Rejected/returned claims resolution tips

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Rejected/returned claims resolution tips

1. U

 se this guide, along with your 277 Health Care Claim Acknowledgement, to assist you in resolving some of the most common rejected/returned claims. You can request

the 277 Health Care Claim Acknowledgment from your vendor.

2. Locate the reason your claim was rejected or returned and resubmit the claim after taking the suggested action, if appropriate.

Category/status/entity codes

Definitions

Translation

Suggested action

A1:19:PR Coventry redirects

This claim/encounter has been received.

Coventry claim.

Claim is being internally routed to the

Coventry claims system.

No action is required.

A3:562:85 Unprocessable claim

Acknowledgement/returned as

unprocessable claim. The claim/

encounter has been rejected and has

not been entered into the adjudication

system. Entity¡¯s National Provider

Identifier (NPI). Billing provider.

This claim has been returned because

there is an issue with the NPI.

Make sure the NPI entered is valid.

It must have 10 digits. Use leading

zeros if necessary.

A7:24:TU Third-party organization

(TPO) ID invalid

Acknowledgment/rejected for invalid

information. Third-party organization

(TPO) ID is invalid.

TPO ID is invalid.

Make sure the TPO ID should be

submitted, and if so, make sure the TPO

ID is correct. Note: This is a field in the

HCP segment of the claim/encounter.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance

Company and its affiliates (Aetna).

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Category/status/entity codes

Definitions

Translation

Suggested action

A7:33 Insured ID missing or invalid

Acknowledgment/rejected for invalid

information. Insured ID missing or invalid.

The ID number of the insured person is

missing or invalid.

Make sure the insured¡¯s ID number

is entered and correct.

A7:128:85 Provider TIN invalid

Acknowledgment/rejected for invalid

information. Provider tax identification

number (TIN) invalid.

Provider TIN is invalid.

Make sure the provider¡¯s TIN is valid.

A7:188 Statement period start and/or

end date(s) invalid

Acknowledgement/rejected for invalid

information. The claim/encounter has

invalid information, as specified in the

status details, and has been rejected.

Statement from ¨C through dates.

Statement date is invalid. The statement

start or end date is a future date.

Make sure the start and end dates are

correct and are not future dates.

A7:189 Admit date is missing or

invalid

Acknowledgment/rejected for invalid

information. For hospital inpatient claims,

a valid admission date is required.

Hospital inpatient claims require a valid

admission date. It cannot be left blank and

cannot be greater than the current date.

Make sure the admission date is correct

for the inpatient hospital claim and is

not a future date.

A7:228 Type of bill invalid

Acknowledgment/rejected for invalid

information. The claim/encounter has

invalid information, as specified in the

status details, and has been rejected.

Type of bill for institutional claim.

The bill type is not a valid code.

Check the bill type code and confirm it

is valid.

A7:255 Diagnosis code invalid

Acknowledgment/rejected for invalid

information. The claim/encounter has

invalid information, as specified in the

status details, and has been rejected.

Invalid diagnosis code.

ICD-9 diagnosis code(s) is invalid based

on the effective date for ICD-10 coding

requirement.

Make sure the diagnosis code is correct

for the date of service. Note: As of

October 1, 2015, ICD-10 codes are

required.

A7:402 Claim total charges

Acknowledgment/rejected for invalid

information. The claim/encounter has

invalid information, as specified in the

status details, and has been rejected.

Note: At least one other status code

is required to identify which amount

element is in error.

The total amount submitted on the

claim is zero.

1. Make sure the claim contains an

actual dollar amount.

2. Double-check the math.

A7:453 Modifier invalid

Acknowledgement/rejected for invalid

information. The claim/encounter has

invalid information, as specified in the

status detail, and has been rejected.

Procedure code modifier(s) for service(s)

rendered.

The procedure code modifier submitted

does not exist.

Make sure the procedure code modifier

submitted is valid.

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Category/status/entity codes

Definitions

Translation

Suggested action

A7:454 CPT code missing or invalid

Acknowledgement/rejected for invalid

information. The claim/encounter has

invalid information, as specified in the

status details, and has been rejected.

Procedure code for services rendered.

Procedure code for services rendered is

invalid.

Make sure the CPT procedure code

submitted is valid.

A7:454 ICD procedure code invalid

Acknowledgment/rejected for invalid

information. The claim/encounter has

invalid information, as specified in the

status details, and has been rejected.

ICD procedure code for services

rendered.

ICD procedure code is invalid for the

date of service.

Make sure the ICD procedure code is

valid for the date of service.

A7:455 Revenue code is missing or

invalid

Acknowledgement/rejected for invalid

information. The claim/encounter has

invalid information, as specified in the

status details. The claim/encounter has

been rejected. Revenue code for services

rendered.

There¡¯s a conflict between the hospital

bill and the revenue codes.

1. If the claim is a facility claim, confirm

the bill type matches the services

rendered.

2. If the bill type is for inpatient services,

confirm inpatient revenue codes are

on the claim.

3. If the bill type is for outpatient services,

remove room and board revenue codes

if any are on the claim.

A7:488 Diagnosis code is missing

Acknowledgment/rejected for invalid

information. Diagnosis code is missing.

The primary diagnosis code can¡¯t be an

accident diagnosis code.

Make sure the primary code is a

non-accident diagnosis code.

A7:507 HCPCS (Healthcare Common

Procedure Coding System)

Acknowledgement/rejected for invalid

information. The claim/encounter has

invalid information, as specified in the

status details, and has been rejected.

The HCPCS code is missing or invalid.

Make sure the HCPCS code is present

and valid.

A7:508 Diagnosis and/or procedure

code invalid

Acknowledgment/rejected for invalid

information. The claim/encounter has

invalid information, as specified in the

status details, and has been rejected.

ICD-9. Note: At least one other status

code is required to identify the related

procedure code or diagnosis code.

Diagnosis and/or procedure codes

include a combination of ICD-9 and

ICD-10 codes.

Make sure the diagnosis and/or procedure

code for the date of service is correct.

Note: As of October 1, 2015, ICD-10

codes are required.

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Category/status/entity codes

Definitions

Translation

Suggested action

A7:700 Procedure code invalid

Acknowledgment/rejected for invalid

information. The claim/encounter has

invalid information, as specified in the

status details and has been rejected.

ICD-10. Note: At least one other status

code is required to identify the related

procedure code or diagnosis code.

Diagnosis and/or procedure codes

include a combination of ICD-9 and

ICD-10 codes.

Make sure the procedure code for the

date of service is correct. Note: As of

October 1, 2015, ICD-10 codes are

required.

A7:720 Occur code invalid

Acknowledgement/returned

as unprocessable claim. The

claim/encounter has been rejected

and has not been entered into the

adjudication system.

The occurrence code is either missing

or invalid.

Make sure the National Uniform Billing

Committee occurrence code is entered

and correct.

Additional resources available at Washington Publishing Company:

reference.



?2016 Aetna Inc.

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