Top 10 CEDI Edits for October 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 October. The edit, its description and tips to resolve the error are provided below.
For more information regarding the CEDI 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. C202 Ordering Provider Not Authorized
The edit C202 is a warning edit. It will not reject the claims until it becomes a rejection in January 2010. The edit indicates that the ordering provider submitted in the claim is not found on the CMS supplied PECOS file of Providers/Suppliers who are authorized to order DME supplies. Contact the ordering provider identified in the edit to verify their information, including their National Provider Identifier (NPI), and eligibility with the Provider Enrollment, Chain and Ownership System (PECOS).
More information can be located at http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp.
2. C200 Referring Provider Not Authorized
The edit C200 is a warning edit. It will not reject the claims until it becomes a rejection in January 2010. The edit indicates that the referring provider submitted in the claim is not found on the CMS supplied PECOS file of providers/suppliers who are authorized to refer DME supplies. Contact the referring provider identified in the edit to verify their information, including their National Provider Identifier (NPI), and eligibility with the Provider Enrollment, Chain and Ownership System (PECOS).
The referring provider does not need to be sent on durable medical equipment (DME) claims. The referring provider may be removed from the submitted claim. However, if the information is sent, it will be checked as part of the CEDI front-end edits.
For more information, visit the CMS Web site at: http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp.
3. C201 Referring Provider Not Authorized
The edit C201 is a warning edit. It will not reject the claims until it becomes a rejection in January 2010. The edit indicates that the referring provider submitted in the claim is not found on the CMS supplied PECOS file of providers/suppliers who are authorized to refer DME supplies. Contact the referring provider identified in the edit to verify their information, including their National Provider Identifier (NPI), and eligibility with the Provider Enrollment, Chain and Ownership System (PECOS).
The referring provider does not need to be sent on durable medical equipment (DME) claims. The referring provider may be removed from the submitted claim. However, if the information is sent, it will be checked as part of the CEDI Front-end edits.
For more information, visit the CMS Web site at: http://www.cms.hhs.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp.
4. 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 DMEMAC 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
5. 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.
6. 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) submitted on the claim does not match what is on file with 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.
7. 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.
8. 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.
9. 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.
10. 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.
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.
Thank you,
National Government Services, Inc.
Corporate Communications
National Government Services, Inc.
Corporate Communications
If you want to update your profile or unsubscribe from any of our lists, you will first need to set up a password for your account. To do this, click on the Login link from the Listserv page on the www.NGSMedicare.com Web site, then select one of the following:
§ Login - existing / transferred subscribers can obtain a new password and subscribe or unsubscribe from lists
Please do not reply to this e-mail. National Government Services' Listserv is for outgoing messages only. Please do not respond back to messages as your response will not be answered, as this is not an authorized mode of communication at this time.
CONFIDENTIALITY NOTICE: This e-mail message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information or otherwise be protected by law. Any unauthorized review, use, disclosure or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.
Posts
