the first diagnosis code on the claim. Contact the DME MAC Jurisdiction where the claim would be processed based on the beneficiary state code for assistance with the diagnosis code entered.
#5 - B108 Billing Provider Not Authorized for Submitter
The NPI submitted is not linked to the Submitter ID under which the claim file was sent to CEDI. If this error is received, the supplier must complete and sign the appropriate form on the CEDI Web site (www.ngscedi.com) and return to CEDI for processing.
Suppliers who use a third party (e.g. a clearinghouse or billing service) must complete the Supplier Authorization Form.
Suppliers who submit their own claims and do not use a third party biller must complete the CMS EDI Enrollment Agreement
#6 - 1001 Required Loop Not Found
This edit indicates a required loop was not found in the file received by CEDI. This typically occurs when loop 2420E (Ordering Provider info) is omitted as it is required on every charge line for Medicare DME. Contact your software vendor for assistance in resolving this edit.
#7 - 3001 Duplicate File Found - File Not Processed
This edit is received when a duplicate file has been submitted to CEDI. A duplicate file is determined by the following:
§ Claim count
§ Service line count
§ Record count
§ Total charge amount
§ First and last patients listed in the claim file.
To work around this edit, submitters should verify the following information with their vendors:
§ If a single ST to SE envelope is being created per claim
- OR -
§ If one ST to SE segment envelope is being created for the entire claim file.
If the first scenario outlined above is being created, please contact the CEDI Help Desk to ask if the record of the duplicate claims can be deleted. The original claims file itself will not be removed, only the data stored to compare future claim files for a duplicate submission. A resubmission of those claims can then be prepared and submitted.
If the second scenario outlined above is being created, either add or delete a claim from the claims file. A resubmission of the claims can then be prepared and submitted.
#8 - C143 Ordering Provider ID Qualifier Invalid
This edit will be received if either the Ordering Provider NPI was not sent or the Ordering Provider's UPIN was sent on a charge line. Verify that the Ordering Provider's NPI is being sent on every charge line of the patient's claim.
#9 - C044 Subscriber Primary ID Invalid
The patient's Medicare ID (HICN) is invalid. Verify the number on the patient's red, white, and blue Medicare card.
#10 - C180 Service Date Greater than Receipt Date
The date of service entered in the claim is greater than the date the claim was submitted to CEDI. Verify that the date of service is valid and not a future date.
For more information regarding the Front-end edits, please review the CEDI Front End Report Manual located on the CEDI Web site at the following link http://www.ngscedi.com/outreach_materials/outreachindex.htm.
Thank you,
National Government Services, Inc.
Corporate Communications
National Government Services, Inc.
Corporate Communications
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