X12 837 QUICKLINK PROFESSIONAL FRONT-END VALIDATION ...

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Level 4 – IMPLEMENTATION GUIDE (IG) EDITSIGE0000021 PROVIDER TAXONOMY CODE ENTERED IS INVALIDHIPAA Provider Taxonomy Codes external code list published by the Washington PublishingCompany (WPC) at www.wpc-edi.com.EMC Front End Validation – Quicklink Commercial Professional 4010A141
LEVEL 5 - EMPIRE BUSINESS EDITSLevel 5 - OverviewThese edits are only performed if the claim passes all of the Level 4 - IG edits.Empire has developed edits to verify that the claim meets WebMD commercial professional business rules.These rules are designed to ensure the integrity of the data; that is, that Empire recognizes the provider and thatthe claims contain critical data needed to pass claims to WebMD. Some of these rules are documented in theEmpire Institutional Quicklink X12 837 4010A1 Addenda Companion Document.These Claim Level Business Edits are not defined in the ASC X12N 837 (004010X098A1) Implementation guidedated October 2002.There are three levels of Commercial Business Edits and they are performed in the order listed below.Critical Transaction EditProvider Authorization EditsClaim level Business EditsCritical Transaction EditThere is one business edit, WP00000001, that is considered critical because a transaction that fails this editcannot be processed by the Empire system. This edit is applied to the BHT segment.FAIL: If a Transaction Set (ST through SE) FAILS the Critical Transaction Edit:All claims for this transaction set (ST through SE) are rejected. Claims for every provider, everysubscriber and every dependent are rejected.The remaining levels of Level 5 – Commercial business edits are not performed.The EMC Commercial Receipt Report will list all errors.The submitter must correct all errors within the ST through SE and resubmit the ST through SE thatwas in error.PASS: If a Transaction Set (ST through SE) PASSES the Critical Transaction Edits:Processing continues to Provider Authorization edits.Provider Authorization EditsThese edits are applied to Loop 2010AA REF segment.There is no hierarchy for the performance of these edits. Edits will be performed simultaneously. If any of theseedits are received, the entire Provider (HL03=20) must be resubmitted, including all claims and dependentclaims for the provider.The Blue Shield provider number must be present in REF02 with the qualifier in REF01 equal to ‘1B’.There must be at least one REF segment with a ‘1B’ qualifier present within the 2010AA loop.There must be a second REF segment present with REF01 containing a qualifier equal to ‘G5’ and REF02containing positions 3-6 of the Blue Shield billing provider number found in the other REF02 for the loop2010AA.Loop 2010AA, NM108 must be equal to ‘24’ and the NM109 must match the tax id on the Empire Corporateprovider file for the Blue Shield provider number submitted in 2010AA REF02 (with REF01 = 1B).EMC Front End Validation Edits – Quicklink Commercial Professional 4010A142
Page 6 and 7: LEVEL 1 - ISA EditsISA0500001INTERC
Page 8 and 9: LEVEL 1 - ISA EditsISA0900001INTERC
Page 10 and 11: LEVEL 1 - ISA EditsISA0000IEACHARAC
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Page 32 and 33: Level 3 - GS EDITSGS Error Codes an
Page 34 and 35: Level 4 - IMPLEMENTATION GUIDE (IG)
Page 46 and 47: Level 5 - EMPIRE BUSINESS EDITSFAIL
Page 48 and 49: Level 5 - EMPIRE BUSINESS EDITSWP00
Page 50 and 51: LEVEL 5 - EMPIRE BUSINESS EDITSWP00

X12 837 QUICKLINK PROFESSIONAL FRONT-END VALIDATION ...

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