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HIPAA 5010: Top 10 Claim Rejections for CMC Transmissions

August 31, 2012

Below are the 10 most common reasons that Medi-Cal rejects electronic claims, either in test or production, through Computer Media Claims (CMC) for the HIPAA ASC X12N 5010 format.

Background
Prior to entry in the daily claims edit cycle, CMC submissions must pass numerous system edits. Claims failing these edit requirements will be rejected. The CMC error codes and messages will appear on the CMC Submission Error Listing Report (CP-O-012). The Computer Media Claims (CMC) Billing and Technical Manual on the Medi-Cal website contains the full list of CMC error codes, as well as testing and activation procedures.

Submitters should review the table below to ensure common problems are corrected before submitting electronic claim files to Medi-Cal. Note there are some errors that are ”passable” in testing, but not in production, which means the errors can be ignored and the test file is successful even with those errors.

Messages Error Code Passable Error Y/N Description Correction
Data was previously accepted for processing 010 Not passable in production or test The same claim was submitted twice. File size, submission date, total provider count, total claim count and total dollar amount are parameters the system looks for in determining duplicate files. No correction is needed since the claim files have already been received and cannot be resubmitted.
Provider/claim type not valid for this submitter 026 Not passable in production or test The provider is not linked to the submitter in the Provider Master File or the claim type, such as Medical or Allied Health, is not valid for this submitter. First submit a Medi-Cal Telecommunications Provider and Biller Application/Agreement (DHCS 6153) before submitting a file. This form can be found on the Forms page of the Medi-Cal website.
Media type/claim type not valid for this submitter 058 Passable in test (error can be ignored), but not passable in production Submitter is not approved for either the media type, such as IPCS or Internet, or is not approved for claim type, such as Medical or Allied Health. Test for the media type or claim type before submitting files to production. The error can be ignored in testing, since the submitter is testing for either the media or claim type; therefore, they are not yet approved and will receive this error message.
Claim sequence number not unique for provider/claim type 054 Not passable in production or test Files contain multiple submitter records. When a file is submitted with more than one submitter record, the entire transaction is rejected. Submitters who have received this error must correct the file and resubmit with only one submitter record in each file.
Duplicate control record for same provider/claim type 044 Not passable in production or test A 2010 AA loop has been submitted twice for one billing provider. The submitter must make the necessary correction(s) and submit a new file.
Amount billed on Provider Control Record does not balance 011 Not passable in production or test Verify the amount numbers in the CLM segment. The submitter must make the necessary correction(s) and submit a new file.
Medicare Denial (COINS=0, DEDUCT=0, BLOOD DED=0, PAID=0) 088 Not passable in production or test 2430 SA segment loop line needs an adjustment for a secondary payer. The submitter must make the necessary correction(s) and submit a new file.
Service facility ZIP code format = Numeric, length of 9 094 Not passable in production or test Check the service facility provider ZIP code, as it must contain nine digits. The first five digits cannot be zeros; the last four digits cannot be zeros or blank spaces. The submitter must make the necessary correction(s) and submit a new file.
Billing Provider Address is invalid; PO Box or Lock Box is not acceptable 091 Not passable in production or test Use a valid physical address for the billing provider. The submitter must make the necessary correction(s) and submit a new file.
Submitter not approved to bill crossover claims for this media type 080 Passable in test (error can be ignored), but not passable in production The submitter must first be approved to bill for crossover claims before submitting a claim. Test for this claim type before submitting files to production. The error can be ignored in testing, since the submitter is testing for crossover claim type; therefore, they are not yet approved and will receive this error.