Specific wording in claim rejections differs drastically between clearinghouses and payers. They can be confusing and cryptic, but with some experience, they can be parsed for the useful message. Some clearinghouses allow you to fix the problem directly through their tools, but we recommend making sure it is fixed in TotalMD as well to prevent repeat issues. Often, speaking to your clearinghouse can be helpful to make sense of the problem but they will likely not be able to help fix it in TotalMD. TotalMD Support is here to help with any of that, but here are a few common issues with easy solutions within TotalMD. Once you’ve corrected the cause of the issue, update the claim and resend it.
Issue: Zip Code invalid/missing/”must be 9 digits”
Explanation: A common rejection involves issues regarding the address of an entity (patient, practice, facility, or provider), and more often than not that is referring to the Zip code. For insurance carriers in particular, the zip code requires the 4 digit extension.
Solution: The easiest way to fill in missing address data is to use the Address Validation Tool. This is the button with the checkbox just to the left of the address fields on most pages. If you don’t have enough information for the system to validate the address, you may need to research the full address elsewhere.
Issue: Missing or Invalid Payer ID
Explanation: When sending electronic claims, a Payer ID is required for all insurance plans. Each clearinghouse has its own Payer List with Payer IDs that may or may not match up with the Payer ID on the patient’s insurance card. This is the primary way the clearinghouse identifies where to send the claim since the actual payer name can often vary. If it is missing or does not match the clearinghouse, it will not go through.
Solution: Check the clearinghouse’s payer list to identify the correct Payer ID for all of your insurance plans.
Here is a list of links to the Payer Lists of our most common clearinghouses:
- TotalMD EDI (Practice Insight) Payer List - eSolutions
- Trizetto (GatewayEDI) Gateway EDI Payer List
- Apex Medical & Dental Insurance Payer List & Payer ID
- Office Ally Office Ally updates payer list
- Availity https://apps.availity.com/public/apps/payer-list/#/
Issue: Charge and Payment data does not add up (secondary claims)
Explanation: When sending electronic secondary claims, payment and adjustment information must be included for all charges - even if the primary insurance denied the claim. Ultimately, the Primary Insurance Payment+Adjustments+Remainder must equal the Charge Amount they’re distributed to.
Solution: First, if there is a patient payment, remove it temporarily until the claim is sent. This will throw off the patient responsibility calculation. If adding payments via electronic remittance advice (ERA), the payments and adjustments should be added for you automatically and you’re done. If you’re entering an EOB manually, take care to distribute payments and adjustments in their respective columns to the correct charge (including $0 payments). Once you’ve entered an Adjustment, you’ll see “Adjustment Code/Reason” appear in the left side-bar which you can use to enter the required details for the adjustments. The patient responsibility is automatically calculated based on the Remainder on the ledger.
Issue: Charges do not add up to Total Fee
Explanation: One way or another, one or all of the procedures on the claim have probably been removed from the claim without the system having a chance to update the Total Fee on the claim.
Solution: Check the claim in TotalMD to verify that transactions are missing and try updating the claim. If that does not work or there are no transactions on the claim at all, simply delete the claim and recreate it from that patient’s ledger. It may be that a transaction moved from that claim to another already existing claim, in which case it won’t create a new claim and you’re probably finished as long as the other claim seems correct.
Issue: Diagnosis code (or member id, etc) not valid for Date of Service
Explanation: Diagnosis codes are revised every year, so this rejection might be taken at face value. However, the most common cause of Date of Service errors is that the date of service was entered incorrectly. For instance, the actual procedure occurred in August of 2019, but the DOS was accidentally entered as 8/24/2020. As of writing this, that is 6 months in the future. The clearinghouse software may not detect that the date is invalid but may detect that it has no record of the diagnosis code in reference to that date.
Solution: Fix the date of service and resubmit.
Issue: Member ID Invalid for Medicare
Explanation: As of 2020, Medicare no longer uses IDs based on the patients’ SSN and has a new unique format. Claims containing IDs in the old format will be rejected.
Solution: Be sure you’ve updated your records for all Medicare patients. This link may be helpful in confirming the numbers you have are correct: Understanding the Medicare Beneficiary Identifier (MBI) Format
Issue: NPI missing or Invalid
Explanation: There are four places on a claim for NPIs, the Billing Provider (Box 33a), the Rendering Provider (24j), the Facility (32a), and the Referring/Operating/Attending/etc. (17b) and having the correct one in the correct place is important and sometimes tricky. Billing Provider must always be present and is either the Group NPI if billing as a group/practice or Individual NPI if billing as the Provider. The Rendering Provider is only needed on an electronic claim if the Rendering Provider is NOT the Billing Provider. The same goes for Facility, only generating eclaim information if the Facility is NOT the same as the Billing Address. The Referring (or other source) Provider will have its own information as appropriate even if it matches the Billing Provider.
Solution: Start in the Insurance Plan info page and verify “Info For Claim” is marked “Provider” or “Practice” appropriately to designate the Billing Provider. Check that “Billing Provider NPI” fits that selection. “Rendering Provider NPI” is usually “Individual NPI” except in certain circumstances. Provider SSN or TIN is rarely anything other than TIN.
If that information is good, make sure the information in the Provider and Address-Referring Provider entry is correct for Individual and Group NPIs.
If all the information in your system seems to check out, contact your clearinghouse (or TotalMD support if you’re using TotalMD EDI) and make sure they have the correct information configured in their system.
Issue: Claim missing Place Of Service
Explanation: Place of Service is required on all claims. There is a mandatory claim-level POS and an optional transaction-level POS (if different from the claim-level). You can set the default Place of Service per Transaction in the Facility entry or the Service Code entry screens (Facility will take priority).
Solution: For the claim-level Place of Service, select View Billing Options from your ledger, go to the Claim Information tab, and enter your Place of Service.
If your transactions involve multiple locations, you can have a different Place of Service code for different transactions on the claim, which you can find by selecting a transaction and clicking “View Details.”
For your convenience should you forget to enter a claim-level Place of Service, the ANSI module is configured to use the Place of Service defaulted in the first transaction on the claim as the claim-level Place of Service.
Issue: Secondary Medicare insurance type code missing/invalid
Explanation: When Medicare is a secondary insurance, an Insurance Type Code is required. It’s a rare case and easy to miss, but will result in rejections. If it’s reported as invalid however, a remnant from an old configuration before the CMS 5010 standards were implemented may be hanging around in your data.
Solution: This is found in the Insurance Plan information screen as “SBR05”. Select one of the options from the dropdown and save. Meanwhile, if it is not a secondary Medicare and you’re getting anomalous data, select something at random from the list and save. Then go back in and click in the dropdown box and press ‘Delete’ on your keyboard to clear the entry. If this occurs more than once, contact TotalMD Support to help clear that field out across the entire database.
The dropdown will contain the necessary codes, but for informational purposes, the codes for this field are:
12 – Working aged beneficiary or spouse with employer group health plan
13 – End-Stage Renal Disease beneficiary in the mandated coordination period with an Employer’s Group Health Plan
14 – No-fault Insurance including Auto is Primary
15 – Worker’s compensation
16 – Public Health Service (PHS) or other Federal Agency
41 – Black Lung
42 – Veteran’s Administration
43 – Disabled Beneficiary Under Age 65 with Large Group Health Plan
47 - Other Liability Insurance is Primary