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| 1 | Paper claim not allowed for payer type | This edit occurs for 1 reason: the client is submitting claims for a payer that they are not enrolled to submit claims for and this payer type does not allow paper claims so we cannot drop them to paper. If this occurs, client must either 1)request enrollment for this payer if they have not done so previously OR 2)if they have requested enrollment, they will need to await payer approval until they can start submitting electronically to this carrier. i-Plexus will notify them of payer approval as per instruction sheet sent to client with agreement |
| 2 | Referring Provider NPI is required if Referring provider name is present | This edit is live for IDPayer 1123 - Medicaid Florida ONLY. This payer now requires NPI for the Referring Provider on all submitted claims; therefore, i-Plexus edits for this information to eliminate clients receiving rejections at the payer site. Clients receiving this rejection can either correct claim in their practice management system and resubmit or they can correct using our online claims editor by adding the required NPI for the Referring Provider on the claim. NOTE: if client did not intend to submit a Referring provider at all on the claim, then they can simply remove the Referring Provider name and resubmit the claim or remove the name on the online claims editor. |
| 3 | EMG is invalid | This edit primarily occurs for Print Image submitters who have switched to using the new HICFA format but have not updated their BX 24C information. Box 24C on the old HICFA 1500 form was for the Type of Service code. The Type of Service code is no longer required on the new HICFA 1500 form and therefore, clients sending the new format need to make sure that the TOS code is no longer present on their electronic claim file in Box 24C. Box 24C on the new form is for the EMG or Emergency indicator. This field can only be a value of blank, N or Y. |
| 4 | Missing or invalid CPT code | This edit occurs for 2 reasons: REASON 1) Client is sending one or more services lines with an invalid or blank CPT code. Clients must correct using code from current approved coding book and resubmit affected claims OR they can input corrected code in online claims editor. REASON 2) Client is sending in print image format and their map has shifted causing their CPT code field to not be read in successfully. If this occurs, we will either remap their new format for standard remap fee OR they can work with their software vendor to get back to the map they already have on file with i-Plexus then resubmit affected claims. |
| 5 | Referring provider name and-or ID qualifier is missing | This edit occurs for 2 reasons: REASON 1) Client is sending the referring provider NPI or legacy provider ID field but is not sending the name of the referring provider. When sending the referring provider name or ID fields, both are required to be HIPAA compliant. Client can either correct in their practice management software and resubmit affected claims or they can input missing data in the online claims editor. REASON 2) Client is sending the name of the referring provider and the provider legacy ID; however, the qualifier they are sending is either blank or invalid. Client needs to confirm valid qualifier listing for the ID that they are sending as required by their specific format (print image, NSF or
837) and resubmit claim OR they can correct using the online claims editor. |
| 6 | Invalid or missing Diagnosis Code Pointers | This edit occurs for 2 reasons: REASON 1)Client is sending service lines on their claims that have blank DX Code pointers. Every service line must have at least one DX code pointer to indicate which diagnosis code the claim needs to be processed under. Client can either correct in their practice managment software and resubmit affected claims OR correct using online claims editor. REASON 2) Client is print image and their format has shifted causing these fields to not be read in successfully. If this occurs, we will either remap their new format for standard remap fee OR they can work with their software vendor to get back to the map they already have on file with i-Plexus then resubmit affected claims. |
| 7 | Date of initial treatment is invalid or missing for spinal manipulation services | This edit occurs for 2 reason: REASON 1) Client is not sending initial treatment date for claims with spinal manipulation services. If this is the issue, they need to correct & resubmit OR use our online claims editor to add date as required. REASON 2) client is print image and is not sending the special code required in BX 19 which is preceeding the initial treatment date; therefore, the system is not reading it in successfully. All clients are provided with the BX 19 guide during implementation and they can also request a copy from support if needed. If this is issue, client must correct in practice management system and resubmit affected claims or they can add required date to online claims editor to release claims. |
| 8 | The sum of the service line charges does not equal the total charge | This edit occurs for 2 reasons: REASON 1) Client is sending total claim charge that does not match the sum of all service line charge amounts. If this occurs, client needs to correct in their practice management software and resubmit affected claims or correct using the online claims editor. NOTE: if the client is getting this error because a service line is completely missing then they cannot use online claims editor to add missing service line. They must correct and resubmit affected claim. REASON 2) Client is print image and their format has shifted causing these fields to not be read in successfully. If this occurs, we will either remap their new format for standard remap fee OR they can work with their software vendor to get back to the map they already have on file with i-Plexus then resubmit affected claims. |
| 9 | Diagnosis Code 1 is invalid or missing | This error occurs for 2 reasons: REASON 1) Client is not sending a valid DX code on their claim per current coding book OR it's blank. If this occurs client either can correct in practice management system and resubmit affected claims or correct using online claims editor. REASON 2) Client is print image and their format has shifted causing these fields to not be read in successfully. If this occurs, we will either remap their new format for standard remap fee OR they can work with their software vendor to get back to the map they already have on file with i-Plexus then resubmit affected claims. |
| 10 | Other Payer Primary ID must be greater than one character and Other Ins name, Other Insured ID, and plan name cannot be empty if claim is MSP or COB or 2ND | This edit occurs when client is sending other insurance information on the claim and it is incomplete rendering it impossible for i-Plexus to create a HIPAA compliant outbound claim. If this edit occurs, client needs to download the other insurance guide from the support download section and review the fields that are required per the format they send to i-Plexus. NOTE: if a client so chooses, we can setup their account to ignore all other insurance information on their claims if they do not want us to forward it to the primary carrier and do not intend to send any secondary claims. They must call to request this before we can proceed with this setup change. |
