FI HIPAA Claim Level Edits

The FIs must reject 837 claims with implementation guide (IG) errors at the claim level. FIs must install the APASS IG edit module in order to reject claims that have implementation guide (IG) errors at the claim level (see example below). If a batch of claims passes the basic syntax edits, the APASS IG edit module will be invoked and only claims that fail the IG edits will be rejected and appropriate reports generated


ISA     (example 1)

GS    (example 2)

ST    (example 3)

PROV A

SUBSCRIBER A      (example 5)

CLAIM A1       (example 6)

CLAIM A2

CLAIM A3

SUBSCRIBER AA

CLAIM AA1

CLAIM AA2

PROV B   (example 4)

SUBSCRIBER B

CLAIM B1

CLAIM B2    (example 6)

CLAIM B3

SE

ST

PROV C

SUBSCRIBER C

CLAIM C1

CLAIM C2

CLAIM C3    (example 6)
PROV D

SUBSCRIBER D

CLAIM D1

CLAIM D2

CLAIM D3

SE

GE

IEA


Example 1 (ISA-IEA level IG edit): Any errors found at this level (envelope) will result in all claims within the ISA-IEA being rejected.

Example 2 (GS-GE level IG edit): Any errors found at this level will result in all claims within the GS-GE being rejected. In this example all claims would be rejected. If a second GS-GE loop followed the first and passed all edits, then any claims within the second GS-GE would be entered into the system providing they passed the IG edits.

Example 3 (ST-SE level IG edit): Any errors found at this level will result in all claims within the ST-SE being rejected. In this example assume only the first ST had errors. In this case claims A1, A2, A3, B1, B2, B3 would be rejected. Claims C1, C2, C3, D1, D2, D3 would be entered into the system providing they passed IG edits.

Example 4 (Provider level IG edit): Any errors found at this level will result in all claims for this provider being rejected. In this example assume only the Provider B had errors (such as an invalid provider number). In this case, claims A1, A2, A3, C1, C2, C3, D1, D2, D3 would be entered into the system providing they passed IG edits and claims B1, B2, B3 would be rejected.

Example 5 (Subscriber level IG edit): Any errors found at this level will result in all claims for this subscriber being rejected. In this example, claims for Subscriber A (A1, A2, and A3) would be rejected. Claims for Subscriber AA (AA1 and AA2) would be entered into the system providing they passed IG edits.

Example 6 (Claim level IG edit): Any errors found at this level will result in only that claim(s) being rejected. In this example assume only claims A1, B2 and C3 had errors. All of the other claims would be entered into the system providing they passed IG edits